Neurosurgery

NEUROSURGERY
Dr. M. Fazl and Dr. D.W. Rowed

Adrian Laxton, Neety Panu and Patrick Tawadros, chapter editors
Sharon J. Kular, associate editor
INTRACRANIAL MASS LESIONS ........... 2 PERIPHERAL NERVES . . . . . . . . . . . . . . . . . . . . . 27

Intracranial Dynamics Injury
Herniation Syndromes Entrapment
Clinical Features
Management PAIN SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . 29
Benign Intracranial Hypertension Physiology of Pain
Medical Treatment
HYDROCEPHALUS . . . . . . . . . . . . . . . . . . . . . . . . 6 Surgical Treatment
Mechanisms Tic Douloureux
Classification Causalgia (Relflex Sympathetic Dystrophy_
Clinical Features Postherpetic Neuralgia
Investigations Thalamic Pain
Management Phantom Limb Pain
INTRACRANIAL MASS . . . . . . . . . . . . . . . . . . . . . 7 PEDIATRIC NEUROSURGERY . . . . . . . . . . . . . . 31

Tumour Spina Bifida
Pus Spina Bifida Occulta
Blood Meningocele
Myelomeningocele
CEREBROVASCULAR DISEASE . . . . . . . . . . . . . 12 Intraventricular Hemorrhage
Subarachnoid Hemorrhage (SAH) Hydrocephalus in Pediatrics
Spontaneous Intracerebral Hemorrhage (ICH) Dandy-Walker Cyst
Intracranial Aneurysm Chiari Malformation
Vascular Malformations of the Nervous System Craniosynostosis
Arteriovenous Malformations (AVM’s) Pediatric Brain Tumours
Cavernous Malformations Child Abuse
SPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cord and Root Compression DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Spinal Cord Syndromes
Syringomyelia SURGICAL PROCEDURES . . . . . . . . . . . . . . . . . 36
Cervical Disc Syndrome
Lumbar Disc Syndrome REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Cauda Equina Syndrome
Lumbar Spinal Stenosis
TRAUMA (BRAIN AND SPINAL CORD) . . . . . 23

Head Injury
Scalp Injury
Skull Fractures
Cranial Nerve Injury
Arterial Injury
Intracranial Bleeding
Extradural “Epidural” Hematoma
Subdural Hematoma
Traumatic Intracerebral Hemorrhage
Brain Injury
Late Complications of Head Injury
Spine Injury
Trauma Management
Key Points
MCCQE 2006 Review Notes Neurosurgery – NS1
INTRACRANIAL MASS LESIONS
INTRACRANIAL DYNAMICS
Intracranial Pressure/Volume Relationship
intracranial volume is constant in the adult
• V brain + Vblood + Vcsf = Vskull = constant
(Monro-Kellie hypothesis)
as lesion expands, Intracranial pressure (ICP) does not rise initially
• CSF, blood, some brain water displaced out of the head
• brain tissue may shift into compartments under less pressure (herniation)
ICP then rises exponentially
ICP mmHg
Eventually further small

When a mass expands increments in volume
within the skull produce larger and
compensatory larger increments in
mechanisms initially intracranial pressure
maintain a normal
intracranial pressure
Volume
Figure 1. ICP-Volume Curve

Adapted from Lindsay KW, Bone I, Callander, R: Neurology and Neurosurgery Illustrated
normal ICP ~ 6-15 mm Hg (8-18 cm H 2 O) for adult,

3-7 mm Hg (4-9.5 cm H 2 O) for child and varies with patient position
consider therapy for high ICP when ICP > 20-25 mm Hg
ICP Measurement
• lumbar puncture (contraindicated with known/suspected intracranial mass lesion)
• ventricular catheter (“gold standard”, also permits therapeutic drainage of CSF to decrease ICP)
• intraparenchymal monitor
• subdural/subarachnoid monitor (Richmond bolt)
Cerebral Blood Flow (CBF)

CBF depends on cerebral perfusion pressure (CPP) and cerebral vascular resistance (CVR)
CPP = MAP (mean arterial pressure) – ICP (intracranial pressure)
• Normal CPP > 50 mm Hg in adults
cerebral autoregulation maintains constant CBF by compensating for
changes in CPP, unless
• high ICP such that CPP < 40 mm Hg
• MAP > 160 mm Hg or MAP < 60 mm Hg
• brain injury: i.e. subarachnoid hemorrhage (SAH), severe trauma
AUTOREGULATION: CBF maintained despite

change in CPP
Cerebral blood
60 torr 150 torr

101u\1cu\
Low BP or high ICP High BP
Cerebral perfusion pressure (MAP-ICP)
Figure 2. Cerebral Autoregulation Curve
Adapted from Lindsay et al: Neurology and Neurosurgery Illustrated
NS2 – Neurosurgery MCCQE 2006 Review Notes

RAISED INTRACRANIAL PRESSURE. . . CONT.
causes of raised ICP
• increased intracranial blood volume
• hypoventilation ––> increased pCO 2 ––> vasodilatation
––> decreased pO 2 ––> (< 60) ––> vasodilatation
• decreased venous drainage
• venous sinus thrombosis
• superior vena cava (SVC) syndrome
• cranial dependency
• valsalva
• cerebral edema
• hydrocephalus
• intracranial mass lesion (tumour, pus, blood – see section below)
• status epilepticus
• systemic hypertension
HERNIATION SYNDROMES
1. Subfalcine
2. Central 1
3. Uncal
4. Upward
5. Tonsillar
2
3
4
5
Figure 3. Herniation Types

Illustration by Heidi Maj
1. Subfalcine (Cingulate) Herniation

definition: cingulate gyrus herniates under falx
cause: lateral supratentorial lesion
clinical presentation
• usually asymptomatic
• pathological/radiological observation
• warns of impending transtentorial herniation
• rarely, frontal infarct due to kinked anterior cerebral artery (ACA)
2. Central Tentorial (Axial) Herniation
definition: displacement of diencephalon and midbrain through tentorial notch (often gradual)
cause: supratentorial midline lesion, diffuse cerebral swelling, late uncal herniation
• rostral to caudal deterioration (sequential failure of
diencephalon, midbrain, pons, then medulla)
• decreased LOC (midbrain compressed)
• EOM/upward gaze impairment (“sunset eyes”, pressure on
superior colliculus in midbrain compresses 3rd nerve nucleus)
• brainstem hemorrhage (“Duret’s”, secondary to shearing of basilar artery perforating vessels)
• diabetes insipidus (traction on pituitary stalk and hypothalamus) - this is an end stage sign

3. Lateral Tentorial (Uncal) Herniation
definition: uncus of temporal lobe herniates down through tentorial notch
cause: lateral supratentorial lesion (often rapidly expanding traumatic hematoma)
• unilateral dilated pupil (earliest, most reliable sign), followed by extraocular muscle
(EOM) paralysis (ipsilateral cranial nerve III compressed)
• decreased level of consciousness (LOC) (midbrain compressed)
• contralateral hemiplegia, +/– extensor plantar response
• +/– “Kernohan’s notch”: contralateral cerebral peduncle compressed due to shift of
brain ––> ipsilateral hemiplegia (a false localizing sign)
4. Upward Herniation
definition: cerebellar vermis herniates through tentorial incisura, causing midbrain compression
cause: posterior fossa mass
• SCA compression ––> cerebellar infarct
• Compression of cerebral aqueduct ––> hydrocephalus
5. Tonsillar Herniation (“Coning”)
definition: cerebellar tonsils herniate through foramen magnum
cause: infratentorial lesion or following central tentorial herniation
• rapidly fatal (compression of cardiovascular and respiratory centers in medulla)
• may be precipitated by lumbar puncture (LP) in presence of space occupying lesion
(particularly in the posterior fossa)
CLINICAL FEATURES
Acute Raised ICP
headache
nausea and vomiting (N/V)
decreased LOC
change in Glasgow Coma Scale (GCS) best index to monitor progress and predict outcome
of acute intracranial process (see Neurology Chapter)
papilledema (see Colour Atlas OP21)
• may take 24-48 hours to develop
abnormal EOM
• CN VI palsy
• longest intracranial course
• causative mass may be remote from nerve root, i.e. CN VI palsy can be a false localizing sign
• upward gaze palsy (especially in children with obstructive hydrocephalus)
Cushing’s Triad (full triad seen in 1/3 of cases)
• increased blood pressure (BP), decreased HR (late finding), abnormal respiratory pattern
(Cheyne Stokes, apneustic, ataxic)
signs/symptoms of herniation syndromes
focal signs/symptoms due to responsible lesion
Chronic Raised ICP
headache
• postural: worsened by coughing, straining, bending over (Valsalva)
• morning headache (H/A): worse on waking in the morning (increased CO 2 ) or
waking with headache in night
visual changes
• enlarged blind spot, preserved vision (until extremely advanced, then episodic constrictions
of visual fields, i.e. “gray-outs”)
• long standing papilledema (not necessarily present) may produce optic atrophy and blindness
differentiate from papillitis (usually unilateral with decreased visual acuity)
Imaging Features
CT and MRI: key diagnostic investigation
• enlarged ventricles - hydrocephalus
• compressed ventricles with midline shift - mass lesion
skull x-rays (academic) in chronic ICP may show
• separation (diastasis) of sutures in infants
• digital markings in skull vault from compression of brain matter against bone
(“beaten copper cranium”)
• thinning of dorsum sellae

MANAGEMENT
goals
• keep ICP < 20-25 mm Hg
• keep CPP > 70 mm Hg
elevate head
• head of bed at 30-45 degrees ––> decreases intracranial venous pressure
ventilate/hyperventilate (pCO 2 30 ± 2 mm Hg)
• decreases pCO 2 , increases pO 2 , decreases venous pressure
mannitol (20% IV solution, 1 gm/kg)
• can give rapidly, effects in 30 minutes, (see Drugs section)
• maintain sBP > 90 mm Hg
corticosteroids
• decreases vasogenic edema around brain tumour, abscess
• no proven value in head injury or stroke
• works slowly (days)
identify etiology (CT, MRI)
surgery
• remove mass lesion
• remove CSF by external ventricular catheter drain (if acute) or shunt
• Note: lumbar puncture contraindicated when known/suspected
intracranial mass lesion
BENIGN INTRACRANIAL HYPERTENSION
(PSEUDOTUMOUR CEREBRI)
incidence ~0.5/100,000/year
raised intracranial pressure and papilledema without evidence of any “mass” lesion,
hydrocephalus, infection or hypertensive encephalopathy
diagnosis of exclusion
Etiology
unknown (majority), but associated with
• diet: obesity, hyper/hypovitaminosis A
• endocrine: menarche, menstrual irregularities, Addison’s disease
• hematological: iron deficiency anemia, polycythemia vera
• drug: steroid withdrawal, tetracycline, nalidixic acid
Clinical Features
usually in 3rd and 4th decade (F>M)
symptoms and signs of raised ICP (headache in > 90%), except no decreased LOC
radiological (CT or MRI) and CSF studies - normal (ventricles may be smaller)
usually self-limited, recurrence is common, chronic in some patients
a preventable cause of (often permanent) blindness from optic atrophy
risk of blindness is not reliably correlated to duration of symptoms,
papilledema, headache, visual acuity or number of recurrences
Differential Diagnosis
true mass lesions (see Intracranial Mass section)
venous outflow obstruction to CSF absorption
• dural sinus thrombosis, jugular vein or sigmoid sinus obstruction
• intrathoracic mass lesion
• superior vena cava syndrome
• congestive heart failure
• hyperviscosity syndromes
infections
inflammatory conditions: e.g. neurosarcoidosis, SLE
vasculitis
metabolic conditions: e.g. lead poisoning
pseudopapilledema associated with hyperopia and drusen
meningeal carcinomatosis
Guillain-Barre syndrome
following head trauma
Management
R/O conditions that may mimic benign intracranial hypertension
D/C offending medications, weight loss, fluid/salt restriction
drugs - acetazolamide (decreased CSF production)
- thiazide diuretic or furosemide
if above fail ––> serial LPs, lumboperitoneal shunt, VP shunt
optic nerve sheath fenestration - if progressive impairment of visual acuity despite treatment
2 year follow-up with imaging studies to rule out occult tumour

