Surgery Marrow Pg 397-406 (Trauma)

Tissue Expanders

• Used to induce tissue growth by stretching and then by tissue growth.
• Creates increased surface area leading to dermal thinning, epidermal thickening and subcutaneous fat atrophy.
• Does not affect skin appendages.

Subarachnoid Hemorrhage (SAH)

• A medical condition where blood bleeds into the space between the brain and the surrounding membranes.
• Can be caused by traumatic injury or ruptured cerebral aneurysms.
• Most common type of aneurysm overall is Berry aneurysm.
• Symptoms include thunderclap headache, neck stiffness, and potentially focal neuro signs.
• Investigations include CT scan, Fischer Grading, lumbar puncture.
• Management:
  • Cerebral angiography.
  • Intervention:
    • Interventional radiology
    • Surgical
• Surgical procedures involve coiling (placement of coils in the aneurysm) or clipping (clamping the aneurysm).

Brain Abscess

• Can occur due to direct spread from sinusitis or otitis media, resulting in frontal or temporal lobe abscess.
• Other causes include hematogenous spread, typically in the parietal lobe.
• Risk factors for hematogenous spread: cyanotic heart disease, immunocompromised status.

Clinical Features of Brain Abscess

• Headache
• Nausea/vomiting -
• Seizures.
• Neurological deficits.

Investigations for Brain Abscess

• CT scan
• MRI

Management of Brain Abscess

• IV antibiotics are administered.
• Solitary abscesses are drained.
• Multiple abscesses require continued antibiotic therapy and close monitoring
• Treated underlying cause of the abscesses.
• Anti-epileptics are used to manage seizures
• Management of increased intracranial pressure (↑ ICP).

Congenital Neural Tube Defects (NTD): Spina Bifida Occulta

• A type of closed spina bifida where the spinal cord does not herniate.
• Defect is in the vertebral arch, affecting the 21st vertebrae.
• Usually asymptomatic and can be diagnosed on X-ray.
• No intervention is required.

Increased Intracranial Pressure (↑ ICP)

• Management:
  • Adequate IV fluids to maintain CPP ≥ 60 mmHg and SBP > 100 mmHg.
  • Avoid dextrose solutions, as they can worsen cerebral edema.
  • IV mannitol, an osmotic diuretic, can reduce ICP.
  • Keep the patient in a propped-up position.
  • Steroids are beneficial in vasogenic edema (caused by tumors).

Kernohan Notch Phenomenon

• False localizing sign associated with bleeding in the brain.
• Bleed causes pressure on the descending pyramidal tract and motor tract, leading to motor function impairments.
• Pressure on the motor tract can result in weakness on the opposite side of the body (contralateral limb weakness).
• Can also cause weakness on the same side as the lesion (ipsilateral limb weakness).
• Suggests uncal herniation, a condition where brain tissue is displaced due to pressure.

Cleft Lip and Palate

• Clinical features:
  • Cosmetic issues
  • Speech impairment (repair should be done before speech development)
  • Feeding problems
  • Middle ear infections

Cleft Lip Management

• Repair is done at 3-6 months of age.

Cleft Palate Management

• Repair is done at 12-15 months of age.
• Allows for complete bony growth.
• Follow “Rule of 10”: 10 weeks old, 10 pounds, 10 gm% (Hb).
• Common repair is Millard repair.

Cleft Lip and Palate Complications

• Bleeding
• Infection
• Mal-aligned cupid's bow
• Velopharyngeal insufficiency (Palate moves with speech).

Cleft Lip and Palate Repair Types

• Unipedicled: Wardill-Kilner/V-Y plasty
• Bipedicled: Von Langenbeck repair

Spina Bifida Aperta

• Open neural tube defect where membranes and/or spinal cord protrude through the vertebral arch.

Meningocele

• Only the meninges (membranes) herniate, not the spinal cord.
• Features:
  • Swelling.
  • Lower limb weakness or spasticity.
  • Bladder/bowel dysfunction.
• Positive fluctuation in the cystic swelling due to cerebrospinal fluid (CSF).
• Needs early surgery.

Myelomeningocele

• Most severe form of neural tube defect.
• The herniated tissue includes both meninges and spinal cord.
• Clinical features are similar to meningocele.
• Requires surgical intervention, which is more complex, leading to a poorer prognosis.
• Increased risk with antiepileptics: Phenytoin and Valproate.
• Prevention: Folate administration during pregnancy.

CNS Tumors

• Most common primary brain tumor: Glioma.
• Second most common primary brain tumor: Meningioma.
• Most common brain malignancy in children: Medulloblastoma.
• Metastatic brain tumors (secondary tumors) are common.

