Handbook of Neurosurgery Mark S. Greenberg Sixth Edition ~Thieme :~iBOivSi l l l 56 HEAD CIRCUMFERENCE 54 52 : tttt~tt~~ .. .6 " " 38 36 " 32 30 ... 0 eM 2 4 6 8 456;891012 14 16 18 10 12 14 16 18 20 22 YEARS MONTHS t AG E 6O: ~~_ GIRLS HEAD CIRCUMFERENCE " 52 ~~~~~+-+-+-j . : :f=I:=I+:~~ 46 +-H,~ .. ~~-t 42 ~-h'-li 40 38 36 34 32 30 o 2 4 6 8 3 4 5678910 12141616 10 12 14 16 18 20 22 M ONTHS I YEARS Reproduced by Pel/russian at Pediatrics, Vol. 41 , pages 101 & 108, ©1968 AG E Theutlulive dinributo. in the Americal and Canada ;1 Thieme New York 333 Seventb Avtnue New York. NY 1000l United States or America (BOO) 782-30188 The "clUllV' d,.tribul.or QIIt.11ida tha Americas 18 Thieme inl<emlOtionai Rudigentraase I~ Stuttgart. Germany +49 (0) 711-8931-126 Wbrary orCongress C"t.logins-;n-PubliClltion Data fa ayaiiable from the publi.h@r HANDBOOK OF NEUROSURGERY MatI< S. Greeobere: ISBN 1-58890-.57_1 (ThIeme Ne ... Yorl.) ISBN 3-13-U0886-X (Geare: Thiem. VerlaS Stutts.rLJ Capyrillht C 2006 Marl< S. Greenbe'll. All nghl.l re~e",e-d. Third ed.itiun, 199<1 Fourth edition. 1997 Fint e-ditiun, 1990 Secvnd edition. 1991 Fifth !!dition. 2001 GTHnberJ Graphk •. Inc, Lakeland, n . •. mail: edil.o~apbic:a.Cllm _w.IP'ITaphiea.cum Cop)'tiant C2006 b)' Gl'Mnbets G.a phla. lnc. This book, i rw:ludinlaU pllU thereor, II itgaUy J)I'Otected by ClDp)'tighl. My UN. aploitltlQII o. eommerda!ltatioll oubide the IIDnow limita _ t byropJriiht legialation, without the publi.her'. conaent." ilIl'galand Ii.ble to ~tioll. 1'biI'PJ)lie. in part!cul.r to p~t.at reproduc:tion. copying. mim· eD(l'Iphilll or duplication of .ny kind, tranalatins, pnparatill!l Dr mkrofiimll, and elecIronic data Proceainl and 'tor.,a. .... Loo.port."t " """ Medieal ~ledp ~ ~"';nl' All ...... TMeatcl! and clinical Mpe'n...... broUot.o our ~J"'" npt,III 1n.1Jpen1 and d"'llhenopy may ba requinld . Th. au_ \lion and ""iton oHM ..... t.atlat <DntaIned hoe",dn b... con.uJt.ed lIOu .... ' believed til be reU.ble jll !he.. eftiltU to PI'O"ide inl'om.alion thIot is «I"'p~ and III aeeo>rd ""til the .tandlll"d8 _pt.ed .L the ti ..... ~p"liI;e"tiorI. H_eoer, in vi.w e(th, popihiHty of hum .... error by th, aulh p.... M_ iton. or publWwr of work hueirJ, "" chana. ,n roedical ilnowlod, e, neithftf th, .uUwm. «1_ ;1On. pubu.h«, ..... al\1 otMr party who hall r-n in~oI~od In the preparation oflhla work. wlJT&II,-!ha1 1hIIi:rt."""-tiIIn <OIItruncd ~ b ill £Yery TUlpoel OUU",II:OI' <Dmplctc.1LDd lMy an ....t ...."....mbLa for ... y .......... or omiPionl or for the _ulta obtainM from u"" of RUch infon:nalOoll. RHcItnI .... _raced toCG<lfitn> the infonn.tioo conl&in«l tM!rein with othtr 110"",*, Per eumploa, .... derr .... odviMd IOdIeck the produet informati.:m lbMt 1nd0Jde.d In the ~ oC~drvr lheypjan ta,dnlillisteftoba_1n lM,t lheinforttlltion contained In this publicatiOll 'ncelln"" and that than.i:es haye !lOt ~ ""...:Ie in the .-""nded dC*O or in the coot ... iodX:.liona for adDIiniuntion. "This recoommendalioo ;. of poorticular ImpOrtonC4 ;n eoo· nection orith DeW or in£reqUolntiy uoed d",1PSomeoflhe FOdud. IWDD, .,.IaIIa, .nd ....... lem delipo refer'tt'CI to in this book.re in f.d; ~Iter'ed tr.demarkl .... p",.,.;.tary na ..... lboup lpecitic referenoe.lO thll flet J. not at ....,. made In !.he Ia!. n.enr....., !he IpperonM1l of. name wllhoul dH;pIIJlOOI •• prop .... t.ary WIlOI. to be<llloDltlued ... repreocnlation to,. the publiober th.t il II In Lht public: domlin, u.. tv'" eo-. iIluatno..... br!boo .~Iho< ~ 1M onteruIo\.e<1ll braiotlom...d II.......1&1"... _10II'" ..HI! pono;- Ir_: '-II sa. Chaq 0.1. p...,. 0 .... I.o6nL. PJ, /)o1A1.. DinIlL pelion"" ... r..ior """'Iar &rWty _ _ _ <hll_1 ad .......-..1- J Nou""u,* 2002, ~1 [4 ~ 1~e6, r ... l.abelod mUW- <A u.. lJ:Ia~, _ _ 80 bo..t ... _1..1_ Prinl.ed ill Onta.ricl, CanIda. Prinlinjr: 6 • 3 2. 1 • Printer: Web<:om, Umlted. NEUROSURGERY DeDI CATION The lixth edition ofthe Handbook ofNcurGllurgery book i. dedicated 1.4 the mC'mory of my mother, MAry, t.II the tOntinued giflor my rather, Lou;', to thc pre"n! ormy dlltlil1l wife. Debbie, and 1.0 the (uture of my child ... n. Shaina, Aleu, Laah and Mich.~1. CONVENTIONS PRACTICE PARAMETER OH'N'T'O"S Standanl5 Pncl ice Sklnd4rd~ indicDI.c I high degTft of clinical OIIrtllinty and are lIenerally balled on CII5S I ",video c", ( _ or more wel!..!~ill1ed. ran· domiled controllP.d au>diell) or atrooll ClISS U "",idl!flctl eal)fti.Uy wh,,,, dn:um. II.Mce:I pnoelucl", r.ndomized clinical trials SUlde line s Practice G.. ;~l~ rell«t • lII.rll le! d~ of clinleal oertDinIy and are I1!OOUIro.:ndeclwhen Ihe revie~ fell th!rt! "'N il\8ll fficN!.nl inform. _ tion to CrftaUlI SklNJc;rd, and are " l llall,y '-d OG C lu .• l1 e .. ide nc .. lone or more weU-duigned tOmplirati.. e dinic, l l tudiu 01" Ie.. well-do-.igned randomiaed ltudiea) Or . PTi!PQnderao.:e ofChw III evidu.u Options T'racticeOpiiOll4 of IlnclelircUnic.l ""rtainly and .... r1I<!'IIDmendft(! when the ...... iew~ra fOllt thetf) ",as ;ll$llffitk!nl lnlormal.ion to create I SIU~dlJrd or C"i~/iIM. and arfl generally based on CI..I IU l viden~ (C¥lIe r;eriu , hi.\() ... ie, 1c:ontroll , cue repOrtii and erperlopUlion) Retommendallon s Some refe~1II:ft use Ihil WmI IftMnully ,oil th~ q>eci1Y the Ilrength ofth. dlta. For th_. the natu .. of the d:lu ",ill 1M gi-..en. A CKNOWLEDGMENTS I would like 10 ockno .... ledge.U the 1OIlt'CU .. Hod ror tile malQrialln thit book.. 'J'hia lnelud<ll tha mnny ~II iovolved;~ m.y mt!dkll and OIIiTOlutJicllll"lliniog. Spi!rial II'" preciaUool. upfftll4!d UI J ohn M. T_ , Jr.. M.D., undoer ",n.-ruidllf>Cf! Il'Klli....d my neu,..".u rgie.allra inlng. II I I... lncludell thou who pnuously rntitOO penninion ~ uM nrurea and \JObiN pr...iOlllly publUl hed . ABBREVIATIONS AbbreviltiON \l.I<!d only locally Ire denn..-:! ill thlt sectlOrl using bold&.oe type.. \\'boere appropriate, pap numbers Cor tho Durin "'-"lion rele .. ant to chll topic i.given • "~cy:sl.~ ...t ..... ~ .. ~""""""' 1 :1 anI..-"", _ _ -- .~MIocIInIII • 31 Q --... - HO _ y t I P . . . . . c . . . . . . MIl~cIr\toI - 2'68 , ....~ ~"Iar c.rv\C;tI di$«IoclOlny & fusion ~..:c<I ...t\in9enl'f1'111O N~UROSURGERY '- 1 ....._Iicoo''' *'toI)'ft)DnII · ruwv asympt<>m1llC: CO<OIicI ~ stenosis · m II! AsympIQmaIlC:Carolld SIUd~ · 813 "'*Y -.tDr~-.y " """ ..,.,-1-·. . " '''' ~'" _~ ""'U\l'llCylorno -41:1 ~ M o -." •. __ 101 ,.. U. S. P\lGkHaa!l'l s.Mce) '" ."""" _... ., .... ., ·~ MI<I.;o.IIIt"'OOI'c.... I>8II"'_f'I .CQUn<lltn<nunodflldft>(:y sr~ ~ . alM>"'-"n as - '" .00 .".G "...... ~ ...n "",fO!roPt'k IIIWai Qr<):IIS • :.2 ...."""""" ."',badln ~IIC>,"."'" ,~ ..,.,.at"" 0.' GO, GO, GO, ,GO ~ _ " ' " ,,..-.,_ 151 biol /la( At\&r; EBA T Mul~ W" tlolfI.I 'I'ii'l.... "'~.,Iy . 74g DoN """Pf'o9_1lc pml .." • rn ,~ _PI·. .,'.a.c:w", ·- ~o_,""",,·511 -, IIe<I , ../II (OIdo"ry ,..IIICUIrI) DoI. .1$1o.uII 665 tnl"''''''' q4iDma _ '20 ~"".".~. -!It' car&aI~"'¥<'P<III'IY- <X),Ot""Y Il1*Y ~ gr.~ COO'..... 'Y l&I'IOr(<IIlloas. _et>raJ _ no.. - 76J '" """_tlOIOod.....e........aDPI... _~ n c.I"'m-clut1lOftl _ . a.~ 00IIgIIniIa! ~ ic r.u~ ~ ~..,, 1 1gen-501 """""I """""'... ~1.ar'Y (lcOy . I rlld) IXIfl\!n.... -...IIIiIu ... cI>r ...... ll'l1\ammoI1ay QefI1yeilrwMlng 1IOIyr. ' diailon..""""hy - 5' Cro;JlZI","'..JDi<Ob dI...... - 227 ""_""". "",1_,.,.,· a.1 CMFI01 c:e<ebral ...., _ ",'" 01 DXYII"" 0010· !IIImop\lOI't ·163 ,OM' awoot·"'....T;xoUt·&54 <GO """HI'!..,... cardl", <IIAj)01 ,~ '0 '" '" '"C, N. '" ""'" ""W "" m '" C'" ~ '" ,~ ,~ GO" '";. ~u. ceI11f" 11'MI<"OOUI" 'y$I~ ~.,dIac ""II'<'I te.-rlOr>O<llirl<> ""!lie celli,,, p)I1'lnot ~ - 12 """'~PI_"'_·~7~ tertbllll pertllalOn ",fIS5<lta - !i-l7 r:taniII nosrv&/., DlfVleaI~rlemy""" lhy·331 C-rIIlClIVO pr<ll,"n ~\"\l1 ~ syndrome· J!f6 c I08I.0 - 911 ,,/fIg. ce<ebtOi Yli. ..... 14 c:I'I.ro<'Jc lnIumallc efl..IQ/lIUopolI')' • G83 CIIfp.l1 '''mer..,....,'''... · 565 ce<eIIroYosculo, ..x:kIeOl. Woke - ~ Cef\lfal VIfICI\I5 prao ... ,. t41leboo...,..,"" _ . l f lromllPJiol-1IIIIl oe/~" reoIII..-.ot - 763 C8\et>rat ""'001IIII:111\ - 79 1 - j~ .... ~ ..IBI""I_:IO<y""... (MI'lI I_ 136 e>t_I~ ...... ftf\)1 ""om" btll/1'l ra<lial00n 'NoIlIUI' O<}'1h4om' ch!onIcuM 234 mig,..,., - l!Ilidu.., """"'1oIna· 669 .~t ....... 1IaI"<u11orlgu1 "'~_"'8d Irnm~ '" .0, '" ". """ ''''''. ....'"'W " OIeCltQnySlllogn-og'aplly - 0132 Hr, ~ *"Il ll'lroal l'*""'lOQOIO\J)') ~ '" "'" ""'. GO. 'N {l.8Iin: ~ll\roI'ItmI! · ~ <lil'fl,$IM"'eIgn1&/1 ~. ~ '00 """"'" ....o.r..fOdOff"/ - B1''''' .. "" "'" <OM _<lor· R4 'H CIDP OW. II1et'lO';enous nlAlloonatJOl'l • 835 <:arol!d-<;a<;811"10<16 I _ I I\$llIla • '"'" '"' '" d1og""'* peritQn6a!IlI• • dogit .. ~trlldoon angioQf8rT\ ~afNe ",me _32:l dur.1 ....." 1I'IrO!r>~ - &88 etMI-.k Marl cbotue GO' CCHD or a,;p(01 (l.,.r,toaiICYIic 1<><1) u""",,"poMIl>IfI DtrtIl~~, (at DNET) <l;58fI'b)'opIa.uc """~ ""'laI fOOl anll)' .OM ......, • l!15 ~1'.&IIOfataryd~f~ ~ 'M '000 dl.bel.. melI~ ... anlllI"'UoDomorI/II o.mirIoOtyt:oa.c» _M1InOpI'I" • 28 p.t!lalll'lt«nC>opl.SlIn lime (0- bIOC<I~1n 0. 0. dj_,O:k.,."..".",$O' OOC • ,,,mO ·OCCrN'" dlSIO<:atio<1· 717 ~, '"''M" M' "" "" '''' "" ~ acou511c: ",..,,""'" • 129 _nSoclery"'A.n .. """ "" .~ ~ . ....- .....,..~,,,..IIg_1 ~'" --.. dIs!lll atl'erioo' ~retw1ll .~ 00 dJl""nlial .1IIJ2 *Ilel.. ~~-'6 <'e/.llyed -...rcNuroiDllicoe(C! · 791 d""'""~tIie~""'81h~ . ""..rIoI llIn'Ilir "'tert>o<!y ,.. &/001 .... CAe ... .., dilI..01!u'Y ·uz "leu""",,, "" '0 "W , "" , a..a.... '"' hI,"""",- 409 '" '"U '" "" '" '" '" "" a.ma-ocuw rI'IUICIn •• I.m.I_OI~ t')'thn>CY\l' ~ ..... aIoohoI (~~) elJdQl"'I:IIetiIUo. ' ' 1'1 .o\er...... nIr.,.,..,<II""'I_~1 F""""'nall~" """"..,. . ... - 901 ,-- ~,hhn....,.1IId """"slon '''''''"'''Y (oe 'lbrorrlUX~1at ~ - 53 "'R'I· 135 ~-. 1 ....'OI..,_<>rIQIro p""",,·.mInotio\ynC aclcI gliotliulOlNO mt.II!i!ctme - 412 G.s Go. Gu,'oIn-aarrt ~ - 53 '" = " ,." ~" ,,.. '"' W. '" "'" "" ,,, "" Glasgow<X)ma oc ..... - IS-C G/""" .. d"" .... . 00 "- ..... y ~I""~(mlc'_y) gianl eel anertlis - sa GI>{I!ie!mI ""'aeIIlb'" .",;1$ - 803 glillll,btJltary -.;leI", "''''.''' • 500 g""""\I"'amyI~ germ""" maW """"",,,",ga- 861 gram~'ods \IV-~ lIt"""'iUO f<)n~ (...il:Ule) M""'"*,,, . ~. ,"",nl _ _ (SAH 11'_1 - 180 "_,I.. B.... ~_ Inl'll'ln "GO t-o.miIled CQfYleaI <be: - 31 B IIydn.teflllllul • , 80 hyperdyNmo: ~6rl'/ - n7 l"IemIIngjaO\HIa - '59 ., human 1mtT!\l..--.cy viru • I\ImIt$ed iIwn!>e' ","".!102 Hgb-"'C~"IC 1>U!"n... ~OWI/l r>oI"""'" HHT nor"""",), .... ",o,,1I.1gic reIq;,cru!a _ i'OH "~ "~ ~, ... Iv:nan Nl<lkocy\II ",,1910 ~_9<1 _ . purpoo ... (",,",la'lt(! """' d.scl -302 "o. "'""oIbI!CI HNPP 1lut0t!il1ll'{ I\Il>ropll!l>y wirII "-1lo1il)l1O .",. DIlliN - S54 pt"'- NEUROSURGERY '" '" "" '" ""SO .. ""' 0' "''" <" "" '''' ,~ IPOM ." _s ~~rI,O!·""'-POI",lIIl)'·.j,eovoI.a.o." o/rnpIIlo _ h"'M· 22:5 n~_1on Inl1iIrt\AlaullllO'I'U","' 1nI"",.. .,.,\I ~"I'>e<nIlOmiI . 67~ In!e'"," ""'''tid an"" 'nI'~_"'"!I'I-8<lU I"uacr_ ~\'QefI ,,","'" (Incle_1CPJ p'_,.. · {;41 inlrect.... In'~ ... ~8'. urO/ ~dIabelel m.lIitu~ 1nQ<II5cIi . .... 