HYDROCEPHALUS
see Colour Atlas NS1
definition: increased CSF volume, decreased CSF absorption
normal CSF volume = 100 - 150 mL (50 in ventricles, 25 around brain, 75 around spinal cord)
CSF production is constant at 0.4-0.6 cc/hr
MECHANISMS
increased CSF production
• e.g. choroid plexus papilloma (0.4-1% of intracranial tumours)
decreased CSF absorption (see below)
CLASSIFICATION
Obstructive (Non-Communicating) Hydrocephalus
absorption is blocked within ventricular system proximal to the arachnoid granulations
causes/location of block
• intraventricular hemorrhage
• ventricular tumours (e.g. 3rd ventricle colloid cyst)
• supratentorial mass causing tentorial herniation and aqueduct compression
• infratentorial mass causing 4th ventricle or aqueduct obstruction
• congenital e.g. aqueductal stenosis, Dandy-Walker malformation, or Chiari malformation
(see Pediatric Neurosurgery section)
CT findings
• lateral and 3rd ventricles dilated
• normal 4th ventricle (e.g. aqueduct stenosis) or deviated/absent 4th ventricle
(e.g. posterior fossa mass)
Communicating (Non-Obstructive) Hydrocephalus
absorption is blocked at some part of extraventricular pathway, such as arachnoid granulations
causes
• meningitis
• SAH
• trauma
CT findings
• all ventricles dilated
Normal Pressure Hydrocephalus (NPH)
gradual onset of classic triad
• incontinence
• gait apraxia/ataxia
• dementia
CSF pressure often within clinically “normal” range
usually communicating
Hydrocephalus Ex Vacuo
enlargement of ventricles (and sulci) secondary to diffuse brain atrophy
usually a function of normal aging
not true hydrocephalus
CLINICAL FEATURES
Acute Hydrocephalus
signs and symptoms of acute raised ICP
usually obstructive type
Chronic Hydrocephalus
similar to NPH
INVESTIGATIONS
CT
ventricular enlargement, may see prominent temporal horns
periventricular lucency (CSF forced into extracellular space)
narrow/absent sulci, +/– 4th ventricular enlargement
Ultrasound (through anterior fontanelle in infants)
ventricular enlargement

HYRDOCEPHALUS. . . CONT.
MANAGEMENT
spinal taps (for transient, communicating hydrocephalus)
remove obstruction (if possible)
excision of choroid plexus papilloma
third ventriculostomy (for obstructive hydrocephalus)
shunts
• ventriculoperitoneal (VP) = ventricle to peritoneum
• ventriculopleural = ventricle to pleura
• ventriculo-atrial (VA) = ventricle to right atrium
• lumboperitoneal = lumbar spine to peritoneum
(for communicating hydrocephalus and pseudotumour cerebri)
Shunt Complications
obstruction
• etiology: infection, obstruction by choroid plexus, buildup of
proteinaceous accretions, blood, cells (inflammatory or tumour)
• signs and symptoms of acute hydrocephalus or increased ICP
• radiographic evaluation: “shunt series” (plain x-rays which only
show disconnection of tube system), CT, isotope shunt study (nuclear medicine)
infection (3-4%)
• etiology: S. epidermidis, S. aureus, gram-negative bacilli
• presentation: fever, nausea and vomiting, anorexia, irritability;
signs and symptoms of shunt obstruction; shunt nephritis (antibodies
generated against bacteria in shunt leads to kidney damage)
• investigation: CBC, blood culture, shunt tap
(lumbar puncture (LP) usually NOT recommended in obstructive hydrocephalus)
overshunting
• slit ventricle syndrome (collapse of ventricles leading to shunt catheter occlusion by ependymal lining)
• subdural effusion, hygroma, hematoma
• secondary craniosynostosis (children)
• low pressure headache
seizures
INTRACRANIAL MASS
see Colour Atlas NS15
differential diagnosis: “tumour, pus or blood”, cyst
history important for localizing and differentiating mass lesions
important features on CT (with and without contrast enhancement)
• lesions (+/– edema, necrosis, hemorrhage)
• midline shifts and herniations
• effacement of ventricles and sulci (often ipsilateral), basal cisterns
TUMOUR (see Colour Atlas NS16 and NS17)

primary versus metastatic
primary tumours (benign or malignant) rarely metastasize
presenting symptoms
• local effects
• dependent on site: focal deficits, lobe syndromes, seizures, headaches
• raised ICP
• acute or chronic depending on tumour growth rate (see Raised ICP section)
• sudden onset of symptoms after hemorrhage (5-10%)
consider by
• location (supratentorial vs. infratentorial)
• age (adult vs. child)

INTRACRANIAL MASS. . . CONT.
Table 1. Tumour Types: Age, Location and Clinical Features
Supratentorial Infratentorial
Children Astrocytoma - all grades Cerebellar astrocytoma
(< 15 years, primarily Craniopharyngioma Medulloblastoma
infratentorial - 80%) Ependymoma Ependymoma
Other: dermoid/epidermoid, pineal tumours, Choroid plexus papilloma
primitive neuroectodermal tumours Brain stem astrocytoma
Adult Astrocytoma (40-50%) Metastatic (20-30%)

(> 15 years, primarily Metastatic (20-30%) Schwannoma (6%)
supratentorial - 80%) Meningioma (15%) e.g. vestibular schwannoma
Pituitary ademona (5%) Medulloblastoma (5%)
Oligodendroglioma (5%) Hemangioblastoma
Signs and Symptoms Raised ICP Raised ICP

Focal or lobar effects Local effects in posterior fossa
Seizures Extremity ataxia
Mental status changes Truncal ataxia
Personality changes CN palsy - often multiple
Visual field deficits Nystagmus
Endocrine disturbances Gait disturbance
(with pituitary tumour) Vertigo
Speech, motor and sensory deficits
Investigations
CT, MRI, stereotactic biopsy (tissue diagnosis)
Management
conservative
• serial history, physical, imaging for slow growing/benign lesions
medical
• corticosteroids to reduce vasogenic cerebral edema
• pharmacological treatment for pituitary tumours (see Pituitary Adenoma section)
surgical
• excisional: total, partial, decompressive, palliative
• shunt if CSF flow is blocked
radiotherapy - stereotactic radiosurgery (Gamma-knife, Linear Accelerator)
chemotherapy – e.g. alkylating agents (temozolomide)
Metastatic Tumours (see Colour Atlas NS19)
most common brain tumour seen clinically
• 15% of cancer patients present with cerebral mets
• source
• Lung 44% (especially bronchogenic cancer)
• Breast 10%
• Kidney 7% (renal cell carcinoma (RCC))
• GI 6%
• Melanoma 3%
route of spread – hematogenous
location – 3/4 are supratentorial, often at grey-white matter junction
diagnosis: metastatic work-up (CXR, CT chest/abdo, abdominal U/S)
• CT with contrast (round, well-circumscribed uniformly lesion)
• consider biopsy (as up to 10% may not be cerebral met in patient with cancer history)
and patient may not have a cancer history
prognosis: median survival with optimal Rx 26-32 weeks but varies depending on primary
treatment: palliative
• single accessible lesion ––> surgical excision + radiation
• multiple lesions ––> whole brain radiation

Astrocytoma
most common primary brain tumour (45-50%)
Table 2. Grading (Multiple Systems)

Kernohan Grade National Brain CT Findings MRI Findings Survival
Tumour Study Group
I Low grade Low density Abnormal signal 8-10 yrs
II Low grade + mass effect + mass effect 7-8 yrs
III Anaplastic Complex Complex 2 yrs

enhancement enhancement
I GBM Necrosis Necrosis < 1 yr

V (ring enhancement) (ring enhancement)
• GBM: anaplastic astro: low grade = 5:3:2
“cystic cerebellar” astrocytoma

• pediatric population, infratentorial
• potentially curable
clinical presentation: middle aged, recent onset of new, worsening H/A,
N/V, +/– focal deficits or symptoms of increased ICP
diagnosis: CT (see Figure 4), MRI with contrast +/– biopsy
therapy:
• surgery: not curative, aim to prolong “quality” survival
• radiotherapy prolongs survival (retrospective evidence)
• chemotherapy (alkylating agents)
compression of heterogenous
ventricles, contrast
midline shift enhancement
ill-defined borders
(infiltrative)
central
necrosis peritumour
edema
Figure 4. Malignant Astrocytoma on CT
Meningioma (see Colour Atlas NS16)

mostly benign (1% malignant), slow-growing, non-infiltrative
common locations: parasagittal convexity, sphenoid wing, falx
presentation: middle aged, symptoms of increased ICP, focal symptoms depend on location
diagnosis: MRI, CT with contrast (see Figure 5)
therapy
• conservative management for slow-growing lesions
• surgery is treatment of choice (curative if complete resection)
• radiotherapy – ineffective
prognosis: > 90% 5-yr survival

homogenous
contrast
enhancement
dural attachment
distinct margins
Figure 5. Meningioma on CT
Vestibular Schwannoma (“Acoustic Neuroma”)

