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Colen Publishing

www.colenpublishing.com

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Colen Publishing, L.L.C.PO Box 36536Grosse Pointe Woods, MI 48236Author and Editor: Chaim B. Colen, M.D., Ph.D.Editorial Assistant: Roxanne E. Colen, PA-C

COPYRIGHT © 2008 by Colen Publishing, L.L.C. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the author’s consent if illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Permissions may be sought directly from Colen Publishing, L.L.C. by writing to the above address.Printed in ChinaColen Flash-Review: Neurosurgery, 2nd EditionISBNVolume 1: 1-935345-01-X Volume 2: 1-935345-02-8 2 Volume Set: 1-935345-00-1

Note: Knowledge in medicine is constantly changing. The author has consulted sources believed to be reliable in the effort to provide information that is complete and in accord with the standards at the time of publication. However, in view of the possibility of human error by the author in preparation of this work, warrants that the information contained herein is in every respect accurate and complete, and that the author is not responsible for any errors or omissions or for the results obtained from use of such information. The reader is advised to confirm the information contained herein with other sources. This is especially important in connection with new or infrequently used drugs. In such instances, the product information sheet included in the package with each drug should be reviewed.

Colen Publishing

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Glossary

COPYRIGHT-------------------------------------------------- 1PREFACE------------------------------------------------------ 1HOW TO USE THIS CARD REVIEW-------------------- 1CONTRIBUTORS-------------------------------------------- 4GLOSSARY--------------------------------------------------- 1NEUROSURGERY------------------------------------------ 110NEUROLOGY ------------------------------------------------ 86NEUROPATHOLOGY-------------------------------------- 238NEUROANATOMY----------------------------------------- 57NEUROCRITICAL CARE---------------------------------- 80NEURORADIOLOGY--------------------------------------- 73NEUROBIOLOGY------------------------------------------- 64 BONUS BIOSTATISTICS---------------------------------- 6

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Preface• The idea to undertake such a large Flashcard review spawned from watching my wife Roxanne

study for her Physician Assistant Boards. Diligently every day she would create a set of 7-10 flashcards from her study material that she would take with her to work. Later on, when I was studying for my written Neurosurgery Board examination, I gleaned information from various texts and other study guides and wrote down the most relevant material on cards for quick review while at work. It was amazing how much time during the day would be available to review these cards. If there was a delay in a OR case, a long lunch-line, a traffic jam (especially the i94 on a Friday afternoon) or waiting for my wife at her OB/GYN appointment -these little cards were specially handy. Always ambitious in life, the thought of giving this study tool to the busy neurosurgery resident was captivating. My expectation is to enable the resident with a quick yet informative review of basic neuroscience principles. With positive encouragement from my fellow residents on the 1st edition, I cautiously proceed here with updating information, adding new images, improved illustrations and clarification of neuroscience concepts. May this endeavor serve to better our wonderful science inherited through the legacy of Harvey Cushing, Neurosurgery.

Chaim September 9, 2008

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The Colen Flash-Review

Author and EditorChaim B. Colen, M.D., Ph.D.Department of Neurological SurgeryWayne State University School of MedicineDetroit, Michigan

Assistant EditorRoxanne E. Colen, M.S., PA-CColen Publishing, LLCGrosse Pointe, Michigan

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AcknowledgementsI would like to give thanks to a great many wonderful persons whose efforts, although not inscribed in