0Ihe!rN11"-'1P)' - 307 I........... oIeeItOllI1OInIS lnsu!If>.i~o growlh IaclOf'1 ("1(.l5Of!lalO~ ""'C)·4041 kI10palhic InIr~ - ~V"""1Mk>rI (pseL.<lDiumor "",1IbrI) . 093 IItiWOP \<IkIpalNe itlI<lIC1ar>\ll ~e<>slcn wllno'" '" we '" '" 15"T ~Mf!mI' ~95 . . - , ap/IT,,"imoplegle. . 565 inI,matkll>Aj """""Il<fd '''UO - 2.l l6Q:Ialllic parJIy~IIg1!""" (P- - . , ' " dlMne) - ., I nlern~lOnaI SUbaredlnoi<l " efll(U"'asI'> " " - " T riol_ 803 """a~tallleler P"SII (mediellllol'l ro\ll4),or '""" ln~,,,,,,,,," ~'.m (H"'~) CO, low Datlc pain 1rO"_ '" " ,,~, ~G ~ U" '''' U' "'" "" "" .," MAOI "'" "' AST~ .... .,"0"'" ~ ~ "" N" "O~ N" -"" MMP' MPTP ."'"'"'". ~, foIrll pof;~"", ",,'lSI! lOW", moIO''''""" _.!l'IOIe«J ...... IIIg ~1 ('_1/_....,.rin3) lola O' coJltC\ou'nU$II_P,-"",,,"" - ~li rnotIO<I ..... o>klaa. inhibit", fOIl"" . ~ m~1 p'~S<J'e """" 0"' _IHma",,"""""'. pl1et...." •• 4 '::r.:::!PwIl 8 ...1' asciculw "'" m)'lee .. -IMV~ "'I"'Qflenlfl9ClClrie' " ~; '" muU!JI4elll'/elotM - 5 , ' Pe/"""iII'/ ""'_ 1-I1'1'1II")'I-4. ",....,,-1 .2,3. 6"'W.~1'd'0Il1'" · 41 MR'~y " ' 37 I!IOIII'IICI1Jn,e~ISJ""'.I'~"'''''' fI'I<I'~pll1 KIefQN • 49 m1c,O'.sculir 1Ieeomr>re"*'" "385 IIIQlectllar WBlg~' Na 0< NI! "$CXIiUm nitrou. nxid. " I NM N·acelyl.SPa<!aNl " 137 ..... SCET NoI!!l Ame"'." Sympt<ol'll411e CIo,Cdl<! Eft. ... rtrlreclO"'y TriaI - 81. "P 11.O.~" . nal~ ~ no40"'~ 38 .'' ' fO..... 361 norI°'l<!<okIaI .n'~amma""" Or"ll • 28 nM1fll/III <:411 eatr;e, ot !he 1ut>iI- "&Ii ... ''''''''....,.·3 _"ItId...,milinU .....rca!O>n ~ u.. RIII9tIo! 1o<!Q<1UdIf>aI1lrl'" menI' :148 0I0g0C_ tNt"<lS I" CSF/_ 51 OCGIpdoillOl'l<l'l"'" Itaclut8 ·121 ~;II-lfOl1l"''lelld) drcumle'...,. OfI'I""m." Jln """"""" «:'511"'- X"1fo/ ."..., ~ PI'''-'.(01'1 LP) (II;lltar~~raphy·811 o~""~m"l1.<~tlof, (I.. witl\OUl pre&c<'c)\iOI1) <>... ' "" pall·af1e!i\llesi. c-.e .".., (AKA r~ PM) (<>t~) arl.rn.s'lOdoY · 61 ~""" .... b,aCl>/al J»a>rus PIIlsy • .562 .'7 Dr ~, ~''''cc:y101'M - ~, P"e>u""'''''' _,,"ion _ ~,0I/lI0Inbjn complu """"""tt:olJo • 24 .. '" "" ,- '"'0' ~, ( ~II'l!\. ~~I IIIOfph"eSllll'" moIOI vaMlde acclde,u <>t~Ia<~ ",$<1" normlllll'''''''''''' i>yd"..,.~ •• 1l1li neurOplllI1oc ~n ossifles!ion 011"" posle<ior lDnglIuOItooi ~ on myo<:IItIIlol "'Ia!CIIon ~ -- RUOIl""'' ' lube ocuklrnoIo. ~hird ~' 1 opHr: _1I>e .tIIl~I''''''''· 4911 -..... -~ m~.m ..... nCIII _ _ ' . -~ InhltWlofy OOI>CO<1tr.,lon enltroooli!iof ","",oJib.roma\olIS· 50\! _I "" ON" ""' "" "'" "" - -'"«'Un," OR" '"''''" '110,.., i>D'r ' CO "'" ,.,- "*'utIoIJ<asl_ ~ 413 1IIiadIlIl;4lret>ta! 811ery NEUROSURGERY ~ ~ So""'" 1nde. - IlOO nIISIl cannl/l. " "'" """ NSAtO NSClC ~, miIIl!Il}I. n ti"'_,~ N" NW "" ''''' ~, ~$aClltlorf>c.5il _ ,~ _"""""" OIsordel, , 5Ol! _~1on~ 'I' fItI<101lring pG$ln, ,,-,lII>'aI ~ WO\9"' ..... " NO lube ~" 10<*'11'_ gIioml' 4G6 _ mcltct>la, IIotxltan MiMoI!I01a ~un'I>N&ic; ..... ,~ ,~ ."'If ,.womlty _r~""1! modlfiIKI '" '" '" PLED. PLr ~ '"' '"' 'N' "'M '''''' '''' ,~ ,~, • "'m orr "'" "" "', • '" "" P!riOiliioI PM\AryCNS Iymp~a · '61 PM'_ CIlmmunlc.11ng ""0<)' ~bu.I"'. CCNU. l """,",,1M (cr.tmOItwnpy) ~.", U>JIIIa...,. wedgl ~\en' ~u •• ~.rl<> .... pa/nlul diabellc""""", ... n, ~.O.MIn! • JIe Physlc:io:ns De •• F!1!1~ ~iaUni (inlillll$ & dnat'N pCsllruo emlssioro ~ (SCIII» .,..,."'" ",,1mOn.>ry luocIion ~ poxlr...,..,.,ic ...."'90 . 367 p/>ertyioIn (tliI.lnIin8j- 27 1 pn1<!Il'" Inl...... ctlet>ellllr 111161'/ I!QOieptIIorm CiIc!IatlIOs In\efDocly fusion poHioaoc "'.'~i ..... pos""" P1C\1"''''''"'""'" ",u~k>cIllI!uII.08nc;epNIoI>a. 1I'tJ ~ 23' .,- pctymy.lgla ' ...... maIlca · 61 ~iIc"" .. P1im_"" __ """ 1_ - ' 12 ~~~ PG"",'h1i<> , . .SIaM ~ynllI8!1c PCN JIIO!I.... _s~"'~-I'IUOI8at ~" o B petC\llMl(M)U' SIfi~ rniloI<Irny flo! ~_f.IOiA)· 36C plllionl ~)'$i<:1III!\efapy ; ",ptOll>follll)ln I,"'" pmgjIOfleOUJ IrigemlniOl IIIUo!Omy IIIn>mboIA$lln IIrN (0< APTT) p.o~1IIi pepllC uke! oi3e_ _......,.," .. ~tlHopLI.1V • 7~ l>I~uok>n-welg!>l.o irTwIgIng (MAl) " AA (L.'I1!; ~""""f meuflllllOlcl rills ,I'V1 1e ,""" ~ ttrroI _ _ """,encr "';'Dlomy ,~ lec~\ia l .o) LacIo, ¥II 136 • .... '" ',.,G "" ~·PA .n '" "" '" "" "" "'-, "" .,"" "'" "" "",. ,~ ,~ '"'''~ ,= "-'" ~ ~ '" "''' '" ,,,,. "" "'" "" '" """ ". ,., , ~ S1 1R .. ,~ ~ TlWI '""" "" """ "''' _ _ ...... CIIIIgIc .....IciI.!I6t ,. -~ n..t;opy ~ G""'II RMooIion I'~" _WltlYOI_ r._ ........ ~ (AJY, ...... __ ~ ...1 ~_~ (or XRT) ~ i'ltomotrl'llge ' 111 m /ug6I<) • 889 IiMuI pla""'"""'ll"" IOCINalOl P.~ ("" WlI)' 1300 rm.!O II>V"I' "' ' ' _"'II toDI""""': O\.KA TS,HIIi _-......·5().IDI w......... oeJ1tt14 II>ytOIcI ·MlIIO .....1itIg I'l0l.,,...., I«A l/Iv!OIrOPt" ~~~ "" ...... '" "" lI.nclala o..JalOn SIJb<I\IraI ......,.,..",. • 223 """ 'baC_~r03l<I ~ superior - - , . . . . , . , stMM .... """' ....... ~ae NO CO!. optIal inIu<\' • 8i8 SIOI"""'~1OIcI (1IlUIC1e) h . ..-...alhemI\Oma · 612 ""'lUI ep/leplicul (/oI .... ...n) • 26<1) II"rW opId.,,-, ab ....11 • 2~O 1000SSEI') _ _ I'ISOIl~~ apea/Ic QlMy sy(ld_OI~ • ..,.idiult!lo:ilo>r. """'" (AOH) seaelkln· 13 tud<I.n " faflt de"'" syncI'_ ""Ilb'1aMf """"II <II~ Iysltmie ~ e"l'h_POUI ... ~ i!)i ~_~r~ '" WI!ut-1!OI1 'Mom",,,, ... _~ . __ ,.,bo\ItIne_1r<jee!Jon 1!etw*1ic: r.<!Ica.IJ9I<)' - 537 (or 8Ep) _--.v ewI<eCI~ -tOIIno ~Ii!i$. lOW''''' Mltc\lo._~.~ ",,*;0. '.5 _!"-' ..... ~ 1....PDlIII.ne.y Su~ T nllltl""'l'OIIebr"' I1 __ ·M. _ · ............ .....-tUlllirnlop) ~\UIio:_I" ___ ::,t._1cuIe! IK",..,... _ . ", T1~~ !CI<1 "'I'Ij).,3oI It ~ IINOe ~ IoIAIJ• 1:15 - ... "_bl*'itojo.ry 1\1CyCIIC..,~ "8RIC'_~ -~-- . ~, 1ilN1O_(""1oCFI~ . , 10*--,_,.,...... 11_ _ _111(81_--"" Ir-... "'0"' "n "" '"' "w """_ ...... l!Ir<ImOO!k"r~_. ----. ~..,..... ' " - otI<ICI.O',ICIn$ ' ~ ~"_' ~ DlIOI1I oc,tc:Wo (..... MAl) ..-y1r"",W.*- - --- upptoI ""tlOty ".ocl~ ~ ..wy.,,~ ... ..nMIIII_""'" .....W""'"''" == .... ~ lGN 1riC _ _JulQIoo. 371 T·H Iw1eoo l~ . .....,kIo\_ - 1O flA iIcfII<IoIc 1IIIad< . 1159 • _ _ (.a-w)~., ' t "~ .,..,110<-..1 ~ InIOlObocly "'.... nso '"' "" " 1Mf:lpy .,;gr..-~ __ ... acw.1Dr I'f'I'IPlI*membrQ". b _ 1 momcuIat 111;,,0...... (1OITIaUj!>SIo; \IffIt!I! • _~u...:.... (_) .•S9 ........ 111..., ____ ~ - --bng,, ...... , ..,,- '" _ .. 0rgI0nIt ...... ~-....,. v.._ tat RT)(, _ _ - Rz - ""..,,;- -..10 -• causes Of "*"'" ~ -~~) --. ~ (~$OMI In 0n<:ribtIg ",""",Of Iefri. -J .~oIlNlII~_ * • 1: ,. 0 !II*.""_ .... ........, ~'~~' " _ .."",,_\JRI.~ medical pearl. ~_orIIIOIiI NEUROSURGERY I. Ctnfral c.an~ I 1.1 . ~aIol J .5. l a l ...... ''''' ...... e Il 3.6'. MiKdllo ...... 84 l.1. "'""'I'b)'Sioloo 84 37.1 8_-Ini~botY\n8' ] 1.2 RcJ:i<mal bniJo J)ndIann U J .1.3 Jwptar ra.-. I)""""" It> ) 1.4 Poriolallcll:& .ylOdroonoo 17 )U . 801>iftU<i .. '" at I.l. C r ~c""- l 1.1 1 H~l 1.1.1. Hl'I'I*_ t>hock16 • .1.3 Nnrop""''''''''-''odom.1 I .J.~I I.!U. IA. 1.'.1. Sit"'" • n..w.""" £10<:1.01,.... II Ele<tIOI,.. abooornW,j, ... 12 1.5. H...... 1GIoo I' 1.l.1. 8IoodCCNlOpOflClWihc'''Pl'19 I.l.l. CooaulolJorl2' l.l.'. E>~U"'l' _OIOf'QidI, 1'1 1.6. "" armKO!oc1 l7 1-'.1. A.......... 21 1.6.2. Aftuspumod"'oImuock ,.. ....... J<I 1.6.3. IlallOd.atq»_U 1.6.-1 . 1 1 .6. " .... h oMl.y ... 9oI ... ,.. hnoiotcyou.\nI..., ....... C).I 4.1 ,1 "'..I\tIoIcI~)'StI.I.u....pl... ~ 4. 1. ~.I . t ~ .l. 1.1. Scd.o,,,... &.pu&lyl"" J6 DtmrfttJ . .... Iindoch..... 1>11".,.. 2.2 .1. 41 I'0Il U'(onyd<>c ...n) Il!/I 46 2..l.1 . U. Pa""...o~t<m U . M~II!pI ..<..raolo U. _)'OI. opllk 4' 49 2 • .l. J. Nfl&~ "ri<<) .u98 no ,-,trII' .....' OSIO 51 1.6. C ~IIl"""8""".)'a_ 5J 2.7. M,.lillf!5 U . \'Hto......s.o.r<eIdlISb: 5' 2.' . V-..litb: ......""",lapIlb] 58 2.9.1 . O.... ,COO _riliJ (CCAJ sa U.1 I'oly..,yal"" ,""""'-" " 1.9.1 . 0. .....~~,~ ... 61 19A F"--.onblrd)'opIawl>l Hlp01llol"",1t ha"",r1omas '" ~A, 4 ~1 . C'rWI~OO>l""" 99 4.lJ. Enocph.lo«l<: 102 4.1>. Chl.r1 """ fo.",.l loo 10J 4.1 . O.nd)'·Wolk... ..,rJfo, ,,," rio<lllO U . A'Iu.duClaI Ik_1t 11 0 4.,. N<w,MI I.. t...Jd'", .. 11I 4.91 . A.~"OI'IM...,....nlJcm.m II. 4.9.2. Spin ~ 1 dylToplima (spina blf\6a) 11 4 4.1 0. Klippf! .FdI oyadnI_ I" (.II . T~II .."'eonI J)nd ..... 4.12. SpJiI <O«I _Ihonnl ll!>n III 4.U. MiKdI _ _ . 1""......111 .......... lief I II 1. N.... rotogy 44 1 .1, 1.1. s.. • •" . Ref.... _ 12.1 NtW"Of"Ydlology lUi V-..J ... d ) "," ~1OI)' lKCp .........1.b)' 64 1,11. Rof• ......nt 66 Nturo. n~tom)' Ynd ph)'siolO&)' 68 l .l . SII.l'l cu,,,,,,,,,,, 6S 3.1.1 . COt1iu1 ... 1nJoIOIII161 ) 1.2. Soor!..,.~ ., IIIa ••_lum69 ll.l S.rr...,.l>ndmarUOI...mcolk.eb rrl<C " 1"" ., '1I00I. """1.0, 11 J.1. C. , alal "".... 7J J .3. SpI .... .... d .., . ..... y 7) J.3 .L . SpinaicordltXlI 71 3.3.2. Qe, ....,orntJ.vod .eo.o.), ......... 1. 3.3.3. Sr lslal cord •• J<u,.,.... 11 J.4 . C.,ebn......-ut., . nlIOIny " 3.4. 1. Ce .. lxal 'OUO\II .. l~ H 2. C.r$'ol _ria, "MlOIf1)" TI JA.3. Cc .. blal "UOno" "OftI)' 11 ,.ni,Otic-. CONTENTS CMtrasl-cnIS'" ... rtneIioIoc1 5.1. 5.l. SJ . SA. l~ kId~ ",,,Il'" H I S.11. Mbcdl _ _. _ 6 4 1.11. 1..1............ llipoom .. 96 U . 4.5. C .. nlol"o<ial .... fI<>tI"' .... 98 4 .51 Nonnal<k"'iop"",nl9B /I.iII ;ahihl'or. 010 Itd.... n..' 41 1 6.l. 8tar1c1n ........ Y'icIIo&)'l9 U. R _ n 4. De"dopmt ntal anomaliu 94 oIlaty pep III R....,hO... lOinn~_u .. <>IIfttm.I _"Ill CAT .... " 1]1 """"",""",{ ... ,-m.. lj 1]0 M~ .""""""lmIJi"l(.'tI.1) ,~ Wonna,_ tlol ).01.1 . Gnoo.... 1,4.2. D;ffIrticM\·Miaf\lCd ,....,,.,. IDWI) SAJ . """ per("'''''''i ..... 'ftl{l'W l) ' " M'IIInelicrcsonMa!-sp«~ (MRS) 1J7 Plala nl .... 138 5.5 . B. I SUI! fi lmllJ1 S.U.. Lumbof.oorai (Uhp''' 1010 5.5.3 . C-S~I"" 1<10 5..6. Mytlogropby 141 5.1. 80 ... SIjaJI 14J ! ,j. R. I• ..., ...... 'O 6, EI""lrodtagnosli(:5" 145 6.1 . Elulrooncep/laiCll'".m ( EEC) lotS ," u. 6..l. r., ....td ""woUah 145 F.Wtt.....'OVOp!oyl'L\.G) .U 'A. IUftr'UlCU'" "7 . Ntl>rolo~kologJr 149 1.1. Elhuoll., U. Opkll&; 151 U . C"""", III lA . "'",ph.tamlna IS) 1.5. Rd.....,..... ISJ Il.!I.1. ocpll.)~i.12? ,10", 1M . 54 AIIP ...... h 111.11< _ _ "".ifftl 1S6 '3. U. IIttn"' ..... .,. ....._ 119 1.1.1 . C..-I ............. 100 U.1. U... "' ......""iooII61 .... IIYpOdr<oml . 61 1 .5. Rdtt.... a IU 9.1. '.3. t.l. 1~ arlin .... th In odul .. 1601 B.. ln .... thln~blld'Ml" 0rJu aod u..... do~ltlon I" 411 CnlcrilrOtqyoJir"'OIICH\I«orpn ...... ,,,,,,161 Orpn...,...;o"", . . .I1 ...;u,1no<o iIIlJIOIl 16\1 M....Jm>mlIr.. . .'n-u, I<Ir<lr. 931 qJ..l .ondDtlol1Ofl16\l U . IItI,",,~a 170 10. CufbrMpl .. al n uld 171 10.1. Iu. IOJ. 10... 10.5. C. .. r "l~romn.LlQn 17 1 ('Sf c"'.. d •....",. 171 Artlr..1oJ c...r 17. CSf fbi .... 17~ Spon~_ ,n 10.0. 11..,.... _ In.......... nlll ~ypOloooioo 11.1. T, .......... ol h yd~h.I'" I n 1111 S""" .. 117 11.2. S hMn.p,o ble""' I~J 11.1. Norm .. p..-.-. hyd ...... pblluI 19Il I IA. 8Undroao ' rom hyd~ph.I ~.lOl 11.5. Hyd ...."1' .... us.., d p'tplnq ZOJ 11-'. IItlo'*"<a2O-l Il . l nftttlarn: "208 n .l . Cn>enlial.......... a t18 I U.l Spoo;ir...... ,booIt<.208 Aotllboota ror ~'r.. lIr&""i...u '" 11.:1. ,. ... plly .... riunUbiolks21l 1l.J. M."llJi!lio2U 12.:1.l. POSH''''l'OI u''lk-a! procedu",..,.· in,ilis'lll U.J.l. ra...mUo.-p.nl ,.. u...........1'... 11.)