progressive unilateral deafness = acoustic neuroma until proven otherwise
slow-growing (average of 1-10 mm/yr), benign posterior fossa tumour
arises from vestibular component of CN VIII at cerebello-pontine angle (CPA)
clinical presentation: compression of structures in CPA
• often CN VIII symptoms, then V, then VII
• CN VIII: unilateral sensorineural deafness, tinnitus, dysequilibrium
• CN V: facial numbness, loss of corneal reflex
• CN VII: facial weakness (uncommon pre-operatively)
• cerebellum: ataxia, nystagmus
diagnosis
• MRI, CT (contrast enhancing mass in CPA)
• audiogram, BAEP (brainstem auditory evoked potentials), caloric tests
• if bilateral: neurofibromatosis type II
management
• conservative: serial imaging
• surgery: several routes, curable if complete resection (almost always possible)
• stereotactic radiosurgery: gamma-knife, linear accelerator
• significant post-therapy morbidity: CN VII, VIII dysfunction (only significant disability if bilateral),
CSF leak
Pituitary Adenomas (see Colour Atlas NS18)
primarily from anterior pituitary, 3rd-4th decade, M=F
may be functional (secretory) or non-functional
a) mass effects
• H/A
• bitemporal hemianopsia (compression of optic chiasm)
• CN III, IV, V1, V2, VI palsy (compression of cavernous sinus)
b) endocrine effects
• hyperprolactinemia ––> infertility, amenorrhea, galactorrhea, impotence
• ACTH production ––> Cushing’s disease
• GH production ––> acromegaly
• panhypopituitarism (hypothyroidism, hypoadrenalism, hypogonadism)
c) apoplexy (abrupt onset H/A, visual disturbances, ophthalmoplegia, and reduced mental status)
and CSF rhinorrhea (rare presenting signs of pituitary tumour)
diagnosis: formal visual fields, endocrine tests (PRL level, TSH, cortisol, fasting glucose, FSH/LH, IGF-1),
imaging (MRI)
differential: parasellar tumours (e.g. craniopharyngioma, tuberculum sellae meningioma),
carotid aneurysm
treatment
• medical
• dopamine agonists (e.g. bromocriptine) for prolactinoma
• serotonin antagonist (cyproheptadine), inhibition of cortisol production (ketoconazole)
for Cushing’s
• somatostatin analogue (octreotide) +/– bromocriptine for acromegaly
• endocrine replacement therapy
• surgical
• trans-sphenoidal, transethmoidal, transcranial approaches

PUS
Brain Abscess (see Colour Atlas NS8)
etiology
• local spread (adjacent infection)
• otitis media, mastoiditis, sinusitis
• osteomyelitis
• dental abscess
• hematogenous spread
• adults: lung abscess, bronchiectasis, empyema
• children: cyanotic heart disease with R to L shunt (blood is
shunted away from lungs preventing filtration of bacteria)
• immunosuppression (AIDS - toxoplasmosis)
• dural disruption
• surgery, trauma
• congenital defect, e.g. dermal sinus
• pathogens
• Streptococci (most common), often anaerobic or microaerophillic
• Staphylococci (penetrating injury)
• Gram negatives, anaerobes
• Toxoplasmosis and Nocardia in immunocompromised hosts
diagnosis
• focal neurological signs and symptoms
• mass effect, increased ICP and sequelae
• seizures
• +/– signs of systemic infection (mild fever, leukocytosis)
• blood cultures rarely helpful, LP not helpful and contraindicated
• CT scan (see Figure 6)
management
• multiple aspiration of abscess and/or excision, and send for C&S
• excision is preferable if location suitable
• antibiotics
• empirically: vancomycin plus ceftazidime plus metronidazole
or chloramphenicol or rifampin
• after sensitivity results return, revise antibiotics
• anti-convulsants x 1-2 years
ring
enhancement
surrounding
edema
central low
density (pus)
Figure 6. Brain Abscess on CT
Other Causes of Pus

subdural empyema (from sinusitis, mastoiditis - rare, 20% mortality)
meningitis, encephalitis, AIDS, toxoplasmosis (see Neurology Chapter)
osteomyelitis of skull (Pott’s puffy tumour), usually seen with sinusitis
granuloma (TB, sarcoid)
BLOOD
Hematoma/hemorrhage
epidural, subdural hematoma (see Trauma section)
intracerebral, intraventricular hemorrhage, SAH (see Cerebrovascular Disease section)
Vascular Abnormality
aneurysm, AVM (see Cerebrovascular Disease section)

CEREBROVASCULAR DISEASE
ischemic cerebral infarction (80%)
• embolic (heart, carotid artery, aorta) or thrombosis of intracerebral arteries (see Neurology Chapter)
intracranial hemorrhage (20%)
• subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (ICH),
intraventricular hemorrhage (IVH)
SUBARACHNOID HEMORRHAGE (SAH)(see Colour Atlas NS3)
Etiology
trauma (most common)
spontaneous
• aneurysms (75-80%)
• idiopathic (14-22%)
• AVMs (5%)
Risk Factors
pregnancy/parturition in patients with pre-existing AVMs
hypertension
oral contraceptives (OCP)
substance abuse (cigarette smoking; cocaine; alcohol (debatable))
diurnal variation in BP
slight increased risk with advancing age, and with LP/cerebral angiogram in patients with cerebral aneurysm
Clinical Features
sudden onset severe headache: “worst headache of my life”
sentinel/warning leaks
• small SAH with sudden severe H/A +/– transient focal neurological deficit
• blood on CT or LP
• 30-60% of patients with full blown SAH give history suggestive of a warning leak
• diagnosis must be made or excluded the first time it is suspected
vomiting, nausea (increased ICP)
meningismus (neck stiffness, positive Kernig’s and Brudzinski’s sign)
photophobia
decreased level of consciousness
focal deficits: cranial nerve palsy (e.g. III, IV), hemiparesis
ocular hemorrhage in 20-40% (due to sudden increase in ICP)
occasionally exertional (straining, intercourse)
Clinical Course/Natural History
10-15% die before reaching hospital
overall mortality 50-60% in first 30 days
major cause of mortality is rebleeding
• risk of rebleeding: 4% on first day, 15-20% within 2 weeks, 50% by 6 months
• if no rebleed by 6 months chance of rebleeding decreases to same incidence
of unruptured aneurysm (2%)
Diagnosis (see Figure 7)
differential diagnosis: migraine, tension H/A, meningitis, stroke, flu
CT without contrast (see Figure 8)
• 90% sensitivity, 100% specificity
• may be negative if small bleed or presentation delayed several days
• positive history for SAH with negative CT - MUST do LP
• hydrocephalus, IVH, ICH, infarct or large aneurysm may be present
• CT may also suggest site of aneurysm that has bled
lumbar puncture (LP)
• contraindications
• known or suspected intracranial mass
• non-communicating (obstructive) hydrocephalus
• decreased LOC, focal neurological deficit (hemiparesis), papilledema
• coagulopathy (platelets < 50, anticoagulants, etc.)
• correctable if no alternative to LP
• change site - e.g. cisternal or C 1 -C2
• infection at site desired for LP (e.g. epidural abscess)
• CSF colour: bloody initially ––> xanthochromic supernatant (yellow) by 12-48 hours
• high sensitivity
• traumatic tap (false positive): if bloody MUST centrifuge and observe the supernatant,
clear supernatant means traumatic tap and xanthochromia means SAH
cerebral angiography
• demonstrates source of SAH in 80-85% of cases

. . . CONT.
History of sudden severe headache
BP
level of consciousness
neurological assessment limb movements
stiff neck
fundi
conscious, alert, no neurological findings, CT scan drowsy, unconscious,

fundi normal localizing neurological findings
lumbar puncture negative positive
negative positive
CT scan
clear, colorless, blood +/–
no microscopic blood xanthochromic
call neurosurgery
home
angiography
Figure 7. Diagnosis of SAH
blood in blood in
blood in suprasellar interhemispheric
basal cisterns cistern fissure
blood on blood in
surface of sylvian
Figure 8. SAH on CT tentorium fissures
Complications
vasospasm
• constriction of blood vessels in response to high pressure arterial
blood outside vessels in the subarachnoid space (starting day 4 after SAH)
• confusion, decreased LOC, focal neurodeficit (speech or motor)
• detect clinically and/or with angiogram (decreased vessel caliber) or
transcranial doppler (increased blood velocity)
• radiographic evidence seen in 30-70% of arteriograms performed 7 days following SAH (peak incidence)
• symptomatic only in 20-30% of patients with SAH
• onset: 4-14 days post SAH (if patient deteriorates within first 3 days, MUST look for another cause)
• can produce permanent infarcts and death
• a major cause of morbidity and mortality
hydrocephalus (15-20%)
• can be acute or chronic - requiring shunt or drain
neurogenic pulmonary edema
hyponatremia (SIADH, cerebral salt wasting)
diabetes insipidus
cardiac - arrhythmia, MI, CHF

. . . CONT.
Management
bed rest, elevate head (30 degrees), minimal external stimulation
control HTN, avoid hypotension since CBF autoregulation impaired by SAH
prophylactic anticonvulsant: short course of Dilantin (one week)
neuroprotective agent: nimodipine (for vasospasm)
early surgery to prevent rebleed
intraventricular catheter if acute hyrdocephalus present
“Triple H ” therapy for vasospasm: h ypertension, hypervolemia, hemodilution
angioplasty for refractory vasospasm
SPONTANEOUS INTRACEREBRAL HEMORRHAGE (ICH)
Definition
bleeding into brain parenchyma without accompanying trauma
can dissect into ventricular system (IVH) or through cortical surface (SAH)
Etiology
hypertension
vascular anomalies
• aneurysm
• AVM’s and other vascular malformations
• cerebral amyloid angiopathy
• vasculitis
coagulopathies
tumours (1%) – often malignant (eg. glioblastoma multiforme (GBM), lymphoma, metastases)
hemorrhagic transformation of previously ischemic area (infarct)
drugs (amphetamines, cocaine, etc.)
anticoagulants (coumadin, tPA, streptokinase)
idiopathic
Clinical Features
30 day mortality rate is 44%, mostly due to cerebral herniation
gradual onset of symptoms over minutes to hours (unlike ischemic stroke)
H/A, vomiting, decreased LOC are common
specific symptoms depend on location of ICH
• putamen
• contralateral hemiparesis progressing to hemiplegia, coma or death
• thalamus
• contralateral hemisensory loss
• contralateral hemiparesis with internal capsule involvement
• cerebellum
• sudden severe vertigo and vomiting
• ataxia, nystagmus, dysmetria, incoordination
• preserved consciousness until late then sudden death, “talk ‘til death”
• mass effect (tonsillar herniation) ––> surgical emergency
• headache (occipital)
• pons
• quadriplegia
• sudden decreased LOC
• “pinpoint pontine pupils”, disconjugate extraocular movements
• respiratory abnormalities
• hyperthermia
• rapid death
• lobar
• frontal lobe: frontal H/A with contralateral hemiparesis
• parietal lobe: contralateral hemisensory loss and mild hemiparesis
• occipital lobe: ipsilateral eye pain and contralateral homonymous hemianopsia
• temporal lobe: on dominant side, fluent dysplasia with receptive aphasia
Diagnosis
high density blood on CT without contrast
MRI does not show blood immediately - not procedure of choice
Management
medical
• correct HTN, coagulopathy
• control ICP (mannitol, hyperventilate, elevate head of bed)
• anticonvulsants