these cards, were instrumental in making this monumental task possible. One exceptional individual to whom I owe special thanks is my mother in-in-law, Colleen Johns, who babysat my daughter Emily and son Joshua for hours on end, while my wife and I toiled through hundreds of pages of various textbooks and journal articles, formatted questions, and drew computer illustrations. To my daughter Emily Rivka, who incessantly tugged at my pants trying to get my attention to the squirrel in our backyard ;and that big bright smile from my son Joshua that continually sent me optimism. To Mahmoud and Abhi who spent hours at my home assisting with typing, researching and editing; Naomi whose positive attitude in life is exceptionally brightening and uplifted the group’s 2 am brainstorming sessions when I still had to wake up early to work the next day, all the pathologists, especially Doha, who assisted in taking photographs, Dr. William Kupsky, for allowing us access to his collection of unique neuropathology, and to all the medical students especially Kristyn, whose hard work is admirable. There are those whose names are not here but did assist in some way, thank you. I am forever indebted to my training program, the Wayne State University neurosurgery program, my Chairman Dr. Murali Guthikonda, and Associate Chairman Dr. Setti S. Rengachary whose moral support over the last five years has kept me on this educational drive. For this second edition, there were fellow residents that gave me input and new insight that has helped to improve this edition over the first.

To my parents Joseph and Leila, educators of true dedicated quality, and to whom I owe my homeschooling education and self-motivation. Lastly to my wife Roxanne, whose patience with my ambitiousness knows no boundaries.

Thank you All,Chaim September 9, 2008

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How to use this Flashcard review

• These cards are intended to cover most of the aspects of the Neurosurgery Board Examination. They are not a COMPLETE review and therefore they are not intended to replace textbooks. We would advise using these cards during the last couple of weeks before your board exam except for the pathology section which you should go through all year to better remember the photographs in it (heavily encountered during the boards!). BOARD FAVORITEquestions are of extreme importance and most likely to bump into during the boards, so make you sure you know how to answer them right.

• Good luck!• Chaim B. Colen, M.D., Ph.D.

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Faculty Reviewers

Murali Guthikonda, MD Professor and Chairman Department of Neurological SurgeryWayne State University School of MedicineDetroit, Michigan

Setti Rengachary, MD Associate Chairman Department of Neurological SurgeryWayne State University School of MedicineDetroit, Michigan

William, J. Kupsky, MDDepartment of Neuropathology Wayne State University School of MedicineDetroit, Michigan

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• With ever increasing scope and complexity of knowledge base, the current day trainee or practitioner of neurosurgery finds it difficult to keep up with the explosion of neurosurgical information. This is compounded by a healthy growth in specialization in various branches of neurosurgery.

• Chaim has made an attempt to make life simpler by incorporating small quanta of knowledge on flashcards accompanied by clear and simple illustrations. The user may review as few or as many cards as his/her time will allow. Although not meant to be substitutes for standard comprehensive texts and atlases, these cards help to refresh the information learned from the bedside, operating room and standard books. Each card represents a mini-examination with instant access to appropriate answers.

• This is a fun way to recall neurosurgical information especially before an upcoming test.

Setti S. Rengachary, M.D.Department of Neurological Surgery

Forward

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Physician Contributing Authors

Mahmoud Rayes, MDDepartment of Neurological Surgery WSU School of Medicine

Erika Peterson, MDUT Southwestern,Department of Neurological Surgery Dallas, Texas

Rivka R. Colen, MDDepartment of RadiologyThe Massachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Doha Itani, MDDepartment of PathologyWSU School of MedicineDetroit, Michigan

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Contributing Medical Students

Darmafall, KristynWayne State UniversitySchool of MedicineClass of 2012

Davis, Naomi Wayne State UniversitySchool of Medicine Class of 2011

Dub, LarissaWayne State UniversitySchool of MedicineClass of 2012

Faulkiner, RodneyWayne State UniversitySchool of MedicineClass of 2012

Galinato, AnthonyWayne State UniversitySchool of MedicineClass of 2012

Gotlib, DorothyWayne State UniversitySchool of MedicineClass of 2009

Kozma, BonitaWayne State UniversitySchool of MedicineClass of 2008

Lai, Christopher Wayne State UniversitySchool of MedicineClass of 2010

Larson, SarahWayne State UniversitySchool of MedicineClass of 2012

Martinez, DerekWayne State UniversitySchool of MedicineClass of 2011

Matthew SmithWayne State UniversitySchool of MedicineClass of 2011

Matto, ShereenWayne State UniversitySchool of MedicineClass of 2012

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Contributing Undergraduates

Jeffrey P. KallasWayne State UniversityClass of 2010

Abhinav KrishnanWayne State UniversityClass of 2010

Peter PaximadisWayne State UniversityClass of 2008

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Neurocritical CareQ.• What is the hallmark indicator for disseminated intravascular coagulation (DIC)?