..1. IU... (pO...... _ ;., _ .."",~lI)1 1 1 1I<c~ .. _nl,.lli.lI1 A""biotin lOt <>rJIfIISfI'" .pe."'' 1.~.21) 11 .... Sb .... IIlfHlIon 1 1( 12.5. WOol .... lnlttlLon:o 1 1' 11.5.1. L..rwnr<' OOIy"OIInd I.....KliooIll6 Ilob. OtteomrcUIliol lh,oj,.ull117 fl .7. C....bnI..b&<:<$I1 I' 11.7.1 . .s...... ""..-1 ........1."" fl<'>dll<; ..... .111 U .ll. Paral.k 1,nfr<1ioolt ft"l1< e NS 2J6 11.14. FIMIpI ;."'dlom .r .... eNS 09 11.15. SpIDf ..rift ...... wt 1115.1 s,.wI.~_a. lotU 11 15.2 . v. ndonl.-.....,....'I.' !4l Il.!D. 0;"'1;0 1(' 11.16. ll.or......... 151 I3.Sdzurl'S !56 .. IJ .I. StlruH ota..II1<aMon 15' tl.l I fOCIOnIll .. Io..-cr''''"''U>ftI~~ ,,~ 1J.l. SpecW '111t'> 01 $tI.~ra zg Ill. l. /<4"CIMd>e«om:sl5S III J. 1'uwno.l'-"l<lDRn 160 t).l.J "I<ohoi witMrlw.~ ..I,-.}Iol I) 1.... Noarpikp..: $Oit"", WZ I} l .s Fcbrilcu;.~ l(IoI IJ J . Sc.o"... piltpI1 .... lM 1)".1. o. ..",llJU lmcm ""'""'lIlT.' 10< w· In L 11I1<."kpo ino> lU .... ""..".,"".. for I"nrrlli1C4C011",I . ."•• """" .pilop'iwo UI6 Miwcllaroeotn _ ....... l<1!l1Cll1 :!68 1l.J.I. "alMpikptk ..... p 161 IlA .1. C1W,r_ofAEDll" IJ.... IH 2 . 119 II . HydriKfphaJus 180 11.1 I M ~I~loeal ~1rl«1"'_.Inol<.... • 12.10. C., u i:I.~IdI.JI.oI>d"'_ U1 12.1I. NOll rol"lk" ml nn.. ~ll ..... at "' 1I1..~ %J(I 11.11 . ..ymc diHloe· ... ....oIo&I< ",..,IIttt.· 8. Com.1S4 U. (; .....-01 9. Brai .. duO. ....... m SuW"""~"'P~"" UJ IU. \1taI oacqo ..... i' b US n ' I He<po> ..""",,~ mcc"".liIk 1tl n.l. Ooat""oI"'I~leprc"",,7M IlA.J. A.I..........u.fIl~r')111'l IJ.!. Sd.~" ... '"Ift")' 181 13.6. 1I. '.rrnra U6" 14.Splne and spl ...l ronl 189 I ~. I . ..., ... b... k ""In IIDd rld •.'uJ<>polhy 189 lal<r • • rt<bMr1 d isc .........1I0 .. :lG I 1~ .l. 1 Lumlwdisc IocrllJltiorrlOl 1 ~ 2.l . Otmut di ... h<mi_ 111 , _rc .."" ........ ,;..,,)7.1 1• .1. ,.1.) 1• .3. ~yt.iwllpl.rtlloeMtJlJ IU .I . St>i>rol)l<""o,,,ns I.... . C n~lcaIjlrfl<lIo., .... uWOl' ...... ,~ .ptno .IoMruIIJUIN JJ6 IU . 1IbNa>I.oId.rtbriU.n1 1 ~ .5 I. UPiJtf«f"41.,....... -ol ..c....ru '" 1406 . P. ,eI·.dioe_:l4O 14 ' .1. p~·.<Ii_orlll<lf'!""141 1• .1 . .......)~ •• .,......ylllilJ4l " ... ()Mifln,1DtI 0( tile pOIl.rlor ,""Iadl. 001 IJpmcm (OPU) :145 1'-'. o.IIIau...llf cho ..'ttIork>a$il"" ..... lip_I (O,-\t.t.1J46 I ~. ". OIIT_Id "p'''IIk_'''h~lOIIb ,.. lUI. SpinrolA\lM.J41 1(.11. Spll>1II m ... lrlgHl <ysl$).IS I~ . IJ. S yrl ~o",y.n. 14 U .I J.t9 NO/H."" ..... i< "l'""'....'~I,. J50 CONTENTS I ~ . U.l. PosI"""","IIC .y';"JlOITI~U. 3S I Syringob<llbillSa 14. 14. Splul.pldll." h . ....1O.... 3SJ 17.1..21. Mooilo,...;,u,prinwyt>l\ll.,U/lIUf> 1 ~ . I).l . 14. 11. S",,,,,I'ubdu u " hot""' ....... m 14.1'. CO<C'Jdynl. JSl 14.11. IId~ •• I>«S.l5S I S. Functional n~uf"1)5urgtr)' 36S 15. 1. IIr.l~ ",. ppla ~ 3M 15.2. S""IkaL IrulGltn, of ... . kl _ ' . cU!.. I S~. - '" UA. Tor1ItoIlb 376 Spa>tl<h)' lii7 15.5. N.......~IK"Ia. «Impnss lon .)1Id ......... '" 15.5 .1 H~ml fl<i.I_", 3 1 1 15.6. KYp'rbldn>d<51 J7J 15.1. T ••..-J1J IS..I!L. Sympa,hec'OfI!J'J7J IS.... Rortu _ J74 16.PBln 376 16.1. N..... _IhlO' ... u.5Jadrorncs 376 16.2 . C r . ~ i "rori .1 poUD .y ndro"," 317 16.l.I . "l'ri,• .m,..ll>Oural,1a 373 16.2..2. (a">$"pbAl)'n~ ...>nl!io 186 16.2.1. Genicula .. I>OlIrol,11 386 16.3. Po<~Ir ""IU"~. J8'7 16,.1 . ..... po-ond ...,.." J90 16.' .1. 16.4':' 16 A3 16.4.4. 16.U . C.. do!GmJ 391 Corn",\.",rol myelOlQtI>y m """".... midll ... m)'1!kI<Qmy391 CNS nar'~ ic od"'in; , u","",)9) Spin. 1'Old Jl;",u~ioq (SCSl195 16.U. o..p bt10iD "'",ul."oo lOX 16.4.7. Onnlllt>Ol~"'1}' <OI'e(OIlEZ) ~ rion. J9S 11>.'.1. no.l" IIOlomy J% 16.5. Complex ~ poln S)'lIdrom. (CJU>SJ J'Ui 16.6. '" 17.3. ..edl. llk bn ie ''' '''''" "-80 17.4. S/.;uIIwm..... "-80 17".1. o._Ut 17 .~2. tI.mon!iotnl4BI Epl""""",d ... dlknnoi.llUln<nol' ...... ,~uIl481 Eo.'nop/Iifo< iranllk",,. 482 No.·n«>pI ... ,1c . kullie<io!>. 4S] 17,01.1. 11.' .4. 17 .• .!i. 17.5. C.n-b<. l m. l.o5laon ~ 17.6. C.n:illO<MlOW _nln~tJ . 4 9 t 17.7. Fo,amtn mlinu", '"m0l"1 4,2 17.l1. Idl"""lhk "" ' Knul" ~y ..."rnMlln '" 17.9. Empt)' H ll.o . ynd, ...... 499 11. IG. Tu",,,.. "",.k... 500 11.11. dJ .......n501 N."•..."......,.... 17.11 . 1. t-kurofob",maIOI;S 50! 17.11.2. TIIbon)U<tck .... ,.5OoI 11.11.3. Snav--Wd.."yndt""",SOl J7.12. Sp;... and Of'ln~1 _d IUIJIOI"l Sll6 17.12. 1. In\Iamt<I<JIlIU)' 1COld I."""" Il .IU . BontI",,,,".oI' liKSpII>OSII 17.12.J. Spino! rpidll ..1 OI"O>!.U<:' Sl 6 11.11. Rd' nna& 511 18. Rlldllitipn thnapy 5J4 ... Ie.! . Con.rn, IoQal IS.II . 1&.1.2. Rer.,me.. Ml8 11 .2. SIt'tolloC6c ndiOSUrtltry 5J7 Iiol. IDltnlltial ~ """lIy u.."pr SoIl 18.4. Rer. , mmo Soll 19.5ttrtlllactk surgny 545 L9 ." Itd....M ... ~ 20.1 . BrKhil.1 plt"lIus 55 1 ...,lphtroL IItIlFOJ>I'lht.. 553 1Il:2..1 MI..,lelftjuJiduil"'rip/l<r.Il"" ..... l eU. 17.1. Gmt nol l nro ",, ~ , IoA oiOl 11.1.1. Bnti.... ,.ldinlcal .... """$· '.... pK"~ 1O:2l. 17 .2. 1'rInI.'y bt.iDlu"' ..... o!O& n .2.1 . IAwil"",,!llom •• 4Oe 11.1,1.. AJIIQC)1Of1l1 4O\l 172.3_ OIlg<Jd< n dtv~ l l _ 11.2,1 . En""P'I"'nl """opol/llu 563 XI.5. lI er......, ... 517 4D 21. Neurophlha lmoklgy 580 Ct"""II>O"""'Ylom ~ 4:!5 lU . 1 1.~.5 M .~lngiOHl" A~"'lku"'ml419 11~ 11 2,7. Pi,."'lr)'adtIlOmU08 Cr.taiql/llr)'ni'orn.4}(i 4M Ihl/lu· l ct.n~~$I4H CoUOId~~"451 tlr","nSiot>l"'omI4S1l CNS Iympll<l"" 461 Cltor-cloml ~ 64 112 .14, alngt""liomI466 17.2 u. l'.... i.,,'~om. <I61 112.16. EpondY""'mI~7(l 172 .11 . Plinll!l"" l>Ouf"llCClOCkmMl "''''''' tPN€l)47l '" W .3. T ha,ati< 01111., $)nd""". 516 2004 . Misc.II."..,.... pc-tipbo ..1n.... 577 11:Z1l .""d,,,,,,,,id 11.2.18 . fpldmnoid ru""", 474 17.1..19. PInul •• 'io!>rurnon .... 7b 17..2.lO. Cltoroid pl.~~II~""""$ 479 CONTENTS tx'.......1bn m , .,II", lon Cllnillllll •• " ... SJS SpiOlI rad ,.tlQn SlG ZO.Pulpl'lfrll l nerve:!i 548 11.Tumur 4(11 11:2.1. 11 .2.9. 11,;UQ. 11.2.11 11.2 .11. t7:2.11. '1',... ~. NyotaplUl 5SO I'rIpUltdtma sao 21.l. l"u"'Il.ory dJ~Q""" sa l "21 J .t . A~ ••• """. In pupillory iii. ..... ' • • Sal ... .j'l,.... 1l A. E~' ... ocu l. r .... tor S84 1U . Ml$«llIInrous /ltliropbt/lII""""ci. lUi. ", RoI"....,.. S89 22.Nt urpjol0l0' 590 n.l . OiQiDUUJHhffl IJo5'" 11 .2. Mm"",'lr dt._ S91 Uol . !'odol ,.. ..... pWy 5n 21 .... H" rtnc tos< 5t7 11.5. Rdu. n<.. S ~ D .Ope.r:al loru; and proctdUR$ 599 U .I. 1""lOpr",.h. d,.. 599 U.2 . Opo ralinS room .... "lpmeM S99 " 2.1.1. S.... t;I<.1 h.mn<UIW IiOO 23... "'n,erlor I pp',,",ch... 10 ,II. opine 600 23.s. c..""lolf.mln 601 13",.1. POI'.rlOt 10011 (~boo:fp'tlil tf1II,e<tomy 6O-l n',l P\cnOnaJ c""'~O/II) 6011 lJ ..'D . T.~\P<'r~ '''"''''amy 60S U.5.4 FIOIU" c..niolomy ro9 lLU. Skull ba>e "or&",), 60\1 13.5.6 Pwol.1 tI. . ~omy 610 "21-'.1. "'ppnw-bo. 10 tho '''....1 ~I< '" n.s,l, "'Pfl'_b<~ . o ,lie l ~inI """trick 610 23-'9, l .ttJIIo:m"~k'_'h611 1U. 10. 00<1", ..1cruidomy 612 :U .6. nklp!uly6Il 23 .7. "~~rIo<lpp ..... chalo ll>o . pI ... 61l Il.l.l T .... .;or.1 0pJ>IO"'h <0 anttllo. c..... _ 10(1"\'0001 )""",;0" ~1 J D .12 ... omior ",CC$S 10 ll>o.Uf'o 0«>-1110...,ltjl.nlo,lonIuppe, ,ikn<ic "P'" e... 1] .7.l . ." n.? ~ "';';'1'1",,613 "'ntt"'" OCC .... IO Ihorat:oI\Kr\lw U .1",. "'n"""" .«nolO mid" J-<'_6 1~ ... ....i.QO "'«MIO ,)&kMt>bAt.pine ." 13.8. 1'm:tt.."""... _ 1) 1.1. "lU.2. lUJ. ~1tIo· ". VOlllm."" _ . "'100 621 ""'<t:I ...... 2).9 ", rinrloolOn[y6U 1).9 5 LI' ..... IIl 621 ll.lO. s..flIl ....... bIopoy 521 13.11. Suf"Jkal ' lISf"" of Ui. ~lcahpIJN W lUI I Upper "",ylc;." .... bl..l un. 8_ .... ft 6U 1l.U . N_ bloo:b U7 B.IJ.I . Sl<JWe pnJIiorIl>Io<\ 621 2).132. Lumbar" Iymp.doclle bll>cl 617 HoI).J In_",,*, """e IrIoc:k 621 !l,III . lI de... ....,.n. 24. lit .d Inurn. 632 M.1. Traasrtf"(>I'1.." .... ,..tiottll7 Mol. ~bn ., .......( In EIR 6J7 14.1..1. Nar ........ ocaI ... """~ .......... lIl1 24.1 .2. It~ .. no _ _ 6010 !H.3. EIIt .......' _ ......r... 64 1 20'1.... &pIonooryllou .......... 64S 14.3. 11'1_ ...... JIfUAInt-'1 M.31 GftIeral"'f....... _ _ lCPfIol1 14J.l ICP _ ....1... 1\019 2A.J..I Icp ""..",... _ 1 I » 2A.3A Hilh-drcrK bartIo_ dIcnpr 1161 :.... Sk .... f f1l<ta<a 1064 14)1 1 PtpmKd"'ull fr..... oes~ 20''' 1. a.. ..."u (nco ...... us • c•.....,r...;.! ,....."" 661 ... S ~ "\I 'rllC ... ,~ .I" podllln< poIlefttl 14.5. H_ .... "lcCO)ftI.oIo« 6119.. !-l.6. Epitluro.l b..... _ 669 - " lA .7. Subd uflI' lIo",ol<lfll.l,n ' 241.1. ........ ..-""""-671 Z4.1.1. 2'-13 . ~oubd ....l 14.7.• • ",l,oll-' o.""",,"-rW""InOIOf1t1I17<t _ '" T......"..io-..lllyt_li71 E/; ...... ioI n.. od <"OI1<rcUo<to ,0<hOl· dofn 678 14.... Nuu;.1on In 011< .....-1,y..'"" ,..11... .~ o..'-.efrom"""'ln_'" ...,.,681 14'. 1H.1. "N.9.l 1"9.3 . ., OU!CCOD<~6I1 ~"""",Ii<_tr_""",,,'II"'Y 2otJ I. G ..... IIot ............ to'~r_ 6801 20'. 11. Noa....u.llr ,.-rodflllho& .......... ci86 24.I!. HIp ........ _ ....... 681 :.&.13. l'edlIlrk....., '-Jury ""' 14.U I Cq:rItIItt&matamI6&I 7~.IJ':'! Ch,lcl_ 619 101 •••. Rd..-- ' " lS.Spine ill.luriu 698 IoI .... c.."'"/Io"S6 ' . 1'1:","",,_ ....tlicul.. pun<"". Su!>Ou' ''Uopbl. lIIml>Arptoct~ ... 61~ a ..... CI.2""nc:,vrcmdc,wrmalIlop6 11 D.9. t;SFdI"'nMlul"]' plD<K"tft ' " 2).9 I VC'llnO;ular clll\l!tonufloa 619 23.92. V~n.n.ulol.lOmyIlC P tMAi ..... 6;tO 13 9J . \1... 01< ...... ,.... 1120 D.9.4. •J ! • .~... ~4 2:5.1. W •• pWb-'-'",~," U.1. p.o;',u"" spIoo U.J. l.iIIIl ....... _ . of .pIn&/CO)'" "V.... I.j_""" '" o ,to 15.... N......-.p:.I_I liO U.5. SpIJOIIl.-I\-.Iu ..... , " IS", .I CornpItIO.,...m ...... iaJlUlO 713 US.:.! IIICCII!lI'ictelJ'ifl4lcoodirojufics714 IU. koII'p;,. rntt .... 717 1.5.5.1 . Ad"'''HICCipioaldllloCllloo 711 e..... e IH,l. OcdpitaJ"lltrNC~721 1.5.6.3 lJ.6... U .6", U.6.6. "" ........ ldi\lotlrl IOll7l1 ....111 (el) fnrc"''''' nl A~ .. (01 r.... ~"'. nA . C_"... . CI .lirtJ"!'Cf7)1 SubUiol(O lItmu,hC7) ,njlr.rlerlf..,,,,_7U Tn:OlopeO. 01' ... bal<oal ttn ...1Mil" ' . ........ 7)9 Spom ",11lIItI o;e ... ",,1 opi ...njuric. 2!i 61 "B.6.1. U .6.9. '" "2S 6.10. Ptb)"td . .... jcaI i<QllIbiluy 7'J l!i61 1 91,,", «:ntlnI.....,. in"n ... 7,u l!i.7. n." - - o p l n c ' '''''lIrti1.w U.I. ~fr .......... 7H 15.... c..10$1!61 ,"011_ 10 ,'''' 'PIIM\ 753 !S.IO. hntirilloo ....." ....... ,'''' DIdo; 7!-6 :5 J C"IIn!nk fJI ' plnll """' la,JuM$lSS !Soil. ltd, ....... 757 I. ......,...."1 l6. Ctnbro....51\:ulllI accidents 163 ;6.1. Slra..1r! .......176.1 2U.I . 16.I.l. 16.1..) M.I A. ,I!." Modif"..tIk fx",," lor wake 764 e • .oIuOlol)ft760 M....,........ 'ofll li'ED.n .... orC ...... ". Card....",," \IonoiuIDboll$m 71J CONT~NTS 16.1 . eVA In ,o"~. 011" ' 1$ 174 l.Kunor Mr...... 176 lAOA. MooU._ .... CVA 178 !'.5. Ih·r...... no .. 17. 16,). ICH In ~_..rn:ru 101..-..... ~emoN"'~ In 1M !!.Ill!:. 19.1. :!9.l. ......,/1'" 19.1. Md~ ........ 8&! _... 3U .0cC:Iu'i"~C\'I"dJro· ... sc:u l. r dl5ease 869 ..MI.I. Albor_k.or.bo-•• _ r di... 11.SAII .. nd .Innu·Y5ms 7111 n .l . 1• •• DClotctI .... O$A II 7. , ll.J . C ..... I•• SA H 7115 n.). InlIl.I .... ~ 1 ..,5A " 1M Vuoopum 1tl l H 1 Oo:r""d_741 nU ~tritrjq: nl «I't\II.J ... _ 1U. n .t.). -". Carocid IIIU)' WI lI).I.2. V..,<bo</booil. i _ff",ICIO')'" .!oIl.l. Cotnb.. l ..vn.t dbHnMm 8Il )0 1.1 . lO':"l JOU. C-Id <lll,.,..;...,n, V~I .. . ~ ... ......,.