. . . CONT.
surgical
• craniotomy with evacuation of clot under direct vision, resection of
source of ICH (i.e. AVM, tumour, cavernoma), ventriculostomy to treat hydrocephalus
• indications
• symptomatic
• marked mass effect, raised ICP - evacuate clot, decompress
• rapid deterioration (especially with signs of brainstem compression)
• favorable location, e.g. cerebellar
• young patient (< 50)
• if tumour, AVM, aneurysm, or cavernoma suspected
(resection or clip to decrease risk of rebleed)
• contraindications
• small bleed: minimal symptoms, high GCS (not necessary)
• massive hemorrhage (especially dominant lobe), low GCS/coma, brainstem lost (poor prognosis)
• medical reasons, e.g. very elderly, severe coagulopathy, difficult location,
e.g. basal ganglia, thalamus (poor surgical candidate)
INTRACRANIAL ANEURYSMS(see Colour Atlas NS12, NS13 and NS14)
anterior communicating artery
anterior cerebral artery
middle cerebral artery
internal carotid artery
posterior communicating artery
posterior cerebral artery
superior cerebellar artery
basilar artery
anterior inferior cerebellar artery
posterior inferior cerebellar artery
vertebral artery
Figure 9. Circle of Willis

Illustration by Andree Jenks
Epidemiology
prevalence of about 5%
female > male
20% multiple aneurysms
age 35-65 years
Types
saccular (berry)
• most common type of aneurysm
• located at branch points of major cerebral arteries (Circle of Willis)
• 85-95% located in the carotid system:anterior communicating artery/anterior cerebral artery (30%),
posterior communicating artery (25%), middle cerebral artery (20%)
• 5-15% in posterior circulation (vertebrobasilar)
fusiform
• atherosclerotic
• more common in vertebrobasilar system
• rarely rupture
mycotic
• secondary to any infection of vessel wall
• most commonly Streptococcus and Staphylococcus
(associated with spontaneous bacterial endocarditis (SBE))
. . . CONT.
Clinical Presentation
rupture (SAH, ICH, IVH, subdural blood) – 90%
mass effect (giant aneurysms)
• internal carotid or anterior communicating aneurysm may compress
1) the pituitary stalk or hypothalamus causing hypopituitarism.
2) the optic nerve or chiasma producing a visual field defect
• basilar artery aneurysm may compress the midbrain, pons (limb weakness),
or CN III (impaired eye movements)
• posterior communicating artery aneurysm may produce a CNIII palsy
• intracavernous aneurysms may compress CN’s III, IV, VI, and V1 producing
ophthalmoplegia and facial pain
small infarcts due to distal embolization
seizures
headache without hemorrhage
incidental CT or angiography finding (asymptomatic)
Management
imaging: CT, magnetic resonance angiography (MRA), angiogram
ruptured aneurysms
• initial management of SAH/ICH
• overall trend towards better outcome with early surgery (48-96 hours after SAH)
• surgical clipping is the optimal treatment
• other treatment options: trapping(clipping of proximal and distal vessels),
thrombosing (endovascular technique), wrapping, proximal ligation
unruptured aneurysms
• 1-3% annual risk of rupture: risk dependent on size of aneurysm
• no clear evidence on when to operate: need to weigh life expectancy,
risk of hemorrhage and mortality/morbidity of SAH vs. that of aneurysm surgery
(age, medical risk, etc.)
• treat unruptured aneurysms >10 mm;
consider treating when aneurysm 7-9 mm in middle-aged or younger patients
• follow smaller aneurysms with serial angiography
VASCULAR MALFORMATIONS OF THE NERVOUS SYSTEM

types
• arteriovenous malformations (AVMs)
• cavernous malformations (cavernoma, cavernous hemangioma, angiographically occult
vascular malformation)
• venous angioma
• capillary telangiectasias
• arterio-venous fistula
clinical significance
• principally AVMs and cavernous malformations produce intracranial hemorrhages and seizures
Arteriovenous Malformations (AVMs) (see Colour Atlas NS9, NS10 and NS11)
description
• tangle of abnormal vessels, arteriovenous shunts, with no intervening capillary beds
or brain parenchyma
• congenital, tends to enlarge with age
• male:female = 2:1
• present in younger age group than aneurysms (average age at diagnosis ~ 33 years)
presentation
• ICH (40-60%)
• risk of major bleed: 4% per year
• 10% mortality (versus 50-60% for aneurysmal SAH) per bleed
• 30-50% morbidity (serious neurological deficit) per bleed
• seizures (50%)
• mass effect (e.g. Tic Douloureux 2º to CPA AVM)
• focal neurological signs secondary to ischemia (high flow ––> “steal phenomena”)
• localized headache (infrequent)
• bruit (especially with dural AVMs)
• increased ICP
• may be silent
diagnosis
• MRI (flow void), MRA
• angiography

. . . CONT.
management
• decreases risk of future hemorrhage and seizure
• surgical excision
• endovascular embolisation (glue, balloon)
• stereotactic radiotherapy (for small AVMs; i.e. δ 3 cm in diameter)
• conservative (seizure control if necessary)
Cavernous Malformations
benign vascular hamartoma consisting of irregular thick and thin
walled sinusoidal vascular channels located within the brain
symptoms: H/A, seizure, neurological deficit, ICH
prevalence: 0.3-0.5%
hemorrhage risk may be up to 3.6% per year
diagnosis: MRI usually not seen with angiography
treatment: surgical excision - depending on presentation and location (most are observed)
SPINE
fasciculus cunaetus
fasciculus gracilis
corticospinal tract
spinocerebellar tract
lateral spinothalamic tract
posterior spinal artery
anterior
spinal artery
Figure 10. Anatomy of the Spinal Cord

Illustration by Aimée Warrell
CORD AND ROOT COMPRESSION

Etiology
congenital
• Chiari malformation
acquired
• trauma ––> hematoma, vertebral fracture, subluxation
• herniated disk (nucleus pulposus of disk herniates through ruptured annulus fibrosus)
• spondylosis (degenerative process of the spine which may result in spinal stenosis)
• spondylolisthesis (anterior subluxation of one vertebral body on another)
• infectious (abscess)
• vascular (AVM=rare)
• neoplastic
• extradural (lymphoma, metastases from prostate, lung, breast, kidney)
• intradural
• extramedullary (schwannoma, meningioma, neurofibroma)
• intramedullary (ependymoma, astrocytoma, hemagioblastoma)

SPINE . . . CONT.
Clinical Features
local pain at site of lesion
radiculopathy
• Motor: weakness, wasting, decreased deep tendon reflex in root distribution
• Sensory: dermatomal decreased pinprick sensation, numbness, paresthesiae, pain
• Trophic changes: eg. dry skin (if long-standing radiculopathy)
myelopathy
• LMN signs/symptoms at level of lesion
• UMN signs/symptoms below lesion
• motor: proximal weakness and spasticity of lower extremities, increased reflexes,
clonus, Babinski sign (extenser plantar response), sphincter disturbance
• sensory: findings may be minimal (reduced vibration, proprioception), +/– Lhermitte sign
LMN (Lower Motor Neuron) UMN (Upper Motor Neuron)
Tone Flaccid Spastic
Reflexes Decreased Increased

Plantar Response Extensor Extensor
Muscles Atrophy, fasciculations Atrophy

arms flexed, legs extended
C2 C2
C3 C3
C4 T1 C4
C5 C5
C6 T2 C6C7 C8
C6 T3
T4
C7
T5
T6
C8 T7
L1 T8 L1
T9 L2
L2 T10 L3
T11
L4
T12
L3 L5
S4 L1
L4 L2
S2
L3
S3
L5 S1 L4
L5
Figure 11. Dermatomes

Illustration by Glen Oomen
Investigations
plain x-ray of spine
CT, MRI
myelogram
electromyography (EMG), electrophysiology
Management
for disc herniation see Lumbar Disk Syndrome
unstable fractures may require surgical intervention
neoplasms are treated with a combination of surgery and radiation therapy

SPINE . . . CONT.
SPINAL CORD SYNDROMES(see Neurology Chapter)

complete spinal cord lesion
• no preservation of motor/sensory function at > 3 segments below lesion/injury
incomplete spinal cord lesion
• any residual function at > 3 segments below lesion
• signs include sensory/motor function in lower limbs and “sacral sparing”
(perianal sensation, voluntary rectal sphincter contraction)
• syndromes include Brown-Sequard’s, central cord, anterior cord and posterior cord syndrome
Brown-Sequard’s Syndrome (Hemisection of cord)
causes include
• penetrating trauma
• extrinsic compression
clinical features
• ipsilateral weakness (UMN lesion) below lesion
• contralateral pain and temperature sensory deficits (deficits are 1 to 2 levels below injury)
• ipsilateral reduction in proprioception and vibration sense below lesion
• light touch preserved
best prognosis of cord injuries (90% independently ambulate and have good sphincter control)
Central Cord Syndrome
most common incomplete spinal cord injury syndrome
cause: spinal extension injury, particularly with pre-existing cervical spondylosis
clinical features
• weakness upper (LMN lesion) > lower (UMN lesion) extremities; more pronounced in the hands
• dissociated sensory loss
• “vest” or bilateral suspended pain and temperature deficit with sacral sparing
• spared touch, joint position and vibration sensation
• sphincter dysfunction (usually urinary retention)
50% recover enough LE function to ambulate
hand recovery variable
Anterior Cord Syndrome
causes
• anterior cord compression or anterior spinal artery occlusion
clinical features
• dissociated sensory loss
• bilateral pain and temperature deficit below lesion
• spared touch, joint position and vibration sensation
• bilateral paraplegia (UMN below and LMN at level of the lesion)
• sphincter dysfunction (urinary retention)
worst prognosis, only 10-20% recover functional motor control
Posterior Cord Syndrome (~rare)
causes
• trauma
• posterior spinal artery infarct
clinical features
• joint position and vibration sensation loss
• pain and paresthesias in neck, upper arms, torso
• mild paresis of upper extremities
SYRINGOMYELIA(see Colour Atlas NS22)
“syrinx”, cavitation of spinal cord substance
Etiology
idiopathic
post-traumatic
associated with
• craniovertebral anomalies (congenital) e.g. Chiari malformation or myelomeningocele
• intramedullary tumours
• arachnoiditis (traumatic)
Presentation
suspended, dissociated sensory loss
• pain and temperature loss in a cape-like distribution at level of cervical syrinx
• preserved light touch and other modalities
LMN arm/hand weakness or wasting
may have spastic weakness of legs
may have hydrocephalus, often asymptomatic
painless arthropathies (Charcot’s joints)

SPINE . . . CONT.
Investigations
MRI is best method
myelogram with delayed CT
Management
conservative if NOT progressing
shunt (syringosubarachnoid, synringoperitoneal or syringopleural)
if associated with Chiari malformation
• first decompress posterior fossa, if not successful then shunt
progressive deterioration in >1/3 despite therapy
CERVICAL DISC SYNDROME
Etiology
most common levels
• C5-C6 (C6 root) more common vs. C6-C7 (C7 root)
less common, but important with respect to activities of daily living
• C4-5 (C5 root), C7-T1 (C8 root)
Table 3. Lateral Cervical Disc Syndrome