A. Decreased fibrin-split productsB. Increased factor XC. Low plateletsD. Decreased d-dimer

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Neurocritical CareA.• The correct answer is C, low platelets. Coagulation factors are decreased. Fibrin-split

products and d-dimers increase.Inciting factor: Ex. crush injury, endotoxin

Systemic activation of coagulation factors

Widespread intravascularfibrin deposition

Consumption of plateletsand clotting factors

Thrombosis & organ failure Thrombosis & organ failure

DIC

Classification: Neurocritical Care, Coagulation Disorders, DIC

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• A 36 year old male presents to the emergency room as a trauma code. During resuscitation, clear fluid is noted dripping out of the left nare. An appropriate statement regarding the bedside glucose test is that it has:

A. high sensitivity, low specificityB. high sensitivity, high specificityC. low sensitivity, low specificityD. high sensitivity, low specificity

Neurocritical CareQ?

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Neurocritical CareA.• The correct answer is C, low sensitivity, low specificity. The bedside glucose test has low

sensitivity and low specificity. Therefore, it should be used only for trying to rule out a CSF leak rather than ruling it in.

• In the emergent setting, when evaluating a patient with rhinorrhea, if the rhinorrhoea contains glucose, the specificity of the test for CSF can be improved by excluding other factors that increase the glucose concentration of nasal discharge. If the nasal discharge is not blood stained, the blood glucose (measured at the same time as CSF glucose) is <6 mmol.L–1, and there are no other symptoms of upper respiratory tract infection, such as sneezing, nasal blockage, cough, sore throat, sputum, or purulent nasal discharge, then this increases the likelihood that the discharge contains CSF. If rhinorrhoea does not contain glucose, then either it does not contain CSF or CSF glucose concentrations are below the limit of detection by the sticks (false negative measurement).

• Beta-2 transferrin test is both highly sensitive and specific but would require a few days to process the Western blot at most institutions.

Chan DT, Poon WS, IP CP, Chiu PW, goh KY. How useful is glucose detection in diagnosing cerebrospinal fluid leak? The rational use of CT and Beta-2 transferrin assay in detection of cerebrospinal fluid fistula. Asian J Surg. 2004 Jan;27(1):39-42.

Classification: Neurocritical Care, CSF Leak, Bedside Glucose Test

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• Name three functions of platelets:A. Attach, agglutinate, agranulateB. Adhere, activate, avascularizeC. Adhere, aggregate, agranulateD. Apoptosis, aggregate, agranulateE. Acidification, activate, agranulate

Neurocritical CareQ?

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VasospasmVasospasm

Vessel InjuryVessel InjuryAdherenceAdherence

AggregationAggregation

AgranulationAgranulation

Vascular phaseVascular phase Platelet phasePlatelet phase

GpIIb/IIIa

vWf

fibrinogen

GPIb-IX-V complexGPIb receptor

Collagen

Platelet

Endothelial cell

GPIb-IX-V complex

PhospholipaseC activation

+

Release of platelet-activation factors

AdherenceAdherence1

+

2

3

Neurocritical CareA.• The correct answer is C, adhere, aggregate, and agranulate (degranulate) (Hint AAA).