~ ,,,,,,,!86 ...... ... P.. boct...·191 le'). £ u no:roalol-ln.rKl'UlaI (ECIlC) by· 17A.l ~.. oI< ...bnoI..-,.."' 191 Tru,,,,,, .. lor 7904 ~1JI.6 V-.pMIII .............. '"pI-.oI" JeA. Crrrlo, D• '" 30.5. MoJUDD)'_ d._an 11,4-" . _~ H.!I . C* ....."'., In.II')._799 11.$.1. CoIodnlou iHlQ<l _ ," ,' h oncu- ryn>101 11.6. 'ttftl ....... ~IonJ for l a ... ry.wa.101 11.7. nftllnt or ... M.., ...........1'). I&l 27 ". Cr ...... 1.. /lnk.1 <onlld.noll..... .., .n· ."r1,,",,"~,,1105 21 •• I In' ~';'·"o","'Y'''' """ . .. 101 17.'. A"" .. ry ... ruur.-e~ oftf,r Ino '''''''' ." J7 .1 0. "'n,,,,")",,", ,ypo b, loco" ..., ' 10 17.111.1 Anocnorm''''''untull''S _ ry . ... u. ')'Im,I IO 17.10.2 O,llOl ""toe""" <" ri>ral lfICry ........ ry_1 11 27. 10.J . I'<lIotoerior _I)' In· • "O' " ml ll 27 .10.4 C_id ~,mll\11:1(bif"r<:... '"",m"",,"'''' I)'IJIU III """I_... 17 111.5 M I6d~ 27 .10.6 1)'.",, 811 S. P""III'o••h"""'l' .....l~ I II "-no.cirtu'lIlorI"",,,,>_") n 107 2710.. n .ll . ,. ".!oI ."ff"J' (MCAI . "' . · a.lilorl>oflllClllo. ~ 115 U".lIpt"'.......".,......II' n .ll. M.,'I...........'~ ....." 17.Il. r ....IH .....*...)...... ' 9 _"')_.:0 n . I~ . Tr'M...1It 17.U . M.to;(llk ..."t'fS..... , l Clon. .....".."..U SAI l Dl lllk ...... .. 17. 1'. NOOIaot • .."..... SAil I II !7. 1, . I"rqMIIQ'IIt 1.. ~I"'_"".e n .•,n.n. 1aoI'"*'·.n on 17.lf. Rtf.. _ .lAO 28. Vll§Cull r mll rlWml liOl'V8.\5 "''''''_allo"135 ztI .l. Art ..... _ _ :II.l. v....'" ZlU. ARc\ovo""lrall, 1M'nI I, .",I_1l'I "'''"'or ",11f_a,""" $>10 ~I.J . ' . C..ettIOII. mol (armauon lol t 111.1 . l)u •• t AVMUl 1lI.5. v.1n IJI C.I.., ",.lforma''''" 144 111.6. C ...... kI .... . er nou. n.'~I. 845 1A.7. k.rtr .....,S46 19. hl l ra~rebrlll h( ",urrh~KI' 849 29. 1. In,,,.,,,,ebr " M ..... ' ~1t" In I ~ '" CONTENTS Je.6. ...,Illo, _ II............ tI.r.... ...,.. 195 J I. Oulcomr 156tSSmrnl 899 11.1. Kde...-901 32. DilTrrr ntial dlagnt>51l; J02 31.1 . Dil'f.~ .. j;" d!.ogn"",,, tOO_) by oi~ . nd .y"""1" .... M J2 L.I Myebplollly'102 32.1 2. SclOl ic.a ~ 1.1 Loo.o bo<;k pain 901 12.1 4 1'ooI1I"'l'909 12.1.5. We oX"",,I"up/Iy ar ,he h.l.nliolUEr n '" HIlli<:ulap:llhy.uWCI." .. m,.y{CCf' '1CI1)9 11 Jl. 1.7. N.d po;o (.,.",.,,1 poi .l fl ! ll_I" 1J\tmlJ' .. 911 nJ9 8 ....".S ......wrecl9 11 J2J .•O. MlIKlep:oWlo ........ 911 n.'.'I . ...<..... pcwplqlo .. ql'ldnpio1Jt. 9 1) 12. ' .12. 11.~.is ... "" IIIipI.".' I ~ 32.l1J Syocnpo _ _I.. 3!.1.6 ·.'i,. ) 9 1~ 'IS 31 J 14 lU.lj 1!nccpIuIopo1ll)'913 T' .........lII'OIask60r",,, J2 1.1 6. Diptop..916 :12.' 17_ A....,.,;a 916 12.1.... M....1pIo <nai.tl ......, ~lliQ (ctarloll ... """""'OUC')917 '32.1.19. 8 ;no<IIl.. bI~9 11 32.' .20. Monactolar bliOldoow. 919 32.1.21. ~91 9 n. '.21. hllI.;lIaslo lid ~ hon9 t' 12.LU. Mac .... .".,..I)"19 ll.I.loI. T;",,;,... 'Y.! I 1l.US. FIO'IOI.......,.,.tlw.rlctS92 1 ». 1.26 Looo_ e dislout>An<c 92 1 12.121. S... III> ..,", diff'ICIIKon 921 J 1.2. OiIT./'tfII'1oi d~ ( D()~1 by Ion · ....,,921 11.1 .1. Ct.rtb<j!won'i~"," (CPA1"" .ion; 922 :.I21.l. ll.2.1. l l .l .... PO>ltf.... rl)O~ IotOM 9D Fnrom<n i<1i<JII1924 ".,..'110..101 JubIU.., k., 9:!-i .... .. (C 2) • • ,.".bf. 10>...... 924 MUlliplc l/IIIac ,.,,'O' lu ...... on CT Jl.! .!1 ll.2 .6. mq.o"''' ", MRI9n .1 31.2.7. Rfn&~"h_ln, 32:18. '" 31,1.9. n.2 .11l. 322. 11 IU ,I"L 32.2.13 32.2.1 4 12.1J!i lesion.- <HI CTIMIU U"~ ot""'rIo'"","lhy 926 C<wpon nllOl"m 1Il1 Soli .. ,oil _I(..-I..ion, 9li IntnIC"'n,>.I <y,u 9'23 0'1o<1Ol !eJloO$ 929 CIWmoI!' jjn<" blQ",929 S~ull "'~iOM 9J() Comblhtd ,nU-=rlni.lle.o".. ranb.l ",.;o.u.9n 12.2.16 InlfXnI","1 c-okirrcaH""i 9)] 12.2.17, In''''vtn<r\cul.. 1<';011$ 9J4 ~i J1.2.IS. f\>ri .... nlticlll ... l..i""-, 936 31.2.19. M,","Il"'" ,,,kkenlna/cM:oooomtnl ". JVLM. Ep<n<!) ....1 oind lubop<n<!ym.l,n. """"'In,,,. 931 32.1.21. I~"""'nlrl<"' .. r.:mom..Jc 9'8 )2.2,12. 32.2.21. H22-i J2.2.1.5 , )2-1. M.d ...1!<",~Ilcbt ",1<,",,938 lnlrll\UlllmtrlrC,"",oJ I.. io", 93$ S",""I 'p>duril '"_ 9J9 De'ln":".~ Inio .. o! lbe 9]9 R,r.~ce. !NO 'pI"" 'll.lnde,r 944 CONTENTS - . ~ 1.1. ' Neuroanesthesia INHALATIONAL AGENTS MOit reduce ce rebr al metaboli~m (e.'<cept nitroull CIlride, .~e bf,low) by luppre>llling oeurona illctivity. Thel:W! agenla distu rb cerebrailiutoregulatign and causetlrebral va· sodilatation which inC""~8es cerebral blood volume (CBy) Bnd ~an increase ICP, With administ.ratiGll» 2 hMl mey intre""" CSF volume which ~nn alllll potenti nily contribute to i.ocrea~ ICP, Most agents increa ..... the Co. reactivity of cerebral blood _ t b, All of these agenla off""t intro-operative EP monitoring (au "bo~), ~ halothane (Fluothnne®) \ I ORUQ INFO \ , In<reus"" CBF al~ CBV, and decreases CSf' ab&orption, all of which can increase [CP, AlitoreguJntion i~ disrupted . Affect.. EEG and EP c.u obow), and produees i.oeleotric EEG lit conceutl1lt b ll of ~ 4.5%. Produces cerebrotol<ic effub at lower level. (~ 2~1. ~ enflurllne (Ethrane®) \ I IlfIUO~Fg \ , A pDQr agent fOT neuroo ne.thellio. III Lower. $ebu~ threihold at thera,P"utic levels (further exace rbated hy hypocapnia ). CS f' production increases and abi;orpllon decre.a~el both or which oontribute to increased ;ntncralllol volume a n d thus increased ICP. ~ nitroc.s oxide (N20) \ / DI\UG!NFO \ , A poLt>ut vasodilator that markedly increases CB r 8nd minimally inCTI':IlU&e<>:rebral rnetabolisn;I. Nitrous o ><ide co ncern. w ith pn culno.;:e ph al u Jl and 11.;" em bo li!fm: · The solubili· ty of nitrou& Oltide (N~O) is ~ 34 times thatofnitrogen' •. When N~Ocomeaoutorsolution in an airtight space it C3n increllse the pressure wh ith roay ro.,vm pnellillocephalu& to · w.n~ion pneumoeephaJus", It may also aWDvate airembolisr.."I. Thus cau\.ion must be used /!!:Ipeci aUy in th~ &ittiRg" position whe r~ signilkant post·op p'>eumo<:I!phalus and lIir embolism areCOD'imon , The ri sk oFtension pnewnOCt!phalua may be reduced by filling the. e8vi ty with fluid in col\i u nct.ion with turning offN.O about 10 minute. prior to compl e· tion of dUTllI closure . Su: PNJllmoctphaiwI en pag" 667, Hal ogenated agents that m ay provide cere bral protec tion AU ohhese agenb suppress EEG activity. ~ i.!ioftllrene (Forane®} \ / OfIOOl>lFO \ , Can produce 1£OI!lectric EEG withou t metabolic toXicity. ImproVe<! neurologic out· come in CIOBes of incom plete global is<hemia (although in uperim eota l studi... On rala. the amount of tiS&ue inJury was greater than with thiope ntal"). / ~ desflurane (Suprane®) \ / OfIUG INFO \ ~'----''--" A cerebrnJ v8Godi istor , ;nCfIIO"ei CBF and Jep. Decrl!&llet> CMR01 which tends to tluBe II competlli8 toty Wlsoetlnst riction. GENERAL CARE 1. 1. Neuroaneslhetia ~ sevoftu rane (Ultaoe®l \ I DRIIGIUFO \ , Mildly incre.uu CBP nnd [CP, find reduoe5CMRD,. MUd negat;ve inotrope. Cll.rdiac w;t.h isoflura.n e or deIlflun.ne . putpll l not fill ....·1'11 ,mllou.inP.Ol . fill INTRAVENOUS AGEtffS BARBITURATES IN AtjESTHESIA Produce flignifiClln~ redu~tion il\ CMROa and scavenge free radical l llJUongl.>ther e ffed.• (mo pC.8' son Produce dose-depr:nd<mt EEG BUpp'Usion which U n be u.ken all the way to illOC!le.:tric. MiuimaUy affect EP, MOlit a re anticonvulsant, bul methohellita l (B . .. vitol®) ~an IOWf' the ""ZllTIl th .... shold (u( pase ,36), MyocaniialluPPreniofl and p"ripher/l. l vllfiOdillltation from harbi turatea may cauu hypoten sion and compro mio;e CPP , e$pe.:ially in hypovolem ic plltienta . NARconcs IN ANESTHESIA increa..e CSF nbso'l'tion ""d minimoU)' reduce ce rebral metabolism . TIley Blow r.he EEG but wilillCll. produ~ ao Iaoelect rlc tracing. II All nlln:otks «IU6E' dOOle-dependent respiratory depression which tan re/iu lt in hypercarbra and concomitan t increased IC? in non -ventilated pali~nt.ll . MOl"p h.lne: d~lnot sign irlcantly CI'(IIIS the BSB. • Oisadvantagt'll in neuro pali\mI8' I. ca uRS hi stam ine release which A . "'",y pro<iu<" bypote=i<N, 8 . 1Il4y cauHocerebrovII.!ICul 4r vlUOdi lBtion - inere/lsl!1l ICPO'-''''' C. !he IIbMe lOgelh~ r ma,y C(lmpromi~ cpp 2. in renAL or hepatic insufficiency, the meUibolite rnorphine·6·glucW'o nide can aecumu late whkh may Cllu8eeonfuaion Meverirlille {Demeroi®:, has nevt.ive illQl.rOpic .. £feeLS, IlJ)d il!I uellroexc;tatory metahohte nor-rnependine ca" cause hyperactivity Or sei~W'I!5 (s •• (ooll.ol., f"l8~ 32). Al so cau.es hl,tamln" relealll! . Syn thetic narcotics * Th~ do.QQL cause histamine rele:ue, WJlike morphone and ITIt!pendine. Fentanyl: crOSiie5!.he 8BB. Re<\ul;@sCMRO" CaVand ICP. S ufenl"n il: "IO~ polenllheu fentnnyl. Dc>6 nOI increase CBP' hut . ra;SftS ICP and Is thus o~n not appropriate for neurOll urlPca l casel. Alre n tllni l: the mo. t mpid on""l and the &h 0rte8t duration oftt.e oarcotil:!i. • NB: also raise. ICP. BENZODtAZEPINES IN ANESTHESIA 1"es .. dn.>gs are GABA aguoisUi nod decreasecerebllli metabolism. Tbey a lso pr0vide IInticonv"I, .nt /lctio o Hnd produce amnesiH. See fXlII. 35 for o,!lonUi lind r"ver..ai, M ISCELUNEOUS DRUGS IN ANESTl-tES!A i1:tornlda Ul! "sed priuuIJily for induction. AliO deacnbed far urebral protection d"riog a neurys m s urgery (Aee pagIIH08). A cerebrova""""ru;trictor , It reduces CBF and ICP. DoeI not a uppress brainstelTl .cth'ily. Suppressf!I cortisol production with pn> longed /uiministrJ!l tion, tl.nd rntI)' induce aeiI W'e5. proporol: a , edative hyPnotic. Reduces ce rebro! metabol i9 m. CBP and ICP. Has been d~bed for~erebral protection lI« pog~ 8QS)and for sedlttion (_ ptJ/le37). Useful ror cort iea! mapping where rllpid reco~ery from anesthes ia i! ne.eded (recovery is not as rapid ... with melhohexital ) Not analgesic. , 1.1 . Neuroane!lthesia GENERAL CARE Lidocai ne . IuppreMU laryntul renex~ wInd. m.,. hf:l~ blunllCP..ue, lhat normally follow endotracheal intubation OT luctioning. Anticonyulunlal]ow doIN, rn.-.y provoke leitu,"" a~ high I:Oneentr~l;on • . REVERSAL OF COMPETITIVE MU SCL E BLOC KADE Ite.n ult. up 10 ~ 20 mlnullII for full rey..-..I ofpancuronium (P.... uJo-o«J}(de pm<i- ;ns on the 1I1'\10Ufll of tim~ .i nee the J.SI dou). Ray.,...! ;, ul ually not .~mpt.ed until paUln! hi.ll al lUll 1 twitch ta.ll Irain of 4 ~limu1Ui, olh, .....i •• reye .... ] may be intomi{patient ill protowldly blocked aDd blockade UlHf reoccur u the revenalwN.l1Iof[ t nt!oUlrmint (P,oU.iiDli.c.~l: 2.5 mil" (minimum ) l(I 5 mK (mlUtimwnl IV (Ua n low , no efficae! /'rem:> Ii m8 aud can prod\l"" M!Vet"e """a~ espi'cially if the mllXlmum dose II ueeI!ded in Ih e abMnoe ofneuramul!t:ulaf hlocltade) PLUS ( to preven t brad~rdj •...). EITHER • 0.5 1011" atropine for each "'II: of IIfiMIlilllnin. p~1.e OR 0.2 mg glyeopyrrolat. (Robinu\®) tor each mil otneo!ligmint E VOKED POTENTIAL MONITORING An~lhaia requu-etnenlJi tOlf intra-operati ... e monitoring of evoked patenl.lal, (EPa): ifinhalatiou.l Mestlletie ag.nl.8 h8'" to b6uHd A. a ... oid halotllan", isonu rane (both reduce the IUJIplil\lde and intnaH th.la· te""'y of EPa InGllow Ihe EEGl.nd Elhranelll B. IlJlWltIF slt.:luld be u.!