C4-5 C5-6 C6-7 C7-T1
Root Involved C5 C6 C7 C8
Motor Deltoid Biceps Triceps Digital flexors
Supraspinatus Intrinsics
Biceps
Reflex No change Biceps Triceps Finger jerk
Sensory Shoulder Thumb Middle finger Ring finger,
little finger
Clinical Features
lateral disc protrusion compresses nerve root
• pain down arm in nerve root distribution, worse with neck extension
• referred parascapular pain
• +/– nerve conduction velocity abnormalities
central cervical disc protrusion compresses spinal cord as well as nerve roots
shoulder lesion
thoracic outlet syndrome (including Pancoast tumour)
cervical spine tumour
peripheral nerve lesion (e.g. carpal tunnel)
acute brachial neuritis
myocardial infarction (MI) (left C6 radiculopathy)
Investigations
C-spine x-ray
CT, MRI (procedure of choice)
EMG, nerve conduction studies
Management
conservative (recovery in 95%)
• NSAIDs, collar, traction may help
• most patients get better spontaneously in 4 to 8 weeks
surgical indications
• intractable pain despite adequate conservative treatment for > 3 months
• progressive neurological deficit
• anterior cervical discectomy is usual surgical choice

SPINE . . . CONT.
LUMBAR DISC SYNDROME(see Colour Atlas NS20)

Etiology
protrusion/herniation of nucleus pulposus
• laterally: compressing nerve root
• centrally: compressing cauda equina
common: (>95% of herniated lumbar disks): L4-5 (L5 root), L5-S1 (S1 root)
uncommon: L3-4 (L4 root)
Table 4. Lateral Lumbar Disk Syndromes

L3-4 L4-5 L5-S1
root Involved L4 L5 S1
Pain Femoral pattern Sciatic pattern Sciatic pattern
Motor Quads (knee extension) Tibialis anterior(dorsiflexion), Gastrocnemius, soleus
Extensor hallusis longus (plantar flexion)
(hallux extension)
Reflex Knee jerk Medial Ankle jerk
Hamstrings
Sensory Medial leg Dorsal foot to hallux, lateral leg Lateral foot
Relative Incidence < 10% 45% 45%
Clinical Features
leg pain > back pain
limited back movement (especially forward flexion)
symptoms and signs of radiculopathy
• pain in root distribution (worse with movement, valsalva)
• dermatomal sensory deficit
• LMN weakness
• reduced deep tendon reflex
• +/– reflex paravertebral muscle spasm (functional scoliosis, loss of lordosis)
nerve root tension signs:
• straight leg raise (SLR: Lasegue’s test), crossed SLR ––> L5, S1 roots
• femoral stretch ––> L4 root
spinal: stenosis, tumour, spondylolisthesis (see Colour Atlas NS21)
leg: spinal stenosis, arthritic hip, sciatic nerve lesion (e.g. tumour)
pelvic bones: tumour
functional /nonorganic
Investigations
X-ray spine (only to rule out other lesions)
CT
MRI
myelogram and post-myelogram CT (if surgery contemplated and plain CT not conclusive)
Management
conservative
• no bedrest unless severe radicular symptoms
• activity modification (reduce sitting, lifting)
• physiotherapy (PT), exercise programs
• analgesics (acetominophen, NSAIDs)
• patient education
• 95% improve spontaneously within 4 to 8 weeks
• intractable leg pain despite adequate conservative treatment for > 3 months
• disabling neurological deficit
• progressive neurological deficit
• cauda equina syndrome

SPINE . . . CONT.
CAUDA EQUINA SYNDROME

Etiology
secondary to compression of lumbosacral nerve roots below conus medullaris
extrinsic tumour, carcinomatous meningitis, arachnoiditis, spinal stenosis,
central posterior lumbar disc herniation
Clinical Features
motor
• weakness/paraparesis in multiple root distribution
• reduced reflexes (usually achilles reflex)
• sphincter disturbace (urinary retention which can lead to overflow incontinence,
and fecal incontinence due to loss of anal sphincter tone)
sensory
• multiple dermatome, bilateral sensory loss or pain
• saddle anesthesia (most common sensory deficit)
other
• sexual dysfunction (late finding)
Management
requires urgent investigation and decompression to preserve bowel and bladder function
LUMBAR SPINAL STENOSIS

etiology
• congenital narrowing of spinal canal combined with degenerative changes
(herniated disk, hypertrophied facet joints and ligaments)
• neurogenic claudication (“pseudoclaudication”)
• neurologic exam may be normal, including straight leg raise test
• symptoms relieved only by changing position (leaning forward, sitting down)
investigations
• MRI, CT
treatment
• conservative (NSAIDS, PT)
• surgical (laminectomy with root decompression)
See RED FLAGS FOR BACKPAIN (see Family Medicine Chapter)
the presence of any or several of these red flags warrants thorough investigations to determine
the cause of the back pain as it may require immediate intervention (eg. cauda equina syndrome)
conditions to keep in mind
• neoplasm
• infection
• fracture
• Cauda Equina Syndrome

TRAUMA (BRAIN AND SPINAL CORD)
HEAD INJURY
Scalp Injury
rich blood supply
considerable blood loss (vessels contract poorly when ruptured)
minimal risk of infection due to rich vascularity
Skull Fractures
depressed fractures ––> double density on skull x-ray
• simple fractures
• compound fractures ––> increased risk of infection
internal fractures into sinus ––> meningitis, pneumocranium
basal skull fractures ––> not readily seen on x-ray, rely on clinical signs
• retroauricular ecchymoses (Battle’s sign)
• periorbital ecchymoses (raccoon eyes)
• hemotympanum
• CSF rhinorrhea, otorrhea
• suspect with Lefort II or III midface fracture
Cranial Nerve Injury
most commonly olfactory
Arterial Injury
e.g. carotid-cavernous (C-C) fistula, carotid/vertebral artery dissection
INTRACRANIAL BLEEDING
Extradural (“Epidural”) Hematoma (see Figure 12) (see Colour Atlas NS2)
young adult, male > female
temporal-parietal skull fracture ––> ruptured middle meningeal artery
symptoms: lateral transtentorial herniation, classically there is lucid interval between concussion and coma
prognosis: good with optimal prompt management, since the brain is often not damaged
CT without contrast: high density biconvex mass against skull, usually with uniform density
and sharp margins “lens-shaped”
management: head elevation, mannitol pre-operatively, evacuation with small craniotomy
compression of
ventricles
blood
(midline shift)
Figure 12. Extradural Hematoma on CT
Subdural Hematoma (see Figure 13) (see Colour Atlas NS4)

acute
• arise from rupture of a vessels that bridge the surface of the cerebral hemisphere and the skull
(e.g. cortical artery, large vein, or venous sinus) due to violent trauma
• prognosis: poor overall, since the brain is often injured
• CT: high density concave mass usually less uniform, less dense and more diffuse
than extradural hematoma
• management: craniotomy

TRAUMA (BRAIN AND SPINAL CORD). . . CONT.
chronic (see Colour Atlas NS5 and NS6)
• often due to minor injuries or no history of injury
• several weeks after injury
• the clot from the original bleed liquifies and becomes bounded by a thick, friable,
vascularized outer membrane and a thin, lucent inner membrane.
• symptoms of raised ICP and sometimes seizures, progressive dementia, gait problem,
obtundation out of proportion to focal neurological deficit, “the great imitator”
(of dementia, tumours, etc.), normal pressure hyrocephalus (NPH) (see Neurology Chapter)
• risk factors: older, alcoholic, patients with CSF shunts, anticoagulants
• expands due to repeated bleeding
• prognosis: brain usually undamaged, however, recurrent bleeding from the outer membrane leads
to expansion of the hematoma, increased ICP, shift of the cerebral hemispheres,
transtentorial herniation, and death
• CT: low density (liquefied clot) concave mass
• management: burr hole drainage, craniotomy if recurrent
compression of ventricles
old blood midline shift
blood
Figure 13. Subdural Hematoma on CT
Traumatic Intracerebral Hemorrhage

any size, any part of brain, may be multiple
immediate or delayed
frontal and temporal lobes most commonly injured (by coup/contre-coup mechanism)
BRAIN INJURY
Primary Impact Injury
mechanism of injury determines pathology: i.e. with penetrating injuries, gun shot wounds
• low velocity ––> local damage
• high velocity ––> distant damage possible (due to wave of compression)
concussion
• American Academy of Neurology (AAN) definition: “a trauma-induced alteration in mental status
that may or may not involve loss of consciousness”
• AAN Classification:
Grade 1: altered mental status <15 min
Grade 2: altered mental status >15 min
Grade 3: any loss of consciousness
• no parenchymal abnormalities on CT
coup (damage at site of blow)
contre-coup (damage at opposite site of blow)
• acute decompression causes cavitation
• followed by a wave of acute compression
contusion (hemorrhagic) (see Colour Atlas NS7)
• high density areas on CT with little mass effect
• commonly occurs with brain impact on bony prominences (falx, sphenoid wing, floor of frontal
and temporal fossae)
diffuse axonal injury (diffuse axonal shearing)
• may tear blood vessels->hemorrhagic foci (may not be proportionate to axonal injury)
• wide variety of damage results
• all brain injury causes shear
• often the cause of decreased LOC if no space occupying lesion on CT

Secondary Pathologic Processes
1/3 who die in hospital after head injury were able to talk after the injury
delayed and progressive injury to the brain due to:
• edema
• intracranial hemorrhages
• ischemia/infarction
• raised ICP (which leads to (decreased cerebral perfusion pressure (CPP) and herniation)
Extracranial Conditions
hypoxemia
• trauma: chest, upper airway, brainstem
• exceptionally damaging to traumatized brain cells
• leads to ischemia, raised ICP
hypercarbia
• leads to raised ICP (secondary to vasodilation)
systemic hypotension
• caused by blood loss, not by head injury (e.g. ruptured spleen)
• cerebral autoregulation lost in trauma
• leads to decreased CPP, ischemia
hyperpyrexia
• leads to increased brain metabolic demands
fluid and electrolyte imbalance
• iatrogenic (most common)
• syndrome of inappropriate antidiuretic hormone (SIADH) secretion (from head injury)
• diabetes insipidus (DI) (from head injury)
• may lead to cerebral edema and raised ICP
fat embolism
• multiple trauma
• long bone fractures
• petechiae and edema
• hypoxia a key feature due to pulmonary effects
• decreased LOC, seizures
coagulopathy
post-traumatic carotid artery dissection
Intracranial Conditions
raised ICP due to
• traumatic cerebral edema OR traumatic intracranial hemorrhage
raised ICP results in
• decreased cerebral perfusion (CPP = MAP – ICP)
• +/– herniation
LATE COMPLICATIONS OF HEAD INJURY
Seizures
5% of head injury patients develop seizures
incidence related to severity and location of injury ––> increased with local brain damage
or intracranial hemorrhage
post-traumatic seizure may be immediate, early, or late
presence of early (within first week) post traumatic seizure, incidence of later seizures rises to 25%
Meningitis
associated with CSF leak from nose or ear
Hydrocephalus
acute hydrocephalus or delayed normal pressure hydrocephalus (NPH)
SPINE INJURY
Vertebral Column (bone, discs, ligaments)
stable fracture
• compression fracture
unstable fracture
• burst fracture (note: not all burst fractures are unstable)
• dislocation
“special” fractures
• Odontoid (Type I, II, III): Type II is unstable and most require fixation
• Jefferson (fractures in ring of C1): due to axial loading (C1)
• Hangman’s (fractured C2 pedicles at pars interarticularis): due to hyper-extension (C2)