Yee DL, Bergeron AL, Sun CW, Dong JF, Bray PF. Platelet hyperreactivity generalizes to multiple forms of stimulation.J Thromb Haemost. 2006 Sep;4(9):2043-50

•Platelets can be activated by binding to collagen, which is mediated directly through glycoprotein VI (GPVI) or indirectly via von Willebrand factor (VWF) binding to GPIb-V–IX. Signal transduction from any of these receptors leads to phospholipase C recruitment, which mediates calcium mobilization, platelet shape change, degranulation, and activation of GPIIb/IIIa to allow binding of fibrinogen and platelet-platelet interactions.

Classification: Neurocritical Care, Coagulation Cascade, Platelet Function

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1. Choose the most common inherited cause of post-operative bleeding?A. Bernard-Soulier diseaseB. Von Willebrand diseaseC. Hemophilia AD. Hemophilia BE. Leiden factor disease

2. Inheritance of this disease is mostly:A. Autosomal dominantB. Autosomal recessive

Neurocritical CareQ?

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Neurocritical CareA.1. The correct answer is B, von Willebrand disease.2. The correct answer is A, autosomal dominant.• Von Willebrand disease is the most common coagulation disorder. Inheritance is

autosomal dominant transmission in 90% of cases. Children born with the disease have either low levels (quantitative defect) of von Willebrand factor (vWF), or defective form (qualitative defect) of the same protein.

• Bernard-Soulier: defective or decreased expression of the glycoprotein Ib/IX/V complex on the surface of the platelets. This complex is the receptor for von Willebrand factor (vWF), and the result of decreased expression is deficient binding of vWF to the platelet membrane at sites of vascular injury, resulting in defective platelet adhesion.

• Factor V Leiden is the most common hereditary hypercoagulability disorder. In this disorder the Leiden variant of factor V, cannot be inactivated by activated protein C.

Franchini M. Advances in the diagnosis and management of von Willebrand disease. Hematology. 2006 Aug;11(4):219-25.

Classification: Neurocritical Care, Coagulation Disorders, Von Willebrand Disease

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• You are consulted on a 22 year-old female who is one day postpartum and has been admitted to the intensive care unit with widespread petechiae, purpura, and mucocutaneous bleeding. Head CT is shown on the right. Which of the following is INCORRECT regarding this condition?

A. Blood clotting mechanisms are activated throughout the body.

B. Thrombocytopenia may occur.C. Thrombocytosis is commonD. Fibrin-split products are increased.

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Neurocritical CareA.• The correct answer is C, thrombocytosis is common• Thrombocytopenia occurs, not thrombocytosis.• The immediate postpartum period is a highly thrombogenic state. There are many risk factors

(amniotic fluid) that can cause a dysregulated hypercoagulable condition resulting in disseminated intravascular coagulation (DIC). DIC occurs when blood clotting mechanisms are activated throughout the body. Small blood clots form throughout the body, exhausting the supply of blood clotting factors which become rare at sites of real tissue injury. Simultaneously, clot dissolving mechanisms are also increased. Hence, this disorder can result in both excessive bleeding and clotting. DIC may be caused by infections (especially gram-negative bacteria) , severe trauma, cancer, blood transfusions, and obstetrical complications.

• Pathophysiology: two main mechanisms- generation of thrombin (microvascular thrombosis and organ ischemia) and generation of plasmin (characterized mainly by hemorrhagic symptoms).

• Fibrin-split products are increased in DIC.

Levi M, de Jonge E, van der Poll T, ten Cate H. Advances in the understanding of the pathogenetic pathways of disseminated intravascular coagulation result in more insight in the clinical picture and better management strategies. Semin Thromb Hemost. 2001 Dec;27(6):569-75. Review.

Classification: Neurocritical Care, Coagulation Disorders, Post Partum

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Neurocritical CareQ?• This ocular fundus is MOST likely seen in which

of the following patients?A. 25 year-old obese female punched in the

stomach with a GCS of 15B. 14 year-old male status post temporal

lobectomyC. 31 year-old male thrown from a 3rd story

window with a GCS of 5D. 56 year-old with a 1 cm cerebellar

hematoma with a GCS of 15

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Neurocritical CareA.• The correct answer is C, 31 year-old male thrown from a

3rd story window with a GCS of 5.• This type of papilledema is seen in the setting of high

intracranial pressure (ICP), such as the above patient who has suffered severe traumatic brain injury.