-ed .. I c:onc:entration l < 0.25'" C. Nrommend: e.l. FOTllna®.t e I 1>tAC (ide.lly < 0.5 MAC) nilt"O...m'~lic techruqutl prefelTad IIIUIIC1e reI .... n ... are pem,jaaible a>lOid benzo<iiueptnttl minimlu pento:h.1 .~ induo:tion. Of uK et.(>mldllU: (upec~ _ 30 mini-ltd of l uj)pnRJon orEPs after ;nducUOtI du e to lfIedicotiolll conlinuO\d infU3ion off~ntanyl is preIem!d oll@rintennitlentinjectionl 1. 2 3. 4. 5. 6.. 1.2. Critical care 1.2.1. Hypertension PA.RENTERAL AGENTS Table l-l show. fOme parellUtralagent.J for acute rontrol of hJJ>trtenalon rrouped ba$ed on their efJect. on lCP'o·. -:...-/ nicardipine(Cardcne®} \~L/~--:-~----,~~ ::-__\-,-~, rv. Calcium channel I:lockl!:f(CCB) !.hatlllay be,;yen UnUkeNTP, does not require Irt.erialline., dOl'!! nDt ' ,iR Ice .nd noe,.nide toxi-cily. Doea not ~\lce heart r1\te, but may be used in tol\iutKlion with e.g. labetalol 01" _101 iflhlt ill desired . 81D1:~ WA I S\\o. nBU5U~, ~iGo S'IO. ~fIO tachycardia 3.S" . R:£ obln It Ii IJIgfU IV (off Ioobl!l: 10 mr/hr fOlly be used in . iluatiOlll where u r~nl reduct iotl. is needed). Ilicreue b, 2.5 mgn-,r 1tYfJ)' 5-15 minutflll up W. muimwn of IS mgihr. 1.2. Crill.,.1 care , ~ nitroprusside (NTP) (Nipride®) \ I DRIOINFO \ , Re.lktl rep in patients ...!th InlrB~rl\nLaJ ma.,lt!II;on,' due ta dlrec~ va5O\lil,talion, arUrial» ",nOIlI (111\1111 eo",n ..'; • • :> large) Msy p~ferent.i.lI)' dilate periphlr1lJ .-enel' b\>Jore eerebrnl vene1,. ltlU' pf'Oduciug. "Ct!tllbl'lll,t.ell" pheoomt!non. At\a in MCOIldt, dura!.lon 3·6 min , 11101: U't'R(;1'9; thiocyonD~ and "Yanidl wxicily (may u ..... lUl'ul1>logie~tilWl' ifuaed:> Z4 hre, at II. .aloe ~ 10 ~mtn, 01' in renal failure: DIC ifth.iOl'Ylinat.e La".I, ,. 10 nlll"l>1, tuhyqrdia, Ulldu'PhJtluil, hypo\.en· .ion which ~an extend II" Ml "coronary l \.eal", "'""id in p~ancy. & rv drip O.:u.·8 l.I&fl<ctmin (ave. '"' 3). To reduee riik of cyanide toxicity. ltan al very law .au ofO,lll&l'kdmin, lind do lIot rive maximWfll'1lte of 10 l'Wk&lmin for mONO than 10 min"t" . To prepllra: put tiO ml in 500 m! D5W (can GIlly btl mixed in O.5W; 10lunon ean be dmlble con(!tntnted to reduct nuid or ,l....aee ]lIIId ) .. 100 I'&lml, C:OVl!r bottle. with roil (I igb~ sensitive ), or hypotenaion)(follow thlooyamlte ~ nitroglycerin l~veJ! (N'I'G) \ I 0AlI(I; INfO \ . Ralse81CP (leMlMa with nitropronided"e to prefuentiaJ ¥<!nol'! &<:bOn' l. Vasodilator, venD"." arterial lIaree I'Oronari-e!J" $mall). Rel"lt: d~ LV liUin, p,"""ure (pr. ·loodl. Does not cao!MI 'C(>rona~ stN.l" (cfn;troprusside). Rs 10·'11) I'efrnin IV dri~ lincrea!lfl by 5· IO)l"0.in II ~- 1 0 min). For angina """'ton.; 0.4 mg SL q II min )( S dotel, check BP before each dose. / ,..---/ labet9.lol \ / OFIUGorfll \ (Nurmooyne®, Trandllte®) 8101'1(11 III seleelivi. B norHlelective (potency < propranolol). ICP nduc:u Or DO chance'. Pol.. rite: deeresses Or no chang • . Cardiac output does notchao~. Does not nM~erbDte 0;:0.0011")' ilO;.lu!mia. May be uM(! in eonLroUed CHP. but not in oYen CHF. C!>nl ra.indl~ted;n ,.. tbml. Renal failore: urne do... Sm~ ~rn:cra: raligue. din.iIl<!R. orth~l.atie hypou!n!ion . Inlravenou. (IV) Ol"ll<'lt II wil"l', peak 10 mini, durAtion 3-6 htl. Rx 1Y: pat",nl . up;na; c.'Ieek 8P II & min ; jfive each ckIIa . Iow IVP(oYar 2 min)q 10 minute, until duiN!d 8P adtieved; doae .eque~ 20, 40. 80. SO, lheo 80 wg (900 mlf total). OnQl controll~, UM .. umetotal dOM IVPq 8 b ... 1U .IY...dJ:Ul (allemllive) add 40 ml (200 mgl to 160 rol of IVF (nolull: I mglmU; NO At 2 mUmin (2 Olcfmin) until d"ired 8P (0 ....1df«tive d_ . $O,~OO m,l Or until aoo mg "nn; then titrate rate(bn.d~.rdi.l;m;tJI dOH. lncruM.lowly);nno eD"M'1 tall" 10 20 minu,""). Orlli (PO) UodereOl!S nrll pMlllivet" degnodal loD. therefore l"fiJuire. higher dOlet PO. PO on- 2 hrs. peo.k.:. hn. Rz £0: 10 ""nvert IV - PO •• tart with 200 mg PO 810. To ,tart wllh PO."ve 100 ITIIl BID.1UId incnll8& 100 mjJ/do..;e q 2 day: IIIU. "' 2400 mdday, let: ~ enaloprilat iVasot.ec®) \ I DIIUEIINI'O \ 1 An angiotensin"«Klvertina: e~ym!' !ACE ) Inhibitor. The active n1l'.t.abolile oftbe orally admini5l.ered dn.oe enalapril (Kf btlowl. Acta wltlUn . 15 miNI or "droinilltrat!oll Sloe EfTICTII: h)'pl!rkaJeOlia <>(:C"re in _ 1*.00 not ""'" durine pregnlUl(,)'. Rz TV: ltan with 1.211 mg ,low IV over 5 mJIUI, may iDcrease up t.o5 IIIg q 6 hrll P RN ~ esmolol <Breviblod'il) \ / DI!OO INFO \ I C<'IrdioHlective short-Kting bela blOC"ker'·, Being investigated for hyperteM i~e ""ff1rtn~ia. Metaboliloo by RBCette".... Elimination half·life: 9 miN. Therapeut.ic . . • ponl!' (.> 20.. d«r@al!'in heart rail', HR < 100, or eonverslOO t.o ainus rhythm) in 72'ot. 5If* uncn: dote relalA!<! hypOte". ion (in 20~), gener ally re$Olvel within 30 min5 IIf • 1.2. Critielll care GENERAL CARE DIC Bronchospllsm 1.,. likely th"n othllr beta bloc:klll"ll . Avoid in CHF. Rx 500 llgi'kg loading dOH over I min. folio,", .... itb. mill infUllion atamng .... ilh 60 ~glttnn. Repeal loading dPS'! and increment infullion rllte by 60 ).Ig/kglmin 115 mins. Rarely", 100 1Ig/k&lmin requJr.. d. l)o;g~s ",:200 IIsfkg1min add li llll•. fenoldopam (Corlopam®) \ I \ VII"oollftlOr, Onse: "rllction < 5 minutes. duroLion 30 mil\$. Rx tv infullion (no bolus dOMJ1: IIUln .... ith 0.1·0.8 mcglkpmin. tilAla by 0.1 mcglkefm.in q 15 min up to II maximum of 1.6 mrg/'k&lmin . .---I prop ranolol (Inderal®) \ I 00I.0C31N1'O \ \ Main use tv is tQ Q)un terflcl LIIchycardia with yasodilatoTII (Ullually d~en'l lower BP a<:UOlly when used alous) . Rx tv: load with 1-10 mg slow !VP, rollow with 3 n'glhr. PO: 80·640 rng q d in divideddOS6. ORAL AGENTS F"r 1e!14 urgent control of HTN (excepUon: sublingual .---I donidine (CetapreS®) \ nifP.dipine(rl~ I belown. OROClINFO \ \ Ad.son oardlov!Oo;cular control reoo:~pt(lrJ ill m«IuUaoblongllla. inhibit,a symplitheUf l>U.tnow. t...o;s confusion lhllll A1domal. but still aedaUna. Tath}'tardia rara. Onse~ < 30 mm . 1iI"'~ E...,.,."., fluid ret<lnllon (",hiob may .... d""" eWecliv...,..., oount<lr wilh diuntic), dry mouth. &edItion (minimi z., by slo .... dou incr"men~J. CQn.tipation, decreased CO & iI.R (by illcreaHd vllgalloOll ..), rebound "TN ifwit.hdrawn rap,dly (caution m un reliable pat.K!nts; treatment for ",boWld HTN ; donidine and lobl!talol, 11ft! paIJ~ 4). Rebound i. less lik~Jy and leSll lcvere with cloQldine patches (Catapret iTS®). applied onee per w!'(!k. Rx Rapid control: 0.2 mg PO. tben 0,1 mg PO III hr. 8top atO.S mg total or ifaltbo· IIWtiC. Mainwnllnce d<.>ae,O ,1 mg PO BrD or TID, in.,.eaH~lowly to m~. 2.4 mgldl\)' (usual 0.2-O.K mglday) , .---I propranolol (lnderal®) \ I DAUOfII'O \ Beta hlocker. Use in HTN: blunts reDell tachycardia from ~alodi liltora. SmE Im'WtWI CHF, symploOlIlati~ bradycardia. bronehoep,um (avoid in ll.5t.hmatics), rapid withdraw! - rell"" tachyc .. rdia - ua~rbat ... myocardl .. J i""hl)l1lill io CAD. Jb: 40 mg PO BIC (usually .... ith diuretic), titrote up to 6~ 0 mglday in 2-3 divided donn. Or, !nd~r .. I.LA, 80 mg POq d. lJtn"Puw; 10, 2040, 60 &80 rug 1II'OTt'!<i t,a1>o. lnden.al LA (lao, acting) 60, 80, 120 & 160 mg clpsul0!8 , .---InifediPine(Procardia®.Adlllat®} \ / ORWINFO \ \ Short-acling calcium channr! blocker (CCB). Deereaaes il)'lItemic va6CUlar reiislanae.ln.,.ease, cardiac indu, CBF lby 10-20'1'), GFR, and Na eXCl'lltio". ReoIponselome. What variable, Onlll!t: .-16 mini . Duratlo,,: 3·5 hn. SmIlEfFf:C1"& lIushiog HiA. palpitation, edema; reflex tlIdl,ycardia. t&ution with belli blocker u negative ino tropy IIllly be additiv • . May taUH 1IIIV0!ft hypotensiun i1l vol ume deplet.ed patiellta (thu, uM with clution with mannitol or futoo;emide). May increase serum phenytQln (Oila"tin®) levels. Ule oraho n-acti"g mil,)' be asaocial.ed with car· diac risk, thusloni·llcti0i agents sbould be uS@odunleuspecific bo!nefit outw~iib. the risk. &- 10-20 mg po. raster onset with sublingua l or buccal admlnistratiou i punclUrt! ~aJ»lule). or ifchewed (pali"llt ~pe!. caJ»lule ~fter che .... ing). Note: the bo!neficial err""ts orlbedrug results rrom swallowing the capaule contents, the medicltion is Il9l ab!iOrbed through the m""""" . ifno reSpOnSB after 20,30 mm. give additionBI 10 mg. cca. GENERAL CARE 1.2. Critical Cln! , labetalol (Normodyne®, TTandate®) \ / \ See page 4 . Chrome administration rna)' have higher incldonce of orthO!ltatic h)'· po\@n.ion, fe~er , leltUa] d)'llmnttlon., lind hepatk toKicity than othl!r beta blocKer.! . .--/ metoprolol (Lopressor®) \~--:,/~_='~_._ro __\-,-~ Beta b~ker that is nlll.uvel), cllrdioseledive (It doses < 200 m!l:. Rx 50·200 mg il\ I 01" 2 doo;ell . .--/ enol:lpril (\'asoteC®) Angiot.l!~in \ I DRU<i.tII'O \ I convertingenzymll lACE ) inhibi tor. 00 OQt Ul!8during pl1!gn8n~. Mol' be le.s effective in !>IIICK pat;etll$. See,"r.loprilr.1 a bove ror IV use. Rx Initial dose 2 .5·5 mg in onl! doee: maintenance 5 ·40 mil in lor 2 desr.s. 1.2.2. Hypotension (shock) Classification: L hypOVolemic: fir~1 .ign usually tachycardio. :> 2IJ..40% 0(111000 vol luna 10&11 mUllt OCCUr berore perfUlio n orvital orgon5 is impairl!d . Includu: A. hemorrhage (exte rnol or internal ) B. bowel Dbstructic.n (w; th third .pacing) 2. septic: lAostonen due to gram negative sepsia ;I. COrdJogeOlC! ,ncJlldes ,'1l, Clrd'omyopllthy, dytirhythm las ('ndndlr'lg .... fib) 4. neurtlgunic: e.g. pual:; s" due to spinal cord inju.ry. Blood pools in venolla capacItance vessels 5. miscellaneoll. A. anaphylBll.ia B. Insulin reaction C ARD IOV ASC ULAR AGENTS FOR SHOCK Pla.rna expanders. Indudo;s: l . ",rysl.alloids: normal saline hos less tendency to promote cerebral edama than others (&ee tv fluids , page 657 unducontrol of elevated !CP) 2. a:>l1njds; e.g. het.astarch lHespan~) . • CA1J'l'ION: repeated administl"lltlon(lYt!Ta pariQd orda)'. mtlY prolong PTIP'rT and dotting UrofS and may ine:.reoee \.be ri~k of rebleeding in oneurysmal SAH" ($« pG//! 7871 3. blood pradu~t.I; upensive . Risk nrtra.ns m;ssible (liseBllU \lr tnIlLBFu~iw:> reaction PReSSORS phenylep hrin e (Neo--Syneph ri ne@) \ ! \ Pure alpha sym pathomimetic. Useful il"l hypotension ilSl.o ci8ted with tachycardia (a triol tachyarrhythmiaa). EIe"Oh!8 BP b)' we .... uing SVR via VASOCOnStriction, cause, rt'1I"" in<Teueln parllll}'Tllpathetic. tone i with resu ltant . lowing of pulse). Lack or 0 action means non-inotropk. no earoiae o«('leration, and no n-lslUItion ofb nmehial l mooU, mUll' de. Cardiac output and TIlna.l blood II"", may d""r" .8<I. A,·oid in spir,al cord illj urit'~ (""e page 703J. Rx pn!Sllor range: l()()..I~O I'Wmin; maintenance: 4()"60 I'Wlllin. To pT1lpare: pu~ 4() mg r4a mps) in 500 ml D5W 1.0 )'ield SO I'g/ml; e rate ors mVhr _ to JIg/min. , 1.2_ Critical car" GENERAl; CARE ~ \ ! dopamine S ..... Tobie /.2 for II &urnm~· /)' of the effects ofdopllmine (OA) at "8"0\1.9 dll6ag<!6. DA il primarily a vB.HlCQnatriclor(6, elfi'C1Ii uaually overridd~n by,,· activity), 25%of dopamine giveo ;8 rllpidly converted to I1OrepinepbriDe (NE L Atdo&el > 10 I'g/kg/min one is e/;Ientilll!y giving NE. May .aulle signi li cant hypergJytf!ml. at high d<>!le8. \ nble 1·2 Popamlne dotage Ooy ......'.. Result Ellecl !