Spinal Cord
cord injury with initial bony or ligamentous trauma or after moving an unstable vertebral column
complete
• no preservation of sensory/motor function below lesion
• no recovery
incomplete lesions (see Spinal Cord Syndromes section)
Nerve Roots
avulsion, e.g. brachial plexus in motorcycle accident
TRAUMA MANAGEMENT(see Emergency Medicine Chapter)
Aims
recovery from primary injury
prevent further damage from secondary pathologic processes
Initial Management
ABC’s of trauma management take priority
A - airway
• ensure that there is no airway obstruction caused by local trauma to the larynx or trachea
• C-spine immobilization to prevent further spinal cord injury (immobilize with collar,
sandbags, fracture board, skull tong or halo traction)
• if intubation is indicated emergently and cervical fracture cannot be ruled
out, orotracheal intubation with in-line neck stabilization is used
B - breathing
• ensure adequate oxygen supply by monitoring with a pulse oximeter
• respiration is often depressed after brain injury when consciousness is depressed
• ventilate with oxygen (100%) if necessary
C - circulation
• differentiate hypotensive shock (BP low, HR high) from neurogenic shock (BP low, HR low)
• ensure adequate perfusion of spinal cord and manage neurogenic shock (dopamine, IV fluids, MAST)
suspect spinal cord injury with weakness, numbness, spine pain, head injury, high energy injury
or multisystem injuries
rule out spinal fracture (cervical, thoracic, lumbar)
5-10% of patients with spinal injuries have injuries at other levels
Neurological Assessment
mini history
• period of LOC
• post traumatic amnesia
• loss of sensation/function
neurological exam
• head and neck (lacerations, bruises, basal skull fracture signs, facial fractures, foreign bodies)
• spine (palpable deformity, midline pain/tenderness)
• Glasgow Coma Scale (GCS) (see Emergency Medicine and Neurology Chapters)
• eyes (pupillary size and reactivity)
• brainstem (breathing pattern, CN palsies)
• motor exam, sensory exam (only if GCS is 15), reflexes
• cranial nerve exam
• sphincter tone
• record and repeat neurological exam at regular intervals
Initial Investigations
CT head and upper C-spine (whole C-spine if patient unconscious)
ABG, CBC, drug screen (especially alcohol)
C,T,L-spine x-rays
• AP, lateral, odontoid views for C-spine
• must see C1 to C7 and C7-T1 interspace (swimmer’s view if necessary) or CT
• ABCS - Alignment, Bone, Cartilage, Soft tissues (see Orthopedics Chapter)
chest and abdominal x-ray as indicated
Late Management
treatment for minor head injury
• observation over 24-48 hours
• wake every hour
• judicious use of sedatives or pain killers during this monitoring period
treatment for severe head injury
• clear airway and ensure breathing (intubate if necessary)
• secure C-spine
• maintain adequate BP
• monitor to detect complications (Glasgow Coma Scale, CT, ICP)
• manage increased ICP if present
• elevation of head
• hyperventilation (target PCO 2 32-35 torr)
• mannitol (temporary preoperative measure)
• remove hematoma if present
treatment of spinal injury
• reduce dislocation if present by traction or surgery
• stabilize spine if unstable (halo vest, fusion, etc.)
• further investigations (CT, tomogram, myelogram, MRI) to rule out cord compression
• emergent surgical decompression and/or fusion if necessary; i.e. patient with neurological deterioration
• more likely to be beneficial in incomplete cord injury
• emergent surgery contraindicated for: complete spinal cord injury > 24 hours,
medically unstable patient, and central cord syndrome
which patients should be admitted to hospital?
• skull fracture
• indirect signs of basal skull fracture
• confusion, impaired consciousness
• focal neurological signs
• extreme headache, vomiting
• seizures
• concussion with > 5 minutes amnesia
• unstable spine
• use of alcohol
• social (i.e. no friend/relative to monitor for next 24 hours)
• if there is any doubt, especially with children
which patients need CT head or transfer to a neurosurgical center?
• remains unconscious after resuscitation
• focal neurological signs
• deteriorating
KEY POINTS
never do lumbar puncture in head injury
all patients with head injury have C-spine injury until proven otherwise
don’t blame coma on alcohol - there may also be a hematoma
low BP after head injury means injury elsewhere
must clear spine both radiologically AND clinically
PERIPHERAL NERVES
INJURY
Classification and Clinical Course
neuropraxia: nerve intact but fails to function, recovery within hours to days
axonotomesis: axon disrupted but nerve sheath intact ––> Wallerian degeneration
(of axon segment distal to injury) ––> recovery 1 mm/day
neurotmesis: nerve completely severed, need surgical repair for recovery
Management
electrophysiological studies (EMG, nerve conduction velocities (NCV))
may be helpful in assessing nerve integrity
surgical repair unless nerve is known to be intact
delay surgical repair for a few weeks (unless first 2 conditions met) to allow
• clean wound
• optimal surgical facilities
• optimal cell metabolism
• possible spontaneous recovery/regeneration
microsurgery: suture nerve sheaths +/– nerve graft
ENTRAPMENT
General
nerve compressed by nearby anatomic structures
often secondary to localized, repetitive mechanical trauma with additional vascular injury to nerve
consider systemic causes
• rheumatoid arthritis
• diabetes mellitus
• hypothyroid
• acromegaly
• vasculitis
• amyloidosis
• pregnancy
symptoms
• pain distal (occasional proximal) to lesion
• burning paresthesia/dysesthesia
• sensory loss in nerve distribution
• muscle weakness/wasting (advanced cases)

PERIPHERAL NERVES . . . CONT.
Carpal Tunnel Syndrome (CTS)
etiology
• most common entrapment neuropathy
• median nerve entrapment at wrist, usually bilateral
• female:male = 4:1
presentation
• classically: patient awakened at night with numb/painful hand, relieved by shaking/dangling/rubbing
• distribution: radial 3.5 fingers
• decreased light touch, 2 point discrimination, especially finger tips
• job/hobby related repetitive trauma, especially forced wrist flexion
• advanced cases: wasting/weakness of thenar muscles, especially abductor pollicis brevis
diagnosis
• history, physical
• +/– Tinel’s sign (tingling sensation on percussion of nerve)
• +/– Phalen’s sign (wrist flexion)
• confirm with nerve conduction velocities (NCV), EMG pre-operatively
management
• conservative
• neutral wrist splints (bedtime)
• NSAIDs
• surgical
• release of flexor retinaculum
• indications for surgery: refractory pain, +++ sensory loss, muscle atrophy
Ulnar Nerve Entrapment at Elbow
second most common entrapment neuropathy
may be entrapped at several locations
• behind medial epicondyle
• at medial intermuscular septum
• distal to elbow at cubital tunnel
presentation
• sensory: pain, numbness in ulnar 1.5 fingers
• wasting of interossei (especially first dorsal interosseous ––> thumb web space)
• weakness (especially abduction of index finger)
diagnosis
• history, physical
• NCV: conduction delay across elbow
management
• conservative: prevent repeated minor trauma (e.g. leaning on elbow or sleeping
with hand under head), elbow pads, NSAIDs
• surgical: nerve decompression and transposition to front of elbow
Less Common Entrapments
common peroneal nerve
• superficial and fixed behind fibular head
• sensitive to trauma (e.g. fracture of fibular head)
• motor: decreased foot and toe extension (“drop foot”), decreased ankle eversion
• sensory: decreased lateral foot and dorsum (less common)
• distinguish from L5 radiculopathy
lateral cutaneous nerve of the thigh (“meralgia paraesthetica”) – pain over anterior/lateral aspect
of thigh (common in obese people,patients post-iliac bone grafts)
motor branch of ulnar nerve at wrist (Guyon’s canal)
posterior tibial nerve (“Tarsal Tunnel”)
radial nerve (“Saturday Night Palsy”) (more often a pressure palsy)
thoracic outlet syndrome
• compression of the lower portion of the brachial plexus (which supplies the ulnar nerve)
as it emerges from the axilla, through a narrow passage beneath the clavicle and
between the anterior and middle scalene muscles, while resting on the first rib
• hard to diagnose
• rule out Pancoast tumour (associated with Horner’s Syndrome) as this may
mimic thoracic outlet syndrome (do chest x-ray)

PAIN SYNDROMES
PHYSIOLOGY OF PAIN
peripheral sensors: free nerve endings
neurotransmitters: substance p, endorphins
gate control theory:
• summation of inhibitory and excitatory afferent input at the synapse to the
second order neuron of the spinothalamic tract determines amount of pain felt
• segmental and higher center influence the perception of pain
perception
• thalamus to cerebral cortex ––> awareness
• personality and mood ––> intensity
• spinothalamic tract, reticular formation and limbic system ––> unpleasant, emotional aspect
MEDICAL TREATMENT
acute pain (< 2-3 weeks duration): analgesics +/– tranquilizers
benign chronic pain: antidepressants, anticonvulsants, topical (capsicin), NOT narcotics or sedatives
malignant chronic pain: strong narcotics in frequent, small doses
SURGICAL TREATMENT
Central
stereotactic thalamotomy
• remove spinoreticular relay
• indication: malignancy of head, neck or brachial plexus
deep brain stimulation
• stimulation of electrodes placed in periventricular gray matter, sensory relay nucleus of thalamus
or internal capsule +/– radiocontrolled stimulator subcutaneously
hypophysectomy (chemical: uses alcohol)
• unknown mechanism
• indication: metastatic disease
dorsal root entry zone lesions
• indication: deafferentation pain (brachial plexus avulsion, postherpetic neuralgia)
• major complication: ipsilateral leg weakness
percutaneous anterolateral cordotomy
• lesion of spinothalamic tract giving pain relief contralaterally
• 90% patients respond
• complications: respiratory difficulties and ipsilateral limb weakness
commisural myelotomy
• division of decussating pain fibers for temporary pain relief
• indication: terminal malignancy
dorsal column stimulation
• percutaneous electrodes in epidural space
• indication: intractable chronic pain
Peripheral
nerve blocks
• dermatomal pain relief, loss of motor and sympathetic function
• permanent: neurolytics (phenol, alcohol)
• temporary: local anesthetics
• paravertebral or peripheral: NOT neurolytics ––> painful neuritis
transcutaneous electrical nerve stimulation (TENS)
• prolonged stimulation of large diameter fibers inhibiting
ascending pain fibers or via higher centers
dorsal rhizotomy
• dorsal root division
• infrequently done: high failure rate and short effect
denervation of facet joints
• cut posterior ramus of spinal nerves
• temporary: relief until nerve regrows

