RCSI Head Injuries & Cerebral Neoplasm Year 2 Past Paper PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Head Injuries & Cerebral Neoplasm Class Year 2 Course Surgery Syafiz Zulkifli Clinical Fellow & Lecturer, RCSI Oct ‘24 update LEARNING OBJECTIVE...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Head Injuries & Cerebral Neoplasm Class Year 2 Course Surgery Syafiz Zulkifli Clinical Fellow & Lecturer, RCSI Oct ‘24 update LEARNING OBJECTIVES Describe the types of head injuries Understand the principle and relationship of raised intra- cranial pressure Recognise the different types of brain haemorrhages Discuss the assessment of a brain injured patient, including GCS Describe the medical and surgical management options available Discuss various types of brain tumours HEAD INJURY  HEAD INJURY 449,000 UK Emergency Department attendances per year Trauma is the leading cause of death under the age of 45 and up to 50% of these are due to a head injury 70% of patients with severe polytrauma has TBI High morbidity & mortality: – 50% of inpatient adults have morbidity from HI Accident and Emergency Statistics – Parliament (2015); Early management of patients with a head injury (NHS; 2009) STATISTICS High morbidity & mortality ▪ 10 per 100,000 per year die, i.e. 450 per year in ROI ▪ 100 per 100,000 per year disabled 50% of major trauma deaths are due to H.I. 2:1 male to female ratio 2/3 are 15-25 Commonest cause of death 1-15 $4.1 million - $9 million = Requirement for lifetime care of 1 survivor of severe head injury  EPIDEMIOLOGY Ghana Emergency Medicine Collaborative Ghana Emergency Advanced Emergency Trauma Course PRIMARY BRAIN INJURY DAMAGE AT TIME OF INJURY PERFORATING AND SCALP SKULL PENETRATING FOCAL DIFFUSE BLOOD LOSS LINEAR EDH CONCUSSION FRACTURES INTRA CEREBRAL ACUTE SDH HAEMORRHAGE SCALP CHRONIC SDH DIFFUSE LACERATION BASILAR AXONAL FRACTURES ICH INJURY VASCULAR INJURY CONTUSION FOREIGN BODY LACERATION DEPRESSED SAH FRACTURES PORTAL OF IVH INFECTION HYPOTHALAMIC & PITUITARY BRAINSTEM CRANIAL NERVES SCALP INJURIES SKULL INJURIES PERFORATING CRANIAL INJURIES FOCAL BRAIN INJURIES MONRO-KELLIE DOCTRINE CONSEQUENCES OF RAISED ICP Herniation syndromes Reduced cerebral perfusion SECONDARY BRAIN INJURY SYSTEMIC INTRACRANIAL HYPOXIA BRAIN SWELLING HYPOTENSION BRAIN SHIFT & HERNIATION HYPERCAPNIA RAISED ICP HYPERTHERMIA POST - TRAUMATIC POOR GLYCAEMIC SEIZURE CONTROL INTRACRANIAL INFECTION Prevention of secondary brain injury is the goal of management of Traumatic Brain Injury  EXTRADURAL HAEMATOMA ▪ Usually Blunt Trauma ▪ Often associated with linear fracture ▪ Usually temporal (70-80%) ▪ Tear of middle meningeal artery ▪ Biconvex due to attachment of dura to skull sutures ▪ Lucid interval ▪ Treatment Requires emergency craniotomy ACUTE SUBDURAL HAEMATOMA ▪ Venous tear / Brain laceration ▪ Covers entire cerebral surface ▪ Crescent shaped ▪ Associated Parenchymal Injury ▪ Morbidity / mortality due to underlying brain injury ▪ Mortality 30 - 90 % Treatment Requires emergency craniotomy CHRONIC SUBDURAL HAEMATOMA ▪ History of minor trauma ▪ Risk factors: age, male gender, anticoagulants, coagulopathy, thrombocytopenia, alcoholism Treatment Early burr hole drainage in the presence of raised ICP or lateralising signs INTRACEREBRAL HAEMATOMA ▪ 15 % Of Fatal Head Injuries ▪ Associated with: Contusions, Diffuse axonal injury Subdural Haematoma Treatment Usually conservative but evacuation of haematoma in the presence of raised ICP or marked midline shift DIFFUSE AXONAL INJURY (DAI) ▪Account For 35 % Of All Fatal Head Injuries ▪Prolonged Unconsciousness In The Absence Of A Mass Lesion ▪Petechial haemorrhage ▪Basal cisterns effaced ▪Ventricles compressed ▪Sulci invisible ▪Loss of grey/white differentiation ▪Management – conservative, decompressive craniectomy PENETRATING INJURIES 1/3 Have a vascular injury 1/3 Result In Infection Universally fatal if crossing midline Management Wound debridement Removal of foreign body angiography Gunshot ASSESSMENT ABC 5-10% have associated c-spine injury Early anaesthetic involvement Rapid transfer to NSU GLASGOW COMA SCORE Best eye response Best motor response Open spontaneously (4) Obeys commands (6) Open to verbal command (3) Localises to pain (5) Open to pain (2) Normal flexion to pain (4) Does not open eyes (1) Abnormal flexion to pain (3) Extension to pain (2) Best verbal response No movement (1) Orientated (5) Confused speech (4) Inappropriate words (3) Incomprehensible sounds (2) No speech (1) Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974,2:81-84 MEDICAL MANAGEMENT Head position - 30° head up Mannitol Anti-epileptics Hypertonic saline ICP Monitoring ANAESTHETIC MANAGEMENT Paralysis Sedation Analgesia Hyperventilation (lower PCO2 – cerebral vasoconstriction) Hypothermia SURGICAL MANAGEMENT Intercranial pressure monitoring INTRACRANIAL PRESSURE MONITOR EXTERNAL VENTRICULAR DRAIN CRANIOTOMY – HAEMATOMA EVACUATION Removal of causative pathology – clot/tumour/swollen brain, etc EVD Decompressive craniectomy LONG TERM SEQUELAE Post-traumatic epilepsy – 5% in first week, 12% after – Incidence higher if post-traumatic amnesia>24 hours, intracranial haematoma, depressed skull fracture, penetrating injury – No benefit in giving prophylactic AED > 1/52 Post-concussion syndrome – Behavioural change, HA, dizziness, mood swings, irritiability, memory loss – Neuropsychology input  RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Brain Tumours Class Year 2 Course Surgery Syafiz Zulkifli Clinical Fellow & Lecturer, RCSI 30/03/23 Learning Objectives : Learn the classification of Brain tumours. Understand the pathogenesis , clinical picture & treatment of Brain tumours. Describe the therapeutic options in treatment of Brain tumours: Surgical v/s non surgical BASIC CEREBRAL ANATOMY ANATOMIC AND FUNCTIONAL LOCATION OF TUMOUR Intracranial Extracranial Intra axial Extra axial CLINICAL PRESENTATION Progressive neurological deficit Symptoms of raised Intracranial pressure - early morning headache, vomiting Seizures Hydrocephalus Haemorrhage Endocrine disturbance Asymptomatic INVESTIGATION AND WORK UP History (symptoms, past history of cancer, rate of progression of symptoms, etc) Physical examination (neurological findings) Imaging – CT as screen but MRI is best CT TAP - thorax/abdomen/pelvis Functional imaging: fMRI , PET ± CSF cytology Pathology – cells of origin Primary Cells within brain - neurons, glial, blood vessels Cranial nerves -Schwann cells Meninges Pituitary gland Pineal gland Skull Secondary Metastasis ADULT PRIMARY TUMOURS ▪ 6/100,000 incidence – Glial most common 60% Astrocytic (grade 1-4) Oligodendroglial Mixed O-A – Meningioma 20% – Pituitary , Pineal10% – Nerve sheath tumours 5-8% – Diverse rare tumours 10% GLIOBLASTOMA Peak age 45-60 50% of astrocytomas 20% of primary brain tumours Pathology – Nuclear pleomorphism – High mitotic count – Necrosis  GBM - THERAPY Maximal safe resection Histopathological/molecular dx Postoperative scan – assess extent of resection Post operative Radio Chemotherapy – STUPP protocol LOW GRADE ASTROCYTOMA 15% astrocytomas Peak age 30 Transform to higher grade 5 year survival with gross resection and radiotherapy is 70% MENINGIOMA Extra-axial Arise from cap cells of arachnoid Primarily a surgical disease Usually classified by location For residual or recurrent meningioma use radiation and/or focused radiation MENINGIOMA VESTIBULAR SCHWANNOMA Arise from vestibular branch of CN VIII Present with slowly progressive hearing loss Bilateral in NF2 Treated options surgery or stereotactic radiosurgery, observation  PITUITARY ADENOMAS Non-functioning (present with visual symptoms, headache, hypopituitarism) Functioning: Prolactin (galactorrhea, infertility) Growth Hormone (Acromegaly) ACTH (Cushing’s syndrome) Rarely pituitary apoplexy Treated with drugs, surgery, radiation PRIMARY CNS LYMPHOMA Most common in immune- suppressed persons (e.g. AIDS; organ transplant) Rate of PCNSL seems to be on the rise, irrespective of immune suppression Treated with biopsy and chemotherapy METASTASIS ▪ Metastases to the brain greatly outnumber primary tumors ▪ Virtually any primary cancer may spread to the CNS: Brain spinal cord Leptomeninges Dura pituitary gland SOURCES OF BRAIN METS IN ADULTS Lung cancer >40% Breast Ca 40% Renal Cell 7% GI 6% Melanoma 3% Undetermined 4% PAEDIATRIC BRAIN TUMOURS PAEDIATRIC GLIAL TUMOURS 2nd most common childhood tumour –19% (Leukaemia -37%) Common solid tumour Astrocytoma >Medulloblastoma >Ependymoma  CEREBELLAR ASTROCYTOMA Most common brain tumour in childhood usually benign, slow growing 90% cure 30% of paediatric posterior fossa tumours are astrocytomas. age group is 5 to 10 years. MEDULLOBLASTOMA This tumor usually arises in the cerebellar vermis. One of the most common brain tumors in children. It is a primitive neuroectodermal tumor. MEDULLOBLASTOMA Extremely malignant characterised by the ability to seed along CSF pathways. Frequently they metastasise down the spinal axis. EPENDYMOMA The tumor arises from cells that line the ventricles or the central canal of the spinal cord. Most common in children and young adults. DIFFUSE BRAIN STEM TUMOUR These tumours balloon the brain stem and infiltrate all layers. They are malignant tumours and have very poor prognosis. Cause cerebellar dysfunction, cranial nerve palsies and paresis.. OPERATIVE CONSIDERATION 5 ALA OPERATING IN ELOQUENT AREAS fMRI DTI AWAKE CRANIOTOMY HEAD INJURIES AND BRAIN TUMOURS Thank you. Any Questions?