~glmln) 0.5-2.0 (S<ITlII' 1ime$1.IP kl5) (anal, mL'Se1lIeril:. COlO- ne~' &j~' 2·10 ,,, <'I, 0 8. 00p8ll1irler!lic: Rx Start wi th 2·5 llllioo\ (0) positNe frto1ropll raeasas nor-epi (vascr ..-., I'glkglmin Dnd titrate. ~ dobutamine (DobutreX®) \ I IlFIUGItlFO \ I Va~odilal.eJ by 0, (primary) lind by increa~ CO from [+ )\notropy C~); result: little or no fall in ap.l~ tad\ycardln than DA. No alphe relea~ nor vS9DConiitricuon , May be uged synergistlca.lIy with nitropl"IIssidl\. Tachyphylaxis after _ 12 It.... PuI'1\! increllJl<'ll > H)% mllY ... acerbate myocardial ischemia. more cornmon at dC~1 > 20 "glkg/min. Optima! ~ requires hemodynantic monitoring, PIlssibl" pLal.elet f'~nctiOfl inhibition. Rx usua l range 2.5 - 10 I'gr\g/min ; rilrelydOfie5 up to 40 ",sed (t.o prepere: put SO mg in 250 IIlL DtiW to yield.200 I'g/ml). / amrinone (Inocor®) ,-----/Nonadrene.rgic cmiotoni.:. \ / DfIUO",O \ ':c"L,------=-----:-:----'~, Pho~phQdie8t1!ra!1e inhibitor. eITecl.ll l ilDilftr to dobIIt amine (i ncluding exacerbation or mYDC8n!ial ischemia). 2'10. incldeuce ofthrombo<;ylopenia. Rx 0.7ti mglkg initially over 2-3 min. then drip 6-10 I'gIlt:Imin. / / DIUlINFO \ ~-'-----:--------:-,-'>--" Primarily vnSocoDl trietor (7 co.unl.erp.oouctiv,., on oerebral vasospasm, 7 deere9I H CBl't B_agon i5t at I(>W dO'le!l . lncruJlea puJmonlu)I voscula. ,..,.i~ laMe. ,-----/ nore pin e ph rine \ epinephri ne \ ~ I ~IIfFO \ , & 0.5-1.0 rug of I: 10,000 ~lutfon [VP: may repeat q 5 minu tes(may boJua p.!' ET lube). Drip: llartat 1.0 J.lglmin, titl'\lle up to 8 J.lglmin (1.0 prep:ire: put I 109 in tOO 101 NS or05W). ~ isoproter enol (Is up rel®} \ / 0RUa 1M'{) \ I Positive chronotropic and inotropic, - iucreased caminc 0 1 consumption. arrhythrni ... vasodilatatioo (b)' BI action) ~ kelet81 muscle " eerebra! ~essel&. ~ p,,~ levophed \~.L/_-:-;-~_~_~ __\-'---, DirectB l timulatlon (jIQ.'!it;ive iuolNpic.and ohrDnot",pi~ ) Rx If tart drip at IH2 J.lglmio ; maintenance 2· 4 I'gfmin (0.1>-1.0 mVminl (to prepare: 2 lOgin SOD rnl NS ~r D5W to yield 4 Ilgfcc). 1.2.3. Neurogenic pulmonary edema A rRra ""mi ition GENERAL CARE a~"""i"t.!<I with A v .. ,-; .. ty Ori nl .... cnoni"l 1.2. Critical cs.re ,,'Hh nl~ .... induoiing:- , • ... barachnoid hemorrhage , lIene ... lhed " i1~', .nd head injury_ Pat hophyfliology Two pon ibly Iynergi, tic mKhan;, m•. Sudden inc~ ... ed lep or hypothalamic ''\i\lmil,. produce II ••1vo of,ympathetic di.charge cauling l'fl!iuribut1Oll of blood to lh. pulmonary circulMion, resulting in ,l,v,tlnn ofpulmon.ry e/IIplltary wedge PI"I!Qur"e' (PC WP ) .lId in<: rellsed permubility. 5«ondly. th, ...oc:iated . urge ol c.tec:hoIamina directly di,rupu the capillary endothelium which incl"I!'_ alveolar permeability. f}' Treatment Supportive, using m eUUTeI .uc h al positive pl"l".ure ~ntil.tiO!l with 19~ I_l,of PEEl> (su pagt. 659) and trelltment to norma liu lep. A PA·eatnete. il u."ally helpful. 'I'h",re may be lOme effIcacy in using II dobu .... mine infusion" . upplemented with fu· rosemide as neflled . The theoretical adv1nt.aaeof'dobutemine OVer ~iolUly attempted alpha. and beta-block.... i. that dOOulamine does 1l2t reduce DerebrailH'rfusion. Niuopros.o;ide may help dilate lhe pulmonary vasculature. 1.3. Endocrinology 1.3.1. Steroids 1.3.1 .1. Replacement therapy Under normal , basal eouditions. the adrenal cortex .e· crete. 1.s.25 mgldayof bydJ'oeortiao ne (AKA cortilO1), and 1..s.40lgid ayorco rli. costeron e. COr1.iJol hili a halr·life of _ 90 minute.. [0 priDlary adrenoc:ortieal ;nlulTt. ciency (Add;lOn', di,. use), both glucocorticoid. and miDeralocorticoid. mud be replaced. In secondary adrenal in. sufficiency eaused by deficient corticotropin (ACTlil release by lhe pituitary. min· eralocorti«lid . ecretion i. usually normal and only glucocorti. coids need to be reo placed. T(lbie ' ·3 sho ..... equivalent daily corti, CO$teroid d<o.el for re' placemenllherapy. Tabl.'·3 equivalenl eor1leoSl~oId dotes" _. _g;.., .-.1IIiW_.~ 1_ ... ....., prImatiIy u\JIUCOCDI' ..........lltItgho<J>C'A1imicl po", IV _ I , gMln; 1M .......,dlll... ~ lor _110_' - . . IV IOCUI C.wIO! t.. '1PdY otoIainod SIenoI:w«l tJrri.PaII8<li1<l<WoO 21 ....,. '" 5 mgo 1 " _ and , - ' <I00I. ~. 1ronI3O 10 5 mgs ...... 611oys; "OS' ~ 10 mg Iab& .,., Itorr> 60 mg 10 10mg ...... '<\aYS; "DS 12.000y" COO'Uins~8 10 mg ,.", and ' - I fromSQ rng 1021:1 mg_ 12diol"l -.,. ~c:oonIIoins 21""" "'. "'lIS .... ttr<1I"_~...., ~ doage from 2. 10 • mgs"""" 6 <»ys _ "" """. , ..... ,., ... _ ,ape" f Physiolo,;c replacement (in the absence of stress) can be accomplished with either: I. hydrooorti.one: 20 rng POq AM and 10 rng PO q PM 2. or p1"flinilOne: 5 mg PO q oUl and 2.5 mg PO q PM Cortitol and corti_ ~ uH r,,1 for chronic: primary adrenocorttcal ill5uffidency or • 1.3. Endocrinol"lO' GENERAL CARE 1M AddisonJan cruJs. Bee... """ or mineralocorticoid IIctivi~y, ""6 for chronk th .... apy or other conditionl (e.g. hypopituitnrismJ may ruult in saJ~ and nuld reW!otion , hypertens ioll and hypokalf.mia. HYPOTHALAMIC-PITUiTARY-ADRENAL AXIS SUPPRESSION Ch.ranic 6wro[d adr.linJstratJon suppresses thll! tlypoLhalomie-pituil.:!",,·Rdre"1I1 l HPA) axis, and eventu~lIy CHUseS adr~nlll atl"Qphy.lf5teraid~ are ~bruptly ,t(Jpped or if aculli iIIne" develops. &ymptl)ms ofadrenoc:ortkal inBulf.c:iency (Al) may ensue (_ Tobit I ..#), which ifsevere may proVi!8I t(J Addisonian cri~i! (_ post II ). RecCWBry of .adrenal oortelt IOg$ beh':1d the pituit.:J.ry. so baul ACTH levels increase before cortilol 1""1'18 do . HI-'A 8UpPNWiJOn depElnds on the specific glueocortiooid used, Lhe routo! , fnquency, tllne, Tobie 1-4 Symptom, of adrenal and duration IIf treat ment. SUppre""ion i$ IInlih· I".ufflclency ly with < 40 Ing predni60nf (or ~quivalent) giveo fallgue in the mllming for leJl$ than. 1 daY~.lIrwith "". ~)'POglyeefl"lI ery-othu-day therapy of <. 40 mg for . 5 Wltek.o". ~.­ aJlhrillgla Some Idren.l s tropI\)' lIUlyOtcUr after 3-.4 day. of AddisfIIlian CliSIII (~ aoor~xia high dOt>esteroidili, und wme IIxis suppreesioll will severei ..ll/T !lsk 01 aimon certainly neeur aner 2 weeks of <10-60 mil" dealh. sae page 11) hydrocortisone (or equi"",lent ) daily. Mer a month Or more ofltEroids, th~ HPA lIXil may be dep~ for ~.long Bli one YEll r. Mft3iuring morning plnma hydrocortisone CIIn evaluate the degree of J"1!<"<Jvery of basal adrenoeorti~al funetion, butdoos ~ useSi' IIdeq uacy ttress r lli5pon6e. -....... STEROID WITHDRAWAL" In ao;lditi!J1l to the above daJJgenof"llypooortisolism in the preYence IIf HPA dUpp>,",!8s ion. too rllllid II taper m.yalUS8 aDore-up of the underiyi nf C(l ndilioll for whleh ! teroldA weTi' presmbed. wnell the risk of H?A suppression illow (as is the ease w.th ahort (OUnles of.le· raids for lelia than - 5·1 :laya" ~ne .... lly Pl'KCribed fot most neurosurgical imiiaotionai ebruptdiscont'n ualion uauallyconie, alow risk of AI. For up t~ 2 weeksofus<>,s teroids ore Wlually 6afely witlldrawn by tapering over 1·2 weeks. For longer treatment. or when withdnwlI! problem. develoll. lise the following woaervatjvr..tanu: 1, makeamall d~ .... menta (equiva lent to 2.5-5 mg prednis~ne) every 3-1 d. Patient may experience mild wlthdrowBI symplOJT1S 01" ; A. fatigue B. anoreKia C. n8U~U O. orthostatic diuine&& 2. "backtrack" (i.e. increase the dose and ",Kurue]l. moregrsdUlli taparl ir allY ofthe (oUawing pa:ur; A. l!)(acerbAtion of thl! Wlderlyinll: condition for which steroid.s were used B. evidu.ce of swroid withdrawal symptoltl$ (P<t TabI~ 1·4) C. intercurrent infection or nei!<! for ~lIrll"e.r:y 'Be-!; Slreu ~I below) 3. OnOO -ph)'@JQlogic~ dOllu ofgJucorortJcotd ba"e b<!en reached labuut20 mg hydrocorti60owday or equivll lent (see Tab/I. 103)1:A. the patient i.$ 5wil.l:hed Ii) 20 mg hydrocortiKOne PO q AM (do !lOt UGe long acUng preparations) B. af\er _ 2-~ """eb, II morning corti&ollevei Is d>echd (prior to th ~ AM hy· dromrtj,uoedose), a.nd the hydrorortisone is tapered by2,5 mg W"'lkJy un!.ii 10 mgtd is n!ached (Ia wer lirnit.s of physiologic) C. then, every 2-4 WHM, theAM cord. ol level i. dre .. n (prior to AM dose) until the 8 AIlI cortisol is > 10 1'81100 ml, indica t ing retum ofbll5elineadrenal I'uncLion O. when this return of baseline adreu.1 function DOCU" : 1. daily steroid..!l a~ stopped, but strMS dosu must stili be given whn needed (u. below) 2, monthly cosyntro]lin Klimulatioo leaL!! (_ pogt 444) Nre JH'rfnrmoo ....ntll oonnll1. The need for stress doaes ofsteroid~ ceases when a PQ5' itive lut is obt ained. The riak for adrenal illl!Ufficie.ncy perl;latii-..2.. )'jlJI.[5, sf\erce$atlon of chronic neroids (upecially thlO first year) GENERAL CARE 1.3. Endocrinology , STFIESS DOSES Duri.rl, ph)'lliologic ".l.rHl" ill , nonnal .dr, nal ",nd proc!uott. .. 250-300 ml bydroooortilOnoid l Y. With cilronie,llucorortiroid therapy leither It pr~lnt, or in lut ].2 yB), fLlppr ulion oftha tIOrmal ".t,ess·r&,pon..- ntoeHeitat. lIupplenHlnt.1 d OIft. In Table 1·5 s.erokl alt, u dol· u 10' "IItcUve . urgery pIIt~" ....!tll .. l uppreued IIPA axi.: for mild mn.-.l • •, . un, co mmon cold), linal. dental eJrtracuon: double t he dally do .e (if off I l.;lroidl, stvII 40 IlII1 hydroo:o/'1ilOn e OlD) fa, modera\e . tl1!ll' (e.,. nU l, minor I W"jIwry lUId e . iIlalllneathe.11I (endO&tOpy, multiple den. tal utraction. ...): giVII 50 InlI hydrocortison • • '0 for m-,j or Illne.1 lpnllumon;a, l )'tle." ic ln fectione, high fever), I16Yi!~ trauma. or llmergenC)' I Ulpry under il8oe rlllllOe.lith l'llll : giVI tOO mg hydnl<;ortil"n.. IV q 6.8 h... far 3.t day .. until the &t re.. l, resolved for .. lec tiYi> urger)" _ rable J·5 for gWdellne- POSSl8LE DELETERIOUS SlOE efFECTS OF STEROIOS Although t.helle aide d l'e cla anI moll! common with prolOll,ed admini$trltion'", lome elln Dec u. liven with . hort. u e a tment cou ....... Po.sibl" Pie "lferts indude''''': aordiovllKU la. and renal • hype...u.nlion • . odium and water retention • hypokalemic alkalosis e NS • progreuive OluJliroalleukoenupl-oalopalhy (pML) (IN P<lGf231) • mental sgitat.ioo 0. -Iterold pilycbOlli.· • I pinal oo,d compreuiO<l from spllUll epidu,allipomalolli.: rare (_ pclIt 903) • pseudOlumor <8rebri (.ee. ldiopalh ~ .n'",r ,..,,,iol AJ'fHr~fUit)n, P"le 493) endocrine • Cll UliOll! bI,a,,,w ot growth lUwresunl effect in children, daily r'ueoron.icold da.ing O~ r proLonged p!!riod.!I should be ,"""Ned ror tbe mJlI l "'lI:ent indiauonl • ~ndary araenOlThea • su ppreaaion ofhypothlJ llrnic-pituitaJy.. dre.IllJ am: mUCH r ndoPnow lteroid ptodu.ctioo - risk of adrenal in3ufficiency wit b steroid withdraw&! (sH .. 60<.01) Cuabillgoid fel hue!! with prolonged USllse (i'\.rogenic Cushins'II!Ild/"OllH!): obe,i ty, bypel1.elllion, hinutilm . .. Gi: .uk inereued only with . terold th~ rapy > 3 weeD dUnlti(lll aru:l ~ of pncdniflOne > 400-1000 mdd 0. deumethuOfIa > 40 mgld" • gUl nt', .Qd .teroid "~I1I; incidence I_red wi\h the twleof flntacict. andto. Ii, antaroni,ta (e.i . Dmelidine, ..ru\.idine_.. ) • • • • PIInc.'f'U!ilil in tel\.i n"J or . i""oid diverticul ... perforatiOll": incidenOo! _ 0.1910. Sine;! steroids may mull. alp orpentonitill, t.hillhou]d be(oll$idereo;l Ln ""tlenlll on steroid. witb Ibdomi nal dWcomfort. especially in th •• ldetly aod thoe. wilb a bisr.:Irr of ru-1Je. Abdominal ..