PAIN SYNDROMES. . . CONT.
TIC DOLOUREUX
Clinical Features
older age
location: V2 + V3 > V2 > V3 > V1 + V2 > V1 + V2 + V3 > V1
R>L
F:M=2:1
short, sharp jabs in series, last a few seconds to a few minutes
violent, terrible, “lightning”, “electrical”, lancinating pain, distinguish from burning pain
may be weeks or months of remission
neurological examination normal
if other neurological findings - consider other diagnosis
triggers: areas on face (especially around mouth), wind, eating, drinking, talking (proprioceptive fibers)
Diagnosis
history
rule out structural lesion affecting trigeminal nerve (tumour, aneurysm) - CT, MRI
may be due to multiple sclerosis (especially in younger patients)
Management
pharmacologic
• drug of choice is carbamazepine 200 mg tabs, 3-5 per day
• phenytoin is second choice
• baclofen (potentiates carbamazepine effect)
• other: sodium valproate, gabopentin, lomotrigine
• response to medication is almost diagnostic
• eventually becomes refractory
procedures
• percutaneous thermocoagulation of CN V
• percutaneous balloon compression of CN VI ganglion
• glycerol injection into Meckel’s cave (trigeminal cistern)
• division/avulsion of branches of CN V in face
• microvascular decompression of CN V at pons
REFLEX SYMPATHETIC DYSTROPHY (CAUSALGIA)
Etiology
incomplete peripheral nerve injury in nerve with sympathetic fibers
Clinical Features
intense, continuous, burning pain
touch worsens pain
red, warm, dry and swollen skin initially (sympathetic overactivity)
cool, clammy, glossy and atrophic skin in advanced stages
Treatment
sympathetic nerve blockade: medical or surgical
POSTHERPETIC NEURALGIA
Etiology
reactivation of latent varicella zoster virus that lay dormant in dorsal root or gasserian ganglion
Clinical Features
burning, constant pain
severe, sharp paroxysmal twinges over area of affected sensory neurons
touch worsens pain
Treatment
no specific treatment and is difficult to treat
medical: antidepressants, carbamazepine, ethychloride spray (temporary relief), topical (capsicin,
promising treatment that works by blocking substance p), steroid injection or topical in eye during
acute eruptive phase (decreases severity of pain and decreases corneal scar), gabopentin
surgical: percutaneous cordotomy, possible dorsal root entry zone lesion
THALAMIC PAIN
Clinical Features
begins with hemianesthesia (due to thalamic infarction or hemorrhage)
becomes diffuse, burning pain contralateral to lesion
worse with light touch (e.g. clothing)
may have prior history of thalamic stereotactic procedure for movement disorder
Treatment
medical: poor response to medication
surgical: stereotactic thalamic stimulation but may increase sensory deficit

PAIN SYNDROMES. . . CONT.
PHANTOM LIMB PAIN
Etiology
complication of 10 % amputation patients
Clinical Features
continuous burning
pain from some point on missing limb
Treatment (see Postherpetic Neuralgia section)
PEDIATRIC NEUROSURGERY
SPINA BIFIDA
Spina Bifida Occulta
definition
• congenital absence of a spinous process and variable amounts of lamina
• no visible exposure of meninges or neural tissue
epidemiology
• 20-30% of the general population
etiology
• failure of fusion of the posterior arch
clinical features
• no obvious external markings
• no obvious clinical signs
• presence of lumbosacral cutaneous abnormalities (dimple, sinus, port- wine stain, or hair tuft)
should increase suspicion of an underlying anomaly (lipoma, dermoid, diastomatomyelia)
investigations
• plain film: absence of the spinous process along with minor amounts of the neural arch
• most common at L5 or S1
treatment and results
• requires no treatment
Meningocele (Spina Bifida Aperta)
definition
• a defect consisting of a herniation of meningeal tissue and CSF
through a defect in the spine
etiology
• 2 theories
• primary failure of neural tube closure
• rupture of a previously closed neural tube due to overdistension (Gardner; unpopular theory)
clinical features
• most common in lumbosacral area
• usually no disability
• low incidence of associated anomalies and hydrocephalus
investigations
• plain films, CT, MRI, U/S, ECHO, genitourinary (GU) investigations
• MRI of entire spinal column because increased liklihood of additioal anomalies
treatment and results
• surgical excision (excellent results)
Myelomeningocele
definition
• a defect consisting of a herniation of meningeal tissue and CNS tissue through a defect in the spine
etiology - same as meningocele
clinical features
• sensory and motor changes distal to anatomic level producing varying degrees of weakness,
anesthesia, urine and fecal incontinence
• 65-85% of patients with myelomeningocele have hydrocephalus
• most patients with myelomeningocele have Type II Chiari malformation
investigations
• plain films, CT, MRI, U/S, ECHO, GU investigations
• preserve intellectual, sensory and motor functions
• prevent CNS infections
results
• operative mortality close to 0%
• 95% 2 year survival
• 80% have IQ in > 80 (but most are 80-95)
• 40-85% ambulatory
• 3-10% have normal urinary continence
• most common cause of early mortality are complications from chiari malformation
(respiratory arrest and aspiration), whereas late mortality is due to shunt malfunction
PEDIATRIC NEUROSURGERY. . . CONT.
meninges meninges
spinal cord
hair tuft
roots
Spina Bifida Occulta Meningocele Myelomeningocele
Figure 14. Diagram Showing Spina Bifida Occulta,

Meningocele, Myelomeningocele
Illustration by Jen Polk
INTRAVENTRICULAR HEMORRHAGE (IVH)

Definition
a disease of the premature, low-birth weight infant
consists of hemorrhage into the germinal matrix of the developing brain
Classification (based on ultrasound or CT)
Grade I: germinal matrix (subependymal) hemorrhage only
Grade II: blood filling lateral ventricles without distention
Grade III: blood filling and distending lateral ventricles
Grade IV: hemorrhage with parenchymal involvement (ICH)
Epidemiology
occurs in 45% of infants born with a birth weight of 1500 g or less
uncommon after 32 weeks of gestation
essentially nonexistent in full-term infants
Predisposing Factors
low gestational age
high cerebral blood flow and cerebral perfusion pressure
• birth asphyxia, resuscitation
• respiratory distress syndrome
• rapid volume re-expansion
• hypoxemia, hypercarbia, acidosis
• seizure, pneumothorax
Investigations
ultrasound is the method of choice to screen for ICH/IVH
should be done routinely to screen preterm babies < 24 weeks gestation or < 1,500 gm
CT scan will also show ICH and IVH as described above
Treatment
best to withhold tapping ventricles, ventriculostomies, and shunting until blood has cleared
if progressive hydrocephalus develops, then
• serial LP
• acetazolamide (25-100 mg/kg/day) and Lasix (2 mg/kg/day)
• ventriculostomy
• shunt (low pressure)
Results
grade I-III hemorrhages can do as well as children without hemorrhages
grade IV: only 50% chance of attaining normal life status
prognosis more dependent on the degree of asphyxia than on hydrocephalus
HYDROCEPHALUS IN PEDIATRICS
Etiology
congenital
• aqueductal anomalies
• primary aqueductal stenosis in infancy
• secondary gliosis due to intrauterine viral infections (mumps, varicella, TORCH)
or germinal plate hemorrhage
• Dandy Walker (2-4%)
• Chiari malformation, especially Type II
• myelomeningocele
acquired
• post meningitis
• post hemorrhage (SAH, IVH)
• masses (vascular malformation, neoplastic)
Clinical Features
symptoms and signs of hydrocephalus are age related in pediatrics
increased head circumference (HC)
irritability, lethargy, poor feeding and vomiting
bulging anterior fontanelle
widened cranial sutures
”cracked pot” sound on cranial percussion
scalp vein dilation (increased collateral venous drainage)
sunset sign - forced downward deviation of eyes
episodic bradycardia and apnea
Management
similar to adults (see Hydrocephalus section)
DANDY-WALKER MALFORMATION
Definition
atresia of foramina of Magendie and Luschka, resulting in
• complete or incomplete agenesis of the cerebellar vermis with
widely separated, hypoplastic cerebellar hemisphere
• posterior fossa cyst
• dilatation of 4th ventricle
• enlarged posterior fossa
associated anomalies
• hydrocephalus (90%)
• agenesis of corpus callosum (17%)
• occipital encephalocele (7%)
Epidemiology
2-4% of pediatric hydrocephalus
Clinical Features
20% are asymptomatic
only 50% have normal IQ
symptoms and signs of hydrocephalus combined with a prominent occiput in infancy
ataxia, spasticity, poor fine motor control common in childhood
seizures occur 15%
Treatment
asymptomatic patients require no treatment
associated hydrocephalus requires surgical treatment

CHIARI MALFORMATIONS
Definition
malformations at the medullary-spinal junction
Clinical Features
Type I (cerebellar ectopia): cerebellar tonsils lie below the level of the foramen magnum
• average age at presentation 41 years
• brain compression: suboccipital headache, nystagmus, ataxia, spastic quadraparesis
• foramen magnum compression syndrome (22%): ataxia, corticospinal and sensory deficits,
cerebellar signs, lower cranial nerve palsies
• central cord syndrome (65%): dissociated sensory loss, occasional segmental weakness
and long tract signs
• cerebellar syndrome (11%): truncal/limb ataxia, nystagmus, dysarthria
• hydrocephalus (10%)
• syringomyelia (50%)
Type II: part of cerebellar vermis, medulla and 4th ventricle extend through the foramen magnum often
to midcervical region
• present in infancy
• findings due to brain stem and lower cranial nerve dysfunction: swallowing difficulties, apneic spells,
stridor, aspiration, arm weakness
• syringomyelia, hydrocephalus in > 80%
Type I and Type II: if symptomatic
Investigations
MRI or CT myelography
Treatment
surgical decompression - indications
• Type I: symptomatic patients (early surgery recommended)
• Type II: neurogenic dysphagia, stridor, apneic spells
CRANIOSYNOSTOSIS
Definition
premature closure of the cranial suture(s)
Classification
sagittal (most common)
• long narrow head with ridging sagittal suture (scaphocephaly)
coronal
• expansion in superior and lateral direction (brachiocephaly)
• bilateral coronal craniosynostosis often associated with Crouzon’s and Apert’s syndrome
lambdoid - least common
metopic (forehead)
multiple suture synostosis or pansynostosis
Epidemiology
0.4/1,000 live births
most cases are sporadic
familial incidence is 2% of sagittal and 8% of coronal synostosis
Clinical Features
skull deformity
raised ICP
ophthalmologic problems
• due to increased ICP or bony abnormalities of the orbit
• strabismus most common
hydrocephalus may accompany multiple craniosynostoses
Investigations
plain radiographs, CT scan (3D)
bone scan: increased activity during active phase of union, decreased once union has occurred
Management
parental counseling about
• nature of deformity
• difficulty growing up as “cone head”
• associated neurological symptoms
surgery for cosmetic purposes, except in cases of elevated ICP

