Neurosurgery Lec 2 PDF

SURGERY NEUROSURGERY Dr. Aous Lec.2 Fractures: skull vault  Closed linear fractures of the skull vault are managed conservatively.  Open or comminuted fractures should be debridem...

SURGERY NEUROSURGERY Dr. Aous Lec.2 Fractures: skull vault  Closed linear fractures of the skull vault are managed conservatively.  Open or comminuted fractures should be debridement and prophylactic antibiotic therapy 1  SURGERY NEUROSURGERY Dr. Aous Lec.2 Fractures: skull base  These are relatively frequent fractures.  Occult radiologically.  Diagnosed on clinical examination.  They can result in CSF fistula that may persist, but which usually seals off after a few days. Types of skull base fractures A. Anterior fossa B. Middle fossa C. Posterior fossa a) Anterior fossa basal fractures May open into the frontal or ethmoidal air sinuses, or run across the cribriform plate. Clinical presentations: 1. Subconjunctival hematoma. 2. Epistaxis. 3. Anosmia: due to olfactory nerve injury. 4. CSF Rhinorrhea. 5. Nasal tip paresthesia: due to injury to the 1st branch of 5th nerve. 6. Periorbital hematoma or ‘raccoon eyes’. Blind nasogastric tube placement is contraindicated in these patients. 2  SURGERY NEUROSURGERY Dr. Aous Lec.2 3  SURGERY NEUROSURGERY Dr. Aous Lec.2 b. Middle fossa basal fractures  Involve the pertrous temporal bone. Clinical presentations: 1. CSF Otorrhoea. 2. Haemotympanum. 3. Battle sign; discoloration over the mastoid process. 4. VII and VIII cranial nerve palsies. c.Posterior fossa basal fractures  Boggy swelling or discoloration at the neck due to extravasations of blood in the suboccipital region.  Injury to cranial nerves: usually involve 9th, 10th, and 11th cranial nerves at the jugular foramen.  Retraction of the head and stiffness of the cervical muscles due to upper cervical nerves irritation. Management of skull base fractures 1. Prevention of infection: prophylactic antibiotics. 2. Control of CSF leakage: conservative or surgical intervention. 3. Treatment of associated brain injury. 4  SURGERY NEUROSURGERY Dr. Aous Lec.2 Indications for surgery(repair of tear) a) Persistence of rhinorrhoea more than 10 days b) Presence of a fracture involving the frontal or ethmoidal sinus. c) Occurrence of meningitis. Extradural hematoma  Is a neurosurgical emergency. It results from rupture of an artery(middle meningeal artery), vein or venous sinus, in association with a skull fracture.  Transient loss of consciousness is typical, and the patient may then present in the subsequent lucid interval with headache but without any neurological deficit.  There is contralateral hemiparesis, a reduced conscious level and ipsilateral pupillary dilatation, the cardinal signs of brain compression and herniation. Although this ‘talk and die’ pattern of deterioration occurs in only one-third of cases 5  SURGERY NEUROSURGERY Dr. Aous Lec.2 Acute subdural hematoma Chronic subdural hematoma Traumatic subarachnoid hemorrhage  Trauma is the commonest cause of subarachnoid haemorrhage and this is managed conservatively.  It is not usually associated with significant vasospasm, which characterises aneurysmal subarachnoid haemorrhage. 6  SURGERY NEUROSURGERY Dr. Aous Lec.2 Cerebral contusions Contusions are common and are found predominantly where the brain is in contact with the irregularly ridged inside of the skull, i.e. at the inferior frontal lobes and temporal poles. ‘Coup contre-coup’ contusions refer to brain injury both at the site of impact and distant to this, where the brain impacts on the inside of the skull as the skull and brain accelerate and then decelerate out of synchrony with each other Diffuse axonal injury This is a form of primary brain injury seen in high-energy accidents that usually renders the patient comatose; it is associated with poor outcomes. It is strictly a pathological diagnosis made at postmortem, but haemorrhagic foci in the corpus callosum and dorsolateral rostral brainstem on CT may be suggestive. 7  SURGERY NEUROSURGERY Dr. Aous Lec.2 Control of intracranial pressure ICP can be controlled by simple measures, including raising the head of the bed and loosening the collar to improve venous drainage. Seizures and pyrexia should be actively controlled. Medical management titrated to ICP includes escalating doses of sedatives, analgesics and ultimately muscle relaxants. 8  SURGERY NEUROSURGERY Dr. Aous Lec.2 Post concussive syndrome is a loosely defined constellation of symptoms persisting for a prolonged period after injury. Patients may report somatic features such as headache, dizziness and disorders of hearing and vision. They may also suffer a variety of neurocognitive and neuropsychological disturbances, including difficulty with concentration and recall, insomnia, emotional lability, fatigue, depression and personality change. 9