·ray ""'Illy ihOW5 ftft intr!lperitoneal air mh..ibi lion orflb.-oOlouu • imPflirod woWld beeling Of \IIIOWId b...,.kdown • lubcutaneout I!q utt atrophy roet.abol.ie • ~intoler __ (~be~ ) Ind & turbance or ni~1I metaboli, m • molar nonket¢ic !;Oma • ~.l.Ipidlmi" divertlcvJ.. ophthalmologic • poIIl.lrior l "bcllPlwa r aou.-.cu • I J·ucoroll musculotkeletaJ • aVNCUlar necl"OlMl (A' 'N) arthe hip or other hone.: ...oolly with p.ol<mge<l admilus ,",!ion - o:\IlhiTl(oid habillR and incl"1lBled marnlw fat"';thin thl bone"' " GENBRAL CARE • • OfittlopoTOli,; 111a.!' preodillpOSfl to veruhral coropreBllion fractures wtllch occur in 30-51)!jl, ofpatientll em prolo"8ed gluCOCl.>l'ticoid..(8ff pag~ U81, Steroid induced boae 1068 may be reveTUd with cydical administration of etldrona!.e>' in <I cyclu 0(400 roWd .. 14 oiaY" followed by 76day8ofo. a] calciumaupplementaoffiOO mgld (not proven to reduced rate of VB fruCl-uns, KI/ fI<l&e 7411) • muscle wulmeN (I~roid myopathy): often wonlt! in prmcimal muscles infectious • mununosuppreasicm: with possible supllrinfect.ion, eapedally fungal, parasitic • pOIIBible reactivation o(TB, chkkenpox hematologic • hypercoagulopalhy from inhii'>ition oHLsaue pJuo::tinogen activator • stcroid~ UU5e demarginat lon of white blood cellJl, which mllY artifactually elevate t.he wac count even in th e aboleou of infection mi.y""llaneoua hlc~uJlll: may r9/1pond to chlorpromatine {ThoNlzimm) 26-50 mil' PO 11D.QlD II 2· 3 daY" (if l ymptoms persill!, giv.. 25·50 rog 1M) ~tc roid. readily 0'0&& the pI8""01.ll. anel {~tailldrenal h.)'poplasia InQy occur wilh the " dministration oflQrge dOll811 during p~gnaDl:y • • 1.3.1 .2. Addisonian crisis An ad ..... n,,1 inlufficlellCY emergency , Symptom.: ment.'lllllatUfl change! (confusion, lel.hargy, or agit.fltion), muscle WGUnI!tS. S igD ~: poetural bypotenaion or shock, hyponat~a. hyperkalemia . hypogiyCflmia. lu1>erthenni" (811 hIgh n lOS' Fl. TREATMENT OF ADOISONIAN CRISIS Ifpoasible. draw ",,",m for cort;'o! det<lrmill£ltlon (dow ",,&.it for the$e resulu to iI1l5titute thertlpy ). Give fluid. auffici""t for dehydration and shock. FOT ~B lu cocurticoid e m ergency" hydroeortilOna 5~um 8u~in"t.a (Solu·Cortel®) 100 mg IV STAT and then .50 mil rvq61\r. AND co'till.me ac<!taI<l75·100 mg 1M STAl'. aM then ,5().705 n'g 1M q 6ltn! }-' o r "'miner alocorticoid e merge ll oy" U&u.Uy not naCBfUliI.<Y it aecondlltY adtenul io."fficiency (e.g. panhypopituitarism ) dll8oltycorticOfii.erone lleetaU!- (D(JC.!l.®): 5 rug 1M BID OR nudroevrti60ne !Florinel@):0.06-0.2mgPOqd NOT re~ mm end ed fo r e m ergenc y trea tm e nt • methylprednisolDne 1.4. Fluids and Electrolytes SERUM OSMOLAUTY Clin ical 8lgnjfi~ ofvariau. aerum osmolarity .,a)ue$ i, shown in To~ }·6. Appro:<inu.l.evaluernay oocalculated usiog ,,,illS Eq I· J. Tllble 1-8 Clln1cal cllrrelallil IIf11 .. rllm o, motallty ,, GENERAL CVlE 1.4. Auid, and Electrolytes u 05mol.licy (m05nVLJ "'- 2, (rNa'J' [I<' J) .. [B1USNI .. lllh;c:se J 1.4.1. Electrolyte abnormalities 1.4 .1.1. Sodium Eq1 ·1 Anti d iure ti c h orm o ne The major SOW"Cfl ofthe cnnopeptide arginine "'as<lpnl'sain. AKA antidiuretic ho ... mon~ (ADI1) is tbe rn&gnO<'elh. lar portion of the s~pr&optic nucleus ofthe hypotho.lamu5. II is "fIn ... eyed alons: Ul!WI. in the supraoptie·hypophyaal tract to the po8to!riorpiluilliry gland (ne urobypopb)'llia) where it is releuo.d inID!.he s)'IItem.ic cirt:ulation. All actions or ADH rUlilt from binding mUle hormone to lIPfl"ifIC membrone bound rffepton on the aurface of target geUs". One of the major eff...,u; of ADH i. to incre~ the p~rme$bility of the distal renal l ubulea resulting in incn!Ased reall!orption of water, dilliling 'he dr· cllitting blood and producing" alncentralA!d urine, The mOllI pOwerf.•d physiologic stirn· 111115 fot ADH release il an in<rease in serum osmolality, e less pOl<lct stimulus is a reduel.;oa ofintravll5<:ular"'olume. AD~I if al.o released io glueoo>nicoid deficiency, and i, inhibited by f!J<ogenousllluoororti"flidlllnd adrenerJic drug., ADH is 9190e potl>nt ... u •• oeonslrietor. H VPONATf'lEMIA ., bit/om)' Usually iI po&toperati... e hyponatremia: a rare condition usually ducribed in YOWlg. otllerwise IIB11II.hy womlln undergoing ele.;ti ... e $\lrgery;' Oue to 510w compa[).llatory me..:hanisml in the bmin, II gradual de<;linll in 8\!1'W:II ~o-­ diwn i. better tolernte-d thMII ropid drop. SympIDms or wild orgrodual hyponatremia include More>d$, headache . irritability, snd muac!e we~knl'1lll. SeV<!re hypOnat~mia « 120 mmol/L)or a rllpid drop (> 0.5 mmoVlIJ') un cause neuromu8cular ucitability, cerebral edrffill, muscle 'wil.ching and erampll. nau!ieR/vomiting, ",nru~ion, !leizu .... s. rtipl' ralory arrest and poI;sibly permanent neurologic iQjury. (Offill!jr deaLb . Cen tral po nti ne myeli nolys is Wbcrtu eMCfl ...;vely .to.... correction of hyponllt ...."". fa .... <K;.~d ",jth Inaecoacd morbidity and mortality• . Inordinately rapid t",Dlment bft~ been associated wjth cenU1l1 pontine myelino!y$i.tI (CPM ), AKA osmotic demyelination syndrome, II taredi!lorder of pon t ine white mattl>r- as wen 11$ olher area~ of~rebral white metier , fint deatribed in al"flholiC!)"', producing iMidioo.lS Oeccid qUlOdriplegia, mentalsiatuedlangu, and cl"lInie] n~e ebDorm.litl~ with a ~udobuJbllT palsy appelltMOl'.ln one re.... iew ... , no patient developed CPM whl\O treated 310wly S/I outlined below. And yet, the rat@ofeorTe..:tionco ... .... Iau.!! poorly with CPM; It may bI! that , .... ~is t llecriti"",j '·lIriabl e>-. F .... tu,..,. comUlOn to patients who develop CPM a""" deloy in the diagnoeisofhyponatremla with .... sultant respiratory BrTi'8t or MlI~ure with probsble hypoxemic "enl rapid ron-eetiOlI to normo· or hYP"I'-nlltremia (> l S5 mEqIt. ) .. llhln 48 houtll of initiation ofthenpy increase oflJ(lt\lm fOdlum by , 25 IUEqIL within 48 hours or;nitiation of therapy O'Ier-ronecting5l1rum ~UID in patil!l1ta with hepatic encephalopathy .NS, many patienta de,".,IDping CPM wen! victims of chn"'icdebilitat.lng disellse. " VI.. Fluid$ and Ele-etrolyt ... GENRRAL CARE malnourishment, or alcoholism and neve r had hyponatr-tmi • • Ma ny had an episode of hypox,ialanoxia'" p1"QO!IlCII ofhyponatremi. > 2~ hlll prior to treatment" TR£ATMENTOF HYPON",TREMIA PUientl with hypon. tremi. of unknown durMKln probably h.ve chronic hyponatre. mia ifminimally . ympto .... tie. and ehould be trealed _lowly, preferably with flu id re· striction. Thoee .. lUI acute Iymptomatic hypon.tremia (convull ionl, Itupor or coma) . hould be treated promptly _inee the! pr_n«o of eNS . ymptoros h.. been _hown to be auocilted with brain edema lrad)ographica Uy and I t necrop.y) and m.y henold impendh" hern.illiOtl and cardio...... prralOry Symptomatic r.:lientl with hyponatremia ofunknown duration InI t heOtle, a t ril k of neurologic HqUl .e.lnd one . boukl,lartoft" .. ith. I"col"l"fttion, followed by. more cradulltrutment u outlined below". TIM followina method for con-ec:ting hyponatremia UNa') < 12S mEqfL) iSll&Ocilled with low riB of deveKlping CPM (although it may not be poMible to define. note of co~tion th.t I, conai. tently free of m k): 1. • CAUTION: avoid oormo- 01" hyper.n.tremia during con-e<:t ion, check frequent ....... m INa" levela and lrIOdul.te therapy ,.. fDllowa:: , top if ..fUn! IN.') " 126 mEqlL over 1 po:riod of. 17 :t I hoU ri stop if the dla.D.p In .......m IN, ' IIe :ll 10 mEqIl. in U hoU ri"' do not e~ a ute of correctioo of. UI :r 0.2 mEqIlJh. 2. , lowlyadmini,te. S'Io(S lS mEq/L)o. S"(856 m£4'L) NaCI toadhere totheabove criteria (Uart with 2S-50 eclhr of the S'" solution and foll ow INa'] closely) 3. aim ultaneou.Jy administer furoaemMle (~l"' to p......... nt volume overload with . ubeequent incn_ in atrial n.triuretic factor and f'IIullJLn t urinal)' dumping Drthe uu. Na' being adm ini.tend 4 . m.....,.. l(' IOIIt in urine .nd repl.ce -rungly ."'"t. SYNDR OME OF INAPPROPRIATE ANllD1URET1C HORMONE SECRETION 1 Key futu ...... 0 rele... of ADH u. the abo5ence 0t,h:faiologic (osmotic) stimul i o f'lluitl in hyponltrem.i. with hi Ilrine OIIlDOlality o \laually 1l(e01D~.IIied by hypervo emiD (OttUionaliy with I!\IlIo!emia) o may be KI n with cert.ein malignanciea.nd many intratrani.l.bnonnalitte. o critical to di&t ingulgh from cerebral Alt wasting which produces ~Iemi. 1 SlADH , AKA Sch "" arh·Bartter ayndrome, w... lintdestribed with broo.c~nic It il Ule releue ofantidiuretic hDrmone (ADm in the al»eDceofpbyaiologic (_ motic) l timuli. nul produc"" elevated urine OIImolality. and upansion oftheeKtraoellu_ liTfl uid vDlume leading to. dilutionsl hypon,uemia, which c.n produce fluid overl.,.d (hypervolemia) butSlAD H may also occur with ",",volemia. For ....1M>n1 thoot ..... undeaT. edema doe. nOt ooc:ur. can~r. E ti o logies o f SlAD H The hyponatremia ofSlADH must be differentiated from that due to «Tebral A lt wast ing (CSW) (u, ~Iow). SLADH may be KIn in the fDllowin6 ... ttin", (KI refe",noel' for more utensive list): L malignant tumD": especially bronchogenic 2. numerous intnerani. 1 prooeISN including: A. men.ingiti.: ... pecially in pediatric patientl•• tao .. ith TB mf'~ti. B. tr.uma: seen in 4.6'1r of head trauma patientl C. increaaed lep D. tumDn E. post cnoniotomy F. SAM (NB: ..... Ie-out CSW, whidl ~ui r.. dilfenl!nt tre.tment. _lH!low) 3. numerous pulmonary dillarden A. malignancy B. pulmonary TB 4. 5. 6. 7. C. aspergillOiIl m.y lO.IIleti mH occur . ecooda.ry to enemia with !tren, ..vere pain. nau ... Dr hypotension (all can st imulate ADH rele...) ooc:uion' Uy _ ... with acute i nterrnjt ~nt porphyrilo (AlP ) d..... gl: A. ehlorpropramide(Oi.binese¢l): mayeauSflI "n1.lIve" SLADIi byincr...ing GENERAL CARE 1.4. Fluid. and Elactrolyt.ea " the renal ... n,it;";ty to endogenOUi ADH 8 . OJIytoci ..... hal""'6 ·croo activity" with Al) ~I , and UlII.)' al., bI contarninllt. eel with ADH C. thiuide diurr.tiet: h.Ydt«hlorothluide . 00 po~ 18) D. arbamaupine ' 1'egretola) DIAGNOSIS OF SIADH In gl!lItnt, 3 diagnostic ail.erilllrl: hyponot.reuua, in'PfH'Op';lllfly conCMt r/l1ed uri"", and DO ."idenc- of ren, 1 or Idrlllnlli dY'f\metion. 10'1 more detai l: 1. Iow ... rum lOdium lhyponatreOl.iI): u.ulllly < 1$4 m£qll.. 2 . low I61,Im o.mollliity. < 2110 mOnnIL 3. hl,h Urilllll')' lIOdiumA :... It wutin,,): 01 le ... l ,. 18 mEqIL. often S()'160 -4 . high rltio o(Urlnl:M n;lm Q8tnOUolil),: onen 1.5-2.5:1, but may be 1:1 $ . norttlllll'f:na\lUndion (ebec:1r. BUN &. ~.Ihlille): BUN eommon ly < 10 6 . normal.d .. n.aol function (no hypoiAnaioD, flO hype rlu lemia) 7 no hypothyroidi.m 8. no .1.". ofdoth)'dl'lltion or _ r hydra t lon (in many pat>enUi with lieull! b rain d,.ea... there i. signLiiaont hypO"Olemia often due to CSW (ou /H!/Qw ) Ind II thi '!