PEDIATRIC BRAIN TUMOURS
20% of all pediatric cancers (second only to leukemia)
80% of pediatric tumours are infratentorial (see Intracranial Mass section)
most common manifestations
• vomiting
• arrest or regression of developmental milestones
• macrocrania
• poor feeding, failure to thrive
• hydrocephalus
• seizures
CHILD ABUSE(Shaken Baby Syndrome) (see Pediatrics Chapter)

subdural hematomas of various ages
retinal hemorrhages
skull fractures
DRUGS
the following are guidelines ONLY; follow clinical judgment and up-to-date prescription recommendations
in practice; dosages refer to adults unless otherwise specified
Carbamazepine (Tegretol)
Tic Douloureux
• dosage: 100 mg PO bid, increase by 200 mg/day up to a maximum of 1,200 mg/day divided tid
• usual optimum dosage: 200 mg tid
seizures
• dosage: 600-2,000 mg/day, start low and increase in small increments
(inpatient: every 3 days; outpatient: every week)
• usual optimum dosage: 800-1,200 mg/day
• monitor CBC (potential hematological toxicity)
Dexamethasone (Decadron)
cerebral edema (e.g. secondary to tumour, head injury, pseudotumor cerebri)
preoperative preparation for patients with increased ICP secondary to brain neoplasms
palliation in recurrent inoperable brain neoplasms
• dosage: loading: 10-20 mg IV maintenance: 4-6 mg IV/day divided qid (may be given PO)
Lorazepam (Ativan)
status epilepticus
• dosage: 4 mg IV over 2 minutes, q5 minutes
• start phenytoin loading simultaneously
Mannitol
raised ICP
• dosage: 1 gm/kg IV rapid infusion (350 mL of 20% solution)
followed by 0.25 g/kg IV q6h
• effect occurs in 1-5 minutes, maximal at 20-60 minutes
• often alternated with furosemide (Lasix) 10-20 mg IV q6h
• indwelling urinary catheter
Nimodipine (Nimotop)
vasospasm in SAH
• dosage: 60 mg PO/NG q4h x 21 days, started within 96 hours of SAH
• causes vasodilation
• only calcium channel blocker (CCB) to cross BBB (blood brain barrier)
• use half the normal dose for liver failure
• monitor BP
Phenytoin (Dilantin)
seizures
• dosage: loading: 18 mg/kg IV
maintenance: 200-500 mg IV/day
or
rate: 40-50 mg
loading: 300-600 mg PO/day divided bid/tid
maintenance: 300 mg PO q4h until 17 mg/kg given
(average maintenance dose: 300 mg/day PO)
• important to give over time to prevent causing a cardiac arrest
status epilepticus
• dosage: 1200 mg IV over 30 minutes (~ 20 mg/kg) (if patient not on phenytoin regularly)
500 mg IV over 10 minutes (if already on phenytoin)
SURGICAL PROCEDURES
Lumbar Puncture
objective
• to enter the subdural space to measure or reduce cerebrospinal fluid (CSF) pressure
or obtain CSF for analysis
indications
• meningitis
• encephalitis
• meningeal carcinomatosis
• subarachnoid hemorrhage
• pseudotumour cerbri
anatomical landmarks
• conus medullaris (spinal cord termination) is usually located around L1/L2
• superior border of posterior iliac crests aligns with the spinous process of L4 (may be variable)
• insert needle with a slight cephalad inclination into the L4-5 interspace
until the subdural space is entered
complications
• tonsillar herniation
• infection
• headache (“low pressure”)
• spinal epidural hematoma
• nerve root trauma
• vestibulocochlear dysfunction
• ocular abnormalities
• dural sinus thrombosis
Burr Hole
objective
• to decompress brain by removing a compressive fluid lesion through a small opening in the skull
(called a burr hole)
• because it is small, cranioplasty is not generally used to fill-in the burr hole
indications
• subdural hematoma
• subdural hygroma
• brain abscess
• ventriculostomy
• biopsy
• varies according to location of trauma or CT/MRI-identified lesion
complications
• seizures
• intracerebral hemorrhage (0.7-5%)
• failure of brain to re-expand
• re-accumulation of compressive fluid
• tension pneumocephalus
• subdural empyema
• infection
• biopsy
Craniotomy
objective
• to gain exposure to any structural lesion in the brain by removing a section of skull (called a bone flap)
so that the lesion may be eliminated without harming intact brain
• once the lesion is eliminated the bone flap is fixed back in place
indications
• brain tumour
• brain abscess
• intracranial aneurysm
• hematoma
• lobectomy
• biopsy
• numerous approaches depending on the site of the lesion (e.g. frontal, frontotemporal, temporal,
subtemporal, pterional, petrosal, suboccipital)
• depending on the approach, important landmarks include the midsagittal line (overlying the superior
sagittal sinus and falx cerebri), coronal suture (often palpable through the scalp; anterior to the
precentral gyrus or motor cortex), glabella, nasion

SURGICAL PROCEDURES. . . CONT.
complications
• intracerebral hemorrhage (0.8-1.1%)
• hematoma
• infection
• cerebral infarction
• seizure
• acute hydrocephalus
• pneumocephalus
• cerebral edema
• vasospasm
Transphenoidal Tumour Resection
objective
• to access suprasellar lesions and remove them without disturbing surrounding cerebral,
neural, or vascular structures
indications
• pituitary adenoma
• craniopharyngioma
• Rathke’s cleft cyst
• meningioma
• germinoma
• epidermoid tumour
• the sella turcica is approached anteriorly through the nasal cavities to the midline nasopharynx which
forms the anterior wall of the sphenoid sinus
• the posterior wall of the sphenoid sinus is the anterior wall of the sella turcica
• maintaining a midline approach is essential to avoid injury to the internal carotid arteries
complications
• CSF leakage
• infection
• hemorrhage
• midbrain or pontine injury
• diabetes insipidus
• panhypopituitarism
• sinusitis
Spinal Decompression
objective
• to remove or repair structural abnormalities compressing the spinal cord or nerve roots
indications
• interverterbral disc herniation
• spondylolisthesis
• spinal stenosis
• spinal fracture or dislocation
• spinal tumour
• cauda equina syndrome
• various approaches depending on the location of the lesion
(e.g. anterior, anterolateral, posterior, postolateral, cervical, throacic, lumbosacral)
• depending on the lesion site, important landmarks include
• the transverse processes of C1
(palpable between the mastoid processes and the angles of the jaw)
• vetebra prominens (indicating the spinous process of C7)
• spinous process of L4 (indicated by an imaginary line between
the superior margins of the posterior iliac crests)
• spinous process of S2
complications
• infection
• hemorrhage
• incidental durotomy
• neural injury
• great vessel injury
• arachnoiditis
• reflex sympathetic dystrophy (RSD)
• bowel perforation

REFERENCES
Aids to the examination of the peripheral nervous system . London, UK: Balliere Tindall, 1986.
Crossman AR, Neary D.Neuroanatomy: an illustrated colour text . Toronto, ON: Churchill Livingston, 1998.
Fitzgerald MJT.Neuranatomy: basic an clinical (3rd edition). Philadelphia: WB Saunders, 1997.
Goetz CG, Pappert EJ. Textbook of clinical neurology (1st edition). Toronto, ON: WB Saunders, 1999.
Greenberg MS. Handbook of neurosurgery (5th edition). New York: Thieme, 2001.
Kandel ER, Schwartz JH, Jessel TM.

Principles of neural science . New York: Elsevier, 2000.
Lindsay KW, Bone I. Neurology and neurosurgery illustrated . New York: Churchill Livingstone, 1997.
Nieuwenhuys R, Voogd J, van Huijzen C.

The human central nervous system (3rd edition). New York: Springer-Verlag, 1988.

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NEUROSURGERY

Dr. M. Fazl and Dr. D.W. Rowed

INTRACRANIAL MASS LESIONS ........... 2 PERIPHERAL NERVES . . . . . . . . . . . . . . . . . . . . . 27

INTRACRANIAL MASS . . . . . . . . . . . . . . . . . . . . . 7 PEDIATRIC NEUROSURGERY . . . . . . . . . . . . . . 31

TRAUMA (BRAIN AND SPINAL CORD) . . . . . 23

Eventually further small

Figure 1. ICP-Volume Curve

normal ICP ~ 6-15 mm Hg (8-18 cm H 2 O) for adult,

Cerebral Blood Flow (CBF)

AUTOREGULATION: CBF maintained despite

60 torr 150 torr

NS2 – Neurosurgery MCCQE 2006 Review Notes

Figure 3. Herniation Types

1. Subfalcine (Cingulate) Herniation

MCCQE 2006 Review Notes Neurosurgery – NS3

NS4 – Neurosurgery MCCQE 2006 Review Notes

MCCQE 2006 Review Notes Neurosurgery – NS5

NS6 – Neurosurgery MCCQE 2006 Review Notes

TUMOUR (see Colour Atlas NS16 and NS17)

MCCQE 2006 Review Notes Neurosurgery – NS7

Table 1. Tumour Types: Age, Location and Clinical Features

Adult Astrocytoma (40-50%) Metastatic (20-30%)

Signs and Symptoms Raised ICP Raised ICP

NS8 – Neurosurgery MCCQE 2006 Review Notes

Table 2. Grading (Multiple Systems)

II Low grade + mass effect + mass effect 7-8 yrs

III Anaplastic Complex Complex 2 yrs

I GBM Necrosis Necrosis < 1 yr

• GBM: anaplastic astro: low grade = 5:3:2

“cystic cerebellar” astrocytoma

Meningioma (see Colour Atlas NS16)

INTRACRANIAL MASS. . . CONT.

Vestibular Schwannoma (“Acoustic Neuroma”)

NS10 – Neurosurgery MCCQE 2006 Review Notes

Other Causes of Pus

MCCQE 2006 Review Notes Neurosurgery – NS11

NS12 – Neurosurgery MCCQE 2006 Review Notes

History of sudden severe headache

conscious, alert, no neurological findings, CT scan drowsy, unconscious,

lumbar puncture negative positive

MCCQE 2006 Review Notes Neurosurgery – NS13

NS14 – Neurosurgery MCCQE 2006 Review Notes

anterior cerebral artery

middle cerebral artery

internal carotid artery

posterior communicating artery

posterior cerebral artery

superior cerebellar artery

anterior inferior cerebellar artery

posterior inferior cerebellar artery

Figure 9. Circle of Willis

VASCULAR MALFORMATIONS OF THE NERVOUS SYSTEM

NS16 – Neurosurgery MCCQE 2006 Review Notes

posterior spinal artery

Figure 10. Anatomy of the Spinal Cord

CORD AND ROOT COMPRESSION

MCCQE 2006 Review Notes Neurosurgery – NS17

LMN (Lower Motor Neuron) UMN (Upper Motor Neuron)

Tone Flaccid Spastic

Reflexes Decreased Increased