• Cerebellar hematoma acutely would cause high ICPs in the infratentorial compartment that potentially could result in acute obstructive hydrocephalus with papilledema, but this is less likely in a patient that has a 1 cm cerebellar hematoma and a GCS of 15.

Bhatt UK. Bilateral optic disc swelling; is a CT scan necessary? Emerg Med J. 2005 Nov;22(11):827-30.

Grade IV papilledema. There is severe swelling in addition to a circumferential halo. The edema covers major blood vessels as they leave the optic disk (grade III) and vessels on the disk (grade IV).A subretinal hemorrhage is present at 7 o'clock. 

Classification: Neurocritical Care, Hematoma, Ocular Changes

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• Which of the following is the preferred ventilation pattern in non-paralyzed patients with central nervous system dysfunction?

A. Continuous mandatory ventilationB. Assist control ventilationC. Intermittent mandatory ventilationD. Synchronous intermittent mandatory ventilationE. Pressure support ventilation

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Neurocritical CareA.• The correct answer is D, synchronous intermittent mandatory ventilation.• Patients with CNS dysfunction tend to exhibit variations in tidal volume and respiratory

drive. • Synchronized intermittent mandatory ventilation (SIMV) delivers volume-cycled

breaths that coincide with spontaneous lung inflations. The patient can breathe unassisted and spontaneously between mechanical breaths. Also, a preselected respiratory rate can be used if the patient`s respiratory drive is insufficient to prevent hypercarbia.

Stock MC, Perel A: Handbook of mechanical ventilatory support. Baltimore: Williams & Wilkins; 1997.

Classification: Neurocritical Care, CNS dysfunction, breathing patterns

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• Which of the following characteristics are seen in patients with acute respiratory distress syndrome (ARDS)?

A. Bilateral lung infiltratesB. Pulmonary capillary wedge pressure less than or equal to 18 mm Hg C. PAO2/FIO2 ratio of < 200 mm HgD. All of the above

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Neurocritical CareA.• The correct answer is D, all of the above.• Acute respiratory distress syndrome (ARDS) is characterized by acute onset, bilateral

infiltrates in chest x-ray, pulmonary capillary wedge pressure (PCWP) less than or equal to 18 mm Hg and a PAO2/FIO2 ratio < 200 mm Hg.

Kollef MH, Schuster DP: The acute respiratory distress syndrome. N Engl J Med 1995 Jan 5; 332(1): 27-37.

Classification: Neurocritical Care, Respiratory Distress Syndrome, Lab Values

BOARD FAVORITE!

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• Which of the following findings will distinguish cardiogenic pulmonary edema from acute respiratory distress syndrome (ARDS)?

A. Bilateral lung infiltrates on chest x-rayB. HypoxemiaC. Pulmonary capillary wedge pressure (PCWP) > 18 mm HgD. All of the above

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Neurocritical CareA.• The correct answer is C, Pulmonary capillary wedge pressure (PCWP) > 18 mm Hg.• Occasionally it is very difficult to distinguish between ARDS and cardiogenic

pulmonary edema. Both can present with hypoxia and bilateral lung infiltrate, but PCWP is > 18 mm Hg in cardiogenic pulmonary edema.

Ware LB, Matthay MA: The acute respiratory distress syndrome. N Engl J Med 2000 May 4; 342(18): 1334-49.

Classification: Neurocritical Care, Acute Respiratory Disress Syndrome, Pulmonary Changes

BOARD FAVORITE!