& I atimulu. for AOH lIr."ellC)n , the ADH relulM IM.lI be "appmpriQIa"") \(further \.eStin, ito required, thl wate ... load Iell Wcmlidered to bl the defini t ive. Ielt-. The pati.nt Ia ulud to con.ume a wal.er load 0(20 m.tIq up to 1:100 mi. In the lib· tenet or,.drenal or ren&! inlu n-'dwty, the fQi\ure to I!;(~rete 65'110 of the ",. lH load in 4 mor ~ in.5 lin indkall's StAnH. . CAUTION : lhito te!lt i. danll~roWl if tile at.arting IM!rllm !NII'I iI ~ 12-6 mEqIL o~ iftbe patient h .. I)'lIIpUlIIlII ofhypormtremil, Ah.emll~ively, OM! may n:e .... u"' IM!ruJD <lr urinary I....ela or AllH "'hid> do nOrn1aUy uodet.ectabl<! In hyponatremia of other uuses. In SlAOH , il IJ ollen detecl.3ble IUld , in the ~tut of the low .... rum ~Jum, UCeII$ivt1e Sym pto ms ot S lADR Symptom. ofStAnH art' lh_ ofbyponatrel1lia ioonfUli<lD, lethargy. NN, ClDmlI, W' lure) Ilnd ponibly /'Iuid DY1!rkNtd. Ifmild , Dr if d ....... n~ of IN.'! i. gra:iul l, it mlly be tQI_ted . INa') < 1.2().12S I1IEqfL i. all1lost&!WlYla)'ZRptomatie. Theaep.atientaoften hlva a pllTadol<ir:a1 (inIPJl"Opri~tlhhint. _mEN>" BellUre that hyponatremia IS notdu .. to CSW 1_ Mloui ) bef<l ... ..,.tsicting nulda. 'I'rola lQl e nt ot a lOlili: SlAD" by anernill: usulllly ....pOll.h 10 trensfusion ;rmild and IS)'tnptomltic: nuid rIIItrittion < 1 Llday lpedr.l Uml/day)(eaulil)n inSAfI; see /lJ'pt>rWJt"",", (olI4wing SAIl, p&ge188 ife~uud i( sevel'll Dr . yroptomllt ie: UM hypertonic .. Un.. and , i(MCeU.ry, fu.-mKla(IH pose 13). CAUTION: CPM IIl.Y botMHcillted wilh uteMiY1!l:,' r.pld cornelion (..~pagt 12) Treatme nt ot ~ SlADU lo"l!·te= nufd n!!Itriniom. 1200-1800 OlIId demeelOG)'cl ioe: 150-300 mg PO q 6 hni, I tetruyelinl antibiotk £OWId to PaTtioJly antliOniH the effeell or ADH on the renal tu~ (uro.emid .. Il..a.ixe): _ -40 mg PO q d (Dna! dlily) aIong"';th hiilh d1eury aodiulll int.ke Ind monitoring for hypochtQremic . lhlDei," ph e nytoin IDiI.ntinG)): mRJI inhibit ADH ~I~IIII! IIlblulII: not very ,,!fICtive and mloy lide effKla Ce REBRAL SAl.T WASTING Cer ebral ...It w a.tinl rcsW): reJ\llll_ oI~lum .. e ...,ull orintrRC'Mlniel dt.hyponatr\lm;" and. d('Je1'f,ll1l in ulI'lf;ellu\ar nuid YGlUDle'l. CAl1MON: with anwl')'llma\ SAlI may have. CSW with hyponatremia .. hich mlmlet SlAOH, ho~ ... r thtre \$ u.ually l ito hYJlO'l'ull!lIli1 in CSW In 1h1t IeltiDa;, ntlid ..,.vic· tion mey eKaeerlNlUl ~a_pAsm Induced itcheoma-- ~u.e, produ~ing pllti.n~ " 1.4. ~1uid •• ndEI..,trtll)'teI GENERAL CltRE The mechanism whel'flby the kidneys fail to conserve sodium in CSW is not known, and may beeither a I'flsult ofan as yet unidenti fied na t riun!tic fBctor ordireo:t neural control mechanisms ($ell Hyponnlremill (oJ.Jcwing SAR, page 788). Laboratory Uleta (seTUm and urinary electrolytes snd osmola!itiea) may be idenTable 1-7 C$W va. $IAOH 30 tical with SIADH and CSW". Fw1.hermore, hypovolemia in CSW may stimulate ADH release. To differentiate: CVP. PCWP, lind plasma volume(a nuclea r med· icine study) are low in hypovolemia (i,e. CSW). Table /·7 compa res IIOllle features of CSW and SIADH. the two rtlOIIt important differences being extracellular volume and saIl ballUlce. An elevated SeTUm [K-1 with hyponatremia is inoompatible with the diagnOl iaofSIADH. 0 • Treatment or csw • Goals: volume replacement and positive sa lt balance. Hyd rate patient with 0.9% NS Or sometimes hypertonic 3% NaC!. Salt may al!!o be replaced oraUy . Blood prOOuct.l may be needed ifanemia iii pruent. Rapid COlTtCticn of hyponatremia haa been 8JlSOCiated with CPM and care should be taken toavoidovercorrection (su page 13). Fludrocortisone acetate acts direetly on the renal tubule to incl'flaJle sodium ab.bbre""'!Ions: j • dset..ued. t • _..ed. t t· sorption. Benefits of giving 0.2 mg IV or PO slg nllican'l~ Jnc',,"sed. WNL • _~ no, ..... !Wl>q d inCSW have been reported", but signif· lls. no A • no cIIIngo , U• """"",,1'0Ii0n, + • p,esenl, • • Ina)' Of may no! t>e pouenl icant complications of pulmonary edema, hypoulemia and HTN may occu r. An alternative tre&tment using urea may be applicable to the hyponatremia of either SIADH or CSW. and therefore may be used before the cause haa been ascertai ned: urea (Ureaphi J®l 0.1) gramslkg (dissolve 40 gn' in 100- 1$0 ml NS) IV over 30-60 mi1lI< q 8 hr&". U~e NS + 20 mEq KCVL at 2 mVkglhr as the main IV until the hypOnatremia i5 corrected (unlike mannitol, urea does oot increase ADH secretion). H VPERNATREMIA Definition: se rum sodium> 11)0 mEq/L. [n neurosurgical jXltien\JI, m08~ often se<ln in the setting of diabetes insipidUl! ( Dl) (.ee below ). S in<.:e nonnal total body wat..'r (TBW) i, . 6O% ofthe patient', normal body weight, the patient's current TaW may be estimated by Eq J·2 . TBW.-.... '" ( N.· l-....~ TBW_, [Na 'l:""".. 140 mEgIL. 0.6. usual body WI {~s> (N~·.k-ou Eq 1-2 The free water deficit to be replaced il given by Eq 1·3. Correction m .... t be made slowly to avoid exace rboting cerebral edema. QnUaIl the water deficit is replaced over 24 houfll, aud the remainder iY given over 1_2 additional days. Judicious replacemen~of deficient ADH in cases of true DI must also be made (see beloUl). fttt watt, d.ficil • 0.6 . usual body wi (kg)_ TBW",""" '" [Na'l~;;;'~~::" mEqil" 0.6" usual body wl (kg) GENERAL CARE 1,4. Fluids and Electrolytes Eq 1·3 " D IABETE S INSIPIDUS TKey ~tu _ ° due to low leve11 of ADH (or, nIT..,i)'. renal in'''Mit;vlt)' to ADH) hi, h output of dilute ur;ns « 200 mo.mol/LQr SO < 1.003) with normll! or ht"h ~""'1Il (llmol",ty • of\en aceompanie<! by (rtI"jng ror water, elp«ial1y ice-waler • danger of HVere dehydntion i f not managed carefully Diabetes in. ipid .... (Oil i. due to ifUluffieient ADH, and resu l ~ in the excell$ivI NO· nalloa ofwat.er and elec1.rolyteL Dl mllJl be produced by two different etiologiel: • ce ntral or Murogenie 01 : a .. bllOTolat lev el. or ADH t outed by hypothalam.ie_pltu _ ita,.,. axil dysfu ~;on. Thi. ia the type mo.! often Hen by neu,..,. .. "¥eonl "De phrore n ie DI", dIM to relative THi,tance of the kidney to normal or upranorm.II...."I. 0( AOH . SHn with IIOms drup t- bcolow) • 1 EtiolQ(iH orOI"; 1. (neur<lt!enkJ diabetH ill8ipid"l 2. A. r~ili.l (a.,t.o.oml! l dolmiMnt) 8 . idiopathic C. poIttraumatic (andudintllurgeryJ D . tUOlor: cran iopha.ryngiolfUl, mlta,ta, il, lyrgphoma ... E. gran .. lom.: neuresarooid ...i•. hit.tiocyto&i. F. inff(:tia.." mlni"';t", enc.ph'litit. G• • utoimmune H .....cul.r: .neurytm. Sheehan', ayndreme (n rely c.us" 01) nephropnk di'betes in,ipid ul A. r, mmal (X-linked recessi ..e) B. hypok.lemia C. hypercalcemi. O. SjilgN:n'lIyndrome E. d .... p: lithium. demeclocydlne. colchicine... F. cbren ~ ren.1 diMue: PYtionephritis, .myloidosis. s ick le ceU disesse, poly_ ey. tic kidney distflse, u n:oidosi. CENTRAL DI ~of ADH ","cretorycapacily mUllt be lost bef...... din~al 01 ens ...... Cha racteri$lic high urine O\Ilput (polyuri.) with low urine ""molality, and (in the conscious patient) cr.ving ror w.ter {polydipsi.). especi.lIy ife-water. Different ial diagnosil of 01: 1. (Detlf"O«!ftic) di.betea iosipidus 2. nephrogenic diabetes insipid ", 3. psychogenic A. idiopathic: from resetting of the osmOila1 B. psychoglenic: polydipsil 4. osmotic diures"' : e.g. following mannitol. or ",ith renal glu<:OM .pilling 5. diuretic use: furosemide, hydroch lorothiuide ... Cen tra l 01 may be ~n in Ih.. foll ..... ing ,itu.lioruo: I. foU ...... ing tr.nssphenoidalsurgery or remoul o(cr.niopharyncioma: (u ....lly Imnsien!, therefore ...oid long •• cting agent. IUltil ite.n t.. detennined if long· term repl.cement i. required ). lJUury to the post.erior piluitary or .talk uluslly causes one of Ihree pal\.ern. ofOlIf: A. Ir.n.ienl 01: . upra·norm.l urin .. oUlpul (UO).nd polydipsi. wh~h norm.li%1'lI _ 12·36 hni .,...I.op S. ·prolonged" 01: UO ItaYllupr.·nono.1 for prolooged period (may be montlu)or eve n permaDf'ntly: only aboul one third oflheu !MItientl will nOI ret urn to new-nonn.l.t one year ~t-op C. · triph ..ic . ... poD ...·: I<o..t eommon ph ... I : injllTY t() piluitary redUQtf AOH I. .... t. for 4-5 d.y' - 01 {polyurialpo:ilydiJlll;.l phase 2: cell de.th liberB," ADH for the ne~t 4·5 d.y. - tralll;enl nonnaJiution or even S lAOH·lilo.e w.t.er retenlion (HB; the ... i. a dan""r of ill advertently eoDtinuin, .. aaopreuin therapy beyond the initi.IOl ph... into this ph ... c....in. l ignificanl hemodilu\i01)l phllSe3: reduced or .~nt AOH teCrelioa - either t r.n.;"nl 01 (•• in "A" ,bov,l cr. · prolonaed" 01 (•• in "S" ahavel " 1.4. Fluid. and Electroly," GeNeRAL CARE 2. following brain deoth (hypo!.halamic production of ADH "",as"51 3. wi th certa in turr.or& (e.g. craniopharyng'iomo. oft.!n pOlItopet~tively): rare. sInce damage 1.0 pituitary Or low" r stalk don oot prevent produetion and relew;e of ADH by hypothalamic nudei -l. . wi!.h o!.her mallll luloflS prt'lOSing on bypo!.ho.lamUli ; e.g. a·comm aneurysm S. following !lead inj urY: pr>"ulfily with ba sal (clive!) . kuU fr3Cture& !&N! P<lI1l! 666) 6. wi!.h encephalitis or meningitis 7. dtug induced: A. ethanol and pllellytoio ean inhibit ADH rele a6e B. "xogenou,et.<>.roidiIT\8Y6fi>m to "bol\(out" DI be\:a.use t.heymayeorTfflad.... nal inBullidency (Bel) Diogmni, bel/lw) and !.hey lnhlbit ADH relea ... 8. Wegener's granulomnto!Jla; 0 YO!lClllitla (He p"gt 61) 9. innamllUll.OrY: lYmphocytic hypophysltia<' (U'l posr 928) or lymph«,ytic infundihuloneur:lhypophYSitilr" (d iatind oonditiollll) DIAGNOSIS The following are u"ually adequ9le 1.0 make the diagnosis (>fDl , /;lIpe<:i~l1y io!.he op-proprillle clilli«ll !etting: I. dilu~ urine: A. urine o l"l>ololit)' < 200 mo.mIL ( u~ uaUy 50-150)'" or s pe<:illol>'Tllvity {SG) < 1.003 (/JIlIY be 1.00 1 to 1.005) B, or theinability toconcentrate unne to:>o 300 mOsmIL in the p ..... enOllordin· ica.l dehydration C. NB: largi! d08e8 ofmannilol fill may he !,lied in hell(\ mumn elIn m>l$k thili by producins p more COMentrllted urine 2, urine OUlplll {UOl:>o 250 cdhr {peds:" 3 eelkgfhrJ 3, norma! D. aoo..e_nonnpl seturn .sodium 4 . normal adrenAl function: OJ cannot oc<:u' in prUnary adremd insufficiency beCl\usea minimum ofmineralOOlrticoid a<:tivity 15 needed for the kidney to make free waler, thus st.eroids may "bring ou t" underlying O! by correcting adrenaJ InBufficien~ In Wlcertaio CIISelI, plot simulta· neoulurine and serum o~molality on the b'Tllph io Fie'''" !.J 1. low ~etum osmolality; tile patient hn polYdipsi~ 2, if the point fall, in the "normol" .... nge, IIlJ.U1tt: !iH!1 WSl<'r depriv9!ion latis neede<l tod.~rmine if the patient can co;>ocenlra~ their !,Irine with dehydration {caution: IU /Hilow} ~ POL Y?IPSIA 3. high setum OIImo[al;ty: d; · agnosia of 01 i! "I!It 81>- 600 lished, and further leating NORMAL is not needed (exrept to differential<' central from nephrog,mie 01. if desired ) t.o differentiate cen· DIABETES ; 200 !.ral from t.ephrogenINSIPIDUS ie 01, give aqueous Pil.rWlinlll5 U SQ: in central D! the !elUIl1 osmolality (mC:>!mo1.) !,Irine osmolality should double within Figure 1-1 Interpretation 01 s lmultall.eou, serum 1·2 ho ul'!l vs. uri"" asmolallty 01. plotting more than one (FIIIVide<I tl'f NnoId M. MOMs. MