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Which type of lymphoma is associated with increased frequency in immunocompromised patients?
Which type of lymphoma is associated with increased frequency in immunocompromised patients?
Chemotherapy is the primary treatment for CNS lymphoma.
Chemotherapy is the primary treatment for CNS lymphoma.
True
What histological feature is associated with oligodendroglioma?
What histological feature is associated with oligodendroglioma?
Fried egg
The tumor type characterized by perivascular pseudorosettes is known as ________.
The tumor type characterized by perivascular pseudorosettes is known as ________.
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Match the following tumor types with their associated histological features:
Match the following tumor types with their associated histological features:
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What is the primary outcome when trauma severity indicates 27 or more?
What is the primary outcome when trauma severity indicates 27 or more?
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The 'ebb' phase of the metabolic response to trauma is characterized by an increase in physiological changes.
The 'ebb' phase of the metabolic response to trauma is characterized by an increase in physiological changes.
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What percentage of cases indicate a limb is consistent with being salvageable after trauma?
What percentage of cases indicate a limb is consistent with being salvageable after trauma?
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In trauma, the _____ phase is characterized by physiological stabilizations.
In trauma, the _____ phase is characterized by physiological stabilizations.
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Match the following phases of the metabolic response with their respective roles:
Match the following phases of the metabolic response with their respective roles:
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What is the correct order of the ATLS process?
What is the correct order of the ATLS process?
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In the primary survey, the assessment of life-threatening injuries is categorized under the Red Category.
In the primary survey, the assessment of life-threatening injuries is categorized under the Red Category.
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What criteria must be met for cervical spine imaging to be required?
What criteria must be met for cervical spine imaging to be required?
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The _____ is an instrument used to stabilize the cervical spine in trauma patients.
The _____ is an instrument used to stabilize the cervical spine in trauma patients.
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Match the following instruments with their usage:
Match the following instruments with their usage:
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Which of the following is NOT part of the information that should be collected from the patient using the AMPLE method?
Which of the following is NOT part of the information that should be collected from the patient using the AMPLE method?
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It is acceptable to transport a patient in the lateral position to stabilize the cervical spine.
It is acceptable to transport a patient in the lateral position to stabilize the cervical spine.
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What should be done first when approaching a trauma scene?
What should be done first when approaching a trauma scene?
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The process of removing a helmet from a patient involves _____ to restrict movement of the cervical spine.
The process of removing a helmet from a patient involves _____ to restrict movement of the cervical spine.
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Match the following terms with their descriptions:
Match the following terms with their descriptions:
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What is the first intervention if endotracheal intubation is not possible?
What is the first intervention if endotracheal intubation is not possible?
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What is the recommended fluid bolus amount in the latest ATLS update?
What is the recommended fluid bolus amount in the latest ATLS update?
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Nasotracheal intubation is contraindicated in cases of skull base fractures.
Nasotracheal intubation is contraindicated in cases of skull base fractures.
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A Glasgow Coma Scale score of 11 indicates a mild head injury.
A Glasgow Coma Scale score of 11 indicates a mild head injury.
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What is the maximum duration for high flow oxygen using a Y-connector during a needle cricothyroidotomy?
What is the maximum duration for high flow oxygen using a Y-connector during a needle cricothyroidotomy?
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The minimum size of IV lines recommended for circulation is _____ gauge.
The minimum size of IV lines recommended for circulation is _____ gauge.
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What dose of Tranexamic acid is recommended for trauma patients with a systolic blood pressure of 110/min?
What dose of Tranexamic acid is recommended for trauma patients with a systolic blood pressure of 110/min?
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The pupil reactivity score of ___ indicates that both pupils are reactive to light.
The pupil reactivity score of ___ indicates that both pupils are reactive to light.
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Match the following interventions with their corresponding uses:
Match the following interventions with their corresponding uses:
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Match the Glasgow Coma Scale components with their corresponding scores:
Match the Glasgow Coma Scale components with their corresponding scores:
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What is the cause of death that occurs immediately after a trauma?
What is the cause of death that occurs immediately after a trauma?
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The 'Golden Hour' refers to the first hour following trauma where care provided decreases mortality.
The 'Golden Hour' refers to the first hour following trauma where care provided decreases mortality.
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What system is used to prioritize treatment in mass casualty events?
What system is used to prioritize treatment in mass casualty events?
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Within the first hour after injury, patients can be saved from __________ if treated promptly.
Within the first hour after injury, patients can be saved from __________ if treated promptly.
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Match the priority groups with their corresponding color and description:
Match the priority groups with their corresponding color and description:
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How many people are required to perform a log roll on a patient without a limb fracture?
How many people are required to perform a log roll on a patient without a limb fracture?
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Pelvic binders should be removed once a pelvic fracture is suspected.
Pelvic binders should be removed once a pelvic fracture is suspected.
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What does the Injury Severity Score (ISS) measure?
What does the Injury Severity Score (ISS) measure?
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In cases of suspected pelvic fractures, a pelvic binder is used to _____ until the fracture is ruled out.
In cases of suspected pelvic fractures, a pelvic binder is used to _____ until the fracture is ruled out.
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Match the trauma severity scores with their descriptions:
Match the trauma severity scores with their descriptions:
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What is the most common primary malignant tumor in children?
What is the most common primary malignant tumor in children?
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Meningiomas are more common in males than in females.
Meningiomas are more common in males than in females.
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What sign is associated with meningiomas in MRI investigations?
What sign is associated with meningiomas in MRI investigations?
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Ependymomas can lead to ________ due to blockage of CSF drainage.
Ependymomas can lead to ________ due to blockage of CSF drainage.
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Match the following tumors with their unique histological features:
Match the following tumors with their unique histological features:
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What is the most common site for Pilocytic astrocytoma?
What is the most common site for Pilocytic astrocytoma?
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Glioblastoma multiforme has the best prognosis among astrocytomas.
Glioblastoma multiforme has the best prognosis among astrocytomas.
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What is the primary management for an oligodendroglioma?
What is the primary management for an oligodendroglioma?
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The grade of a Pilocytic astrocytoma is _____ grade.
The grade of a Pilocytic astrocytoma is _____ grade.
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Match the type of astrocytoma with their grade:
Match the type of astrocytoma with their grade:
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Study Notes
CNS Lymphoma
- Increased frequency in immunocompromised patients (HIV, post-transplant).
- Diffuse large B cell lymphoma (DLBCL) is the most common type.
- Partial tumor regression with steroids is characteristic, known as "ghost cell" phenomenon.
- Diagnosis is made through biopsy.
- Treatment involves chemotherapy and sometimes surgery, followed by radiation therapy.
Histopathological Features
-
Pilocytic astrocytoma:
- Rosenthal fibers and microcysts.
-
Glioblastoma multiforme (GBM):
- Serpentine necrosis and glomeruloid bodies.
-
Oligodendroglioma:
- Fried egg appearance, chicken wire blood vessels, and calcification.
-
Ependymoma:
- Perivascular pseudorosettes and small round blue cells.
-
Medulloblastoma:
- Homer Wright rosettes.
-
Meningioma:
- Psammoma bodies, Antoni A, and Antoni B.
-
Schwannomma:
- Verrocay bodies.
Metabolic Response to Trauma: Ebb and Flow
- Post-trauma metabolic response characterized by two phases: Ebb and Flow.
Ebb Phase
- Short-term, characterized by decreased metabolic rate and oxygen consumption.
- Lasts for 24-48 hours.
- Prominent hormonal response with increased release of catecholamines, cortisol, and glucagon.
Flow Phase
- Increased metabolic rate, oxygen consumption, and hypercatabolism.
- Lasts for several days.
- Characterized by increased insulin resistance, hyperglycemia, and protein catabolism.
Advanced Trauma Life Support (ATLS)
- A standardized system for the management of trauma patients.
- Follows a structured approach: Airway, Breathing, Circulation, Disability.
ATLS Process
- Initial assessment focuses on identifying and managing life-threatening injuries.
- Primary Survey involves:
- ABCD assessment for immediate, life-threatening injuries, categorized as "Red Category".
- Secondary Survey:
- Detailed examination for all injuries.
- Tertiary Survey:
- Performed after extubation of intubated patients.
-
Whole Body CT can be used instead of the Secondary Survey:
- Benefits: quick assessment, reduces radiation exposure.
- Drawbacks: Only appropriate for stable patients.
Airway Assessment
- Signs of compromised airway indicative of intubation:
- Unable to speak; GCS ≤ 8; unexplained confusion; coma.
- If any sign is positive, a Philadelphia collar and C-spine imaging are required.
- Negative signs indicate no need for imaging.
Cervical Spine
- C-spine examination must be performed before airway assessment.
-
NEXUS Criteria used to determine the need for C-spine imaging:
- Neuro deficit; Ethanol intoxication; Extreme distracting injury; Unable to provide history; Spinal tenderness (midline).
Pre-Hospital Care
- Initial approach involves evaluating the scene, initial assessment, triage transport, critical investigations, and patient transport.
- Information collection from driver/responder (MIST): Mechanism; Injuries; Signs & symptoms; Treatment given.
- Information collection from patient (AMPLE): Allergies; Medical conditions; Past history; Last meal; Events leading to trauma.
Transportation
- Supine: Head, thorax, and pelvis strapped for immobilization.
- Prone: To prevent aspiration.
- Lateral position: Not recommended due to instability of C-spine.
Complete Immobilization
-
Two-person helmet removal:
- Person 1: Restricts cervical spine movement.
- Person 2: Removes helmet and assists with C-spine stabilization.
Secure Definitive Airway
- Endotracheal intubation: Preferred method, either orotracheal or nasotracheal (contraindicated in skull base fractures).
-
Alternative interventions:
- Emergency intervention: Needle cricothyroidotomy.
- Definitive intervention: Tracheostomy.
Breathing
- Chest examination with auscultation and pulse oximetry.
Circulation
- Minimum: Two 18G IV lines.
- Fluid bolus: 1 litre (if not possible).
-
Alternative interventions:
- Emergency intervention: Venous cut-down (access to great saphenous vein).
- Definitive intervention: Central line (preferred in trauma patients).
Intraosseous Infusion
- Implemented below the tibial tuberosity for rapid fluid and medication administration in cases where IV access is difficult.
Timeline Concept: Trimodal Distribution of Mortality
- Post-trauma mortality follows a trimodal distribution.
- Highest mortality immediately after trauma, followed by a decrease and then a subsequent increase over days/weeks.
Causes of Death
-
Immediate:
- Head injury: Airway obstruction, tracheobronchial injury, tension pneumothorax, open pneumothorax, acute circulatory arrest, cardiac tamponade, hemothorax.
- Within 1 hour of injury: Potential for survival through timely intervention.
- Days/weeks: Infections and delayed head injuries.
Golden Hour
- The first hour post-trauma during which immediate interventions are critical to reduce mortality.
- Serves as a performance metric for trauma centers.
Triage
- Involves sorting and prioritizing patients during mass casualty events to direct treatment.
Four Color Coded System
- Used for triage prioritization:
- Red: Emergency (immediate treatment required for survival).
- Yellow: Urgent (immediate treatment not essential, can be delayed).
- Green: Delayed (minor injuries, first aid sufficient).
- Blue: Expectant (Moribund patients, pain management provided).
- Black: Dead.
Trauma
-
Updates in ATLS (10th Edition):
- Smaller fluid bolus (1 litre instead of 2) for more judicious fluid management.
- CRASH-2 Trial (investigational) suggests administering 1g of Tranexamic acid over 10 minutes, followed by 1g over 8 hours for patients with a systolic blood pressure ≥ 110 mmHg.