Clinical Features of CNS Tumors

• Focal neurological deficits.
• Seizures.
• Headache, worsening in the morning.
• Vomiting, due to increased intracranial pressure (↑ ICT).
• Frontal lobe tumors:
  • Witzelsucht syndrome (pathological joking).
  • Personality changes.

Investigations for CNS Tumors

• Initial imaging: MRI.
• Further evaluation: PET/CT (may miss brain lesions).

Management of CNS Tumors

• Treatment options: Surgery, radiotherapy, chemotherapy.
• Surgery is typically performed for solitary or 1-2 lesions.
• Chemotherapy: Agents that can cross the blood-brain barrier, intrathecal chemotherapy.
• Radiotherapy: Whole brain radiotherapy, stereotactic radiosurgery.

Brain Metastases

• Common metastases: Lung cancer to the cerebrum, breast cancer to the leptomeninges.
• Imaging: MRI.
• Management:
• Solitary lesions: Surgery.
• Mainstay treatment: Radiotherapy.
• Leptomeningeal disease: Chemotherapy.
• Vasogenic edema: Steroids.
• Prevent seizures: Antiepileptics

Cerebrovascular Accidents (CVA) - Stroke

• Ischemic Stroke:
  • Thrombotic Stroke: Blood clot forms in the brain.
  • Embolic Stroke: Blood clot travels from another part of the body to the brain.
• Hemorrhagic Stroke: Bleeding in the brain:
  • Intracerebral Hemorrhage:
    • Most common cause: High blood pressure.
    • Most common site: Basal ganglia (putamen).
  • Subarachnoid Hemorrhage (SAH)
  • Extra dural Hemorrhage (EDH)
  • Subdural Hemorrhage (SDH)

Cerebral Arteries Diagram

• The diagram shows the location of berry aneurysms within the arterial system.
• Relative frequency of berry aneurysm sites:
  • Anterior cerebral artery: 40%.
  • Anterior communicating artery: 20%.
  • Middle cerebral artery: 34%.
  • Posterior communicating artery: 4%.

Brain Herniation Syndromes

• Breakdown of the Monroe-Kellie doctrine: Increased intracranial pressure (↑ ICP) leads to a decrease in cerebral perfusion pressure (CPP) and Cushing's reflex.
• CPP should be maintained at ≈ 60 mmHg.

Types of Brain Herniation

• Uncal (Lateral Transtentorial) Herniation:

  • Ipsilateral cranial nerve III palsy ("blown pupil") and contralateral hemiplegia/posturing (Kernohan notch phenomenon).
  • Temporal lobe mass pushing the medial temporal lobe under the tentorium cerebelli.
  • Coma, bilateral small pupils progress to decorticate, decerebrate posturing and then respiratory paralysis and death.

• Central Transtentorial Herniation:

  • Coma, contralateral weakness progressing to posturing, especially of the legs and ACA stroke.
  • Frontal or parietal mass pushing the cingulate gyrus under the falx cerebri.

• Subfalcine Herniation:

  • Not included in the document.

• Cerebellar Herniation (↑ or ↓):

  • Cerebellar signs and symptoms, medullary dysfunction progressing to coma and bilateral posturing.

• Note*: In aortic dissection, use esmolol to control heart rate and permissive hypertension.

Brain Herniation Syndrome Complications

• Re-bleeding
• Hydrocephalus: Blood blocks CSF flow.
• Delayed ischemic neurological deficits (2-10 days later): Due to vasospasm.
• Management: Nimodipine.

Chiari Malformation

• Type I:

  • Usually presents in young adults with neck/cervical pain.
  • May present with hydrocephalus.
  • Caudal dislocation of the medulla is unusual in Type I.

• Type II Malformation:

  • Presents in infancy
  • Presents with progressive hydrocephalus and respiratory distress.
  • Caudal dislocation of the medulla is present.
  • Inferior vermis, medulla, and 4th ventricle are displaced into the cervical canal.
  • Hydrocephalus is rarely absent.
  • Spina bifida is rarely absent.
  • Management: Hydrocephalus treatment often required, with poor prognosis.

Dandy Walker Syndrome

• Abnormal development of the cerebellum and fourth ventricle.
• Marked cystic dilatation of the fourth ventricle.
• Hypogenesis or agenesis (absence) of the cerebellar vermis.
• Superior displacement of the tentorium and lateral sinus.
• Clinical features:
  • Prominent occipital region.
  • Macrocephaly (large head).
  • Hydrocephalus.

Test your knowledge on tissue expanders, subarachnoid hemorrhage (SAH), and brain abscesses. This quiz covers the mechanisms, symptoms, diagnostics, and management of these medical conditions. Ideal for students and professionals in healthcare and medicine.