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• What is most common finding on ECG in patients with pulmonary emboli?A. Large Q wave in lead IIIB. Inverted T wave in lead III C. Right axis deviationD. Wide S complex in lead IE. Right bundle branch blockF. Sinus tachycardia

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Neurocritical CareA.• The correct answer is F, sinus tachycardia.• All of the answers can be seen in case of pulmonary emboli. The classic findings of

“S1,Q3,T3” are not very sensitive in diagnosis of acute pulmonary embolism.

Feied CF: Pulmonary embolism. In: Rosen and Barkin, eds. Emergency Medicine Principles and Practice. Vol 3. 4th ed. 1998:chap 111.

Classification: Neurocritical Care, Pulmonary Emboli, ECG Changes

BOARD FAVORITE!

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• A 21 year-old patient with history of recurrent sinusitis developed an allergic reaction after transfusion of a cross matched blood. What is the most likely cause?

A. Selective IgA deficiencyB. Lab errorC. Rh group incompatibilityD. Rapid transfusion of blood products

Neurocritical CareQ?

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Neurocritical CareA.• The correct answer is A, selective IgA deficiency.• Selective IgA deficiency syndrome is the most common primary immunodeficiency.

Usually the patient is asymptomatic, but a history of recurrent infections may be present; most commonly ear infections, sinusitis, and pneumonia. Allergies are another possible symptom including allergic reaction to blood products.

• If only fever develops within 1-6 hours of receiving cross matched blood, this is caused by antibodies in recipient blood that react to donor leukocytes. Leukocyte poor red cells can be used to prevent this reaction.

Ballow M. Primary immunodeficiency disorders: antibody deficiency. J Allergy Clin Immunol. Apr 2002;109(4):581-91.Zhao SM. Clinical assessment of preventing febrile nonhemolytic transfusion reaction by leukocyte-depleted blood transfusion. 2002 Dec;10(6):568-70.

Classification: Neurocritical Care, Congenital Immune Disorders, IgA Def. Syndrome

BOARD FAVORITE!

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• Which of the following is the appropriate immediate treatment in case of an intra-operative venous air embolism?

A. Irrigation of the surgical fieldB. Lower the patient’s head with lateral left decubitus positionC. Aspiration of air from a multiforce central venous pressure catheterD. Manual occlusion of the jugular veinsE. All of the above

Neurocritical CareQ?

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Neurocritical CareA.• The correct answer is E, all of the above.• Intraoperative venous air embolism (VAE) has a high incidence during procedures

performed in the sitting position. VAE is characterized by the development of bronchoconstriction, hypoxia, hypercarbia, hypotension, shock, cardiac arrhythmias, increased airway pressure, and decreased end tidal CO2.

• The most sensitive diagnostic modality for VAE is transesophageal echocardiography.

Ballki M.Venous air embolism during awake craniotomy in a supine patient.Can J Anaesth. 2003 Oct;50(8):835-8.

Classification: Neurocritical Care, Intraoperative Venous Embolism, Treatment

BOARD FAVORITE!

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• Match the following arterial blood gas values with the appropriate acid/base disorder. A. Metabolic acidosisB. Metabolic alkalosisC. Respiratory acidosisD. Respiratory alkalosisE. Combined respiratory acidosis and metabolic acidosis

1. pH 7.26, PaCO2 53 mmHg, HCO3- 24 mEq/L

2. pH 7.49, PaCO2 46 mmHg, HCO3- 33 mEq/L

3. pH 7.30, PaCO2 33 mmHg, HCO3- 18 mEq/L

4. pH 7.27, PaCO2 41 mmHg, HCO3- 18 mEq/L

Neurocritical CareQ?

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Neurocritical CareA.• The correct answers are….• To obtain the answer to this question and to view over 250 more comprehensive

neurocritical care questions please purchase the full product here !

Narins RG, Emmett M: Simple and mixed acid-base disorders: a practical approach. Medicine (Baltimore) 1980; 59(3): 161-87.

Classification: Neurocritical Care, Acid Base Disorders, Lab Values

BOARD FAVORITE!