Disability
- Glasgow Coma Scale (GCS): Used to assess level of consciousness (eye opening, best verbal response, best motor response).
-
Interpretation:
- Mild head injury: GCS 13-15
- Moderate head injury: GCS 9-12
- Severe head injury: GCS ≤ 8.
Pupil Reactivity to Light
-
Pupil reactivity score (PRS):
- Both pupils reactive: 2
- One pupil reactive: 1
- No pupil reactive: 0
Log Roll
- Performed to examine the patient's back, requiring 4-5 people (additional person for limb fracture).
- Limited role in pelvic fractures or abdominal trauma (except for penetrating abdominal injuries to check wound path).
Pelvic Binder
- Used for suspected pelvic fractures.
- Must be kept until fracture is ruled out.
- Alternative: Tie a long cloth around the hip if a binder is unavailable.
Severity Scores
-
Injury Severity Score (ISS):
- Based on the Abbreviated Injury Score (AIS) of the top three injuries.
-
Revised Trauma Score (RTS):
- Measures Glasgow Coma Scale, systolic blood pressure, and respiratory rate.
-
Trauma Score and Injury Severity Score (TRISS):
- Predicts survival probability based on RTS, ISS, mechanism of injury, and age.
-
Mangled Extremity Severity Score (MESS):
- Evaluates the severity of mangled extremity injuries based on injury type, ischemia group, shock group, and age group.
Ependymoma
- More common in children than adults.
- Spreads through the 4th ventricle, blocking CSF drainage and leading to hydrocephalus.
-
Investigations:
- MRI for diagnosis.
- Histopathological examination (HPE) reveals pseudorosettes.
-
Management:
- Surgery followed by craniospinal radiation therapy.
Meningioma
- Extra-axial, dural-based tumor.
- More common in females.
-
Clinical presentation:
- Often asymptomatic.
- Motor deficit may occur.
-
Investigations:
- MRI displays "dural tail sign".
- HPE shows psammoma bodies.
-
Management:
- Surgery.
Medulloblastoma
- The most common primary malignant tumor in children.
- Peak incidence between 3-4 years.
-
Association:
- Turcot syndrome (a variant of FAP with APC gene mutation on chromosome 5).
-
Metastasis:
- Drop metastasis through cerebrospinal fluid (CSF).
-
Investigations:
- MRI for diagnosis.
- HPE reveals small round blue cells and Homer-Wright rosettes.
-
Management:
- Surgery followed by craniospinal radiation therapy.
Astrocytomas
- Classified into four grades based on aggressiveness.
Grading
| Grade | Astrocytoma Type |
|---|---|
| 1 | Pilocytic astrocytoma |
| II | Low grade (Fibrillary astrocytoma) |
| III | Anaplastic astrocytoma |
| IV | Glioblastoma multiforme (GBM) |
Pilocytic Astrocytoma
- More common in children.
-
Presentation:
- Mural nodule (non-infiltrative).
- Grade: Low grade.
- Most common site: Posterior fossa.
- Investigations: MRI.
- Management: Excision of the lesion.
Glioblastoma Multiforme (GBM)
- Rapid progression and the worst prognosis among astrocytomas.
-
Management:
- Surgery followed by radiation therapy and oral temozolomide.
Oligodendroglioma
- Most common age: 40-60 years.
-
Investigations:
- MRI reveals calcifications.
- HPE is essential for diagnosis.
-
Management:
- Surgery followed by radiation therapy and oral temozolomide.
Calcifications in CNS Tumors
- Calcifications are a hallmark of several tumors, including:
- Medulloblastoma
- Oligodendroglioma
- Meningioma
Surgery v1.0 Marrow 8.0 2024
- Indicates the document version and creation date.
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Description
Explore the critical aspects of CNS lymphoma, including its frequency in immunocompromised patients and the types of histopathological features associated with different brain tumors. Understand the diagnostic and treatment approaches and the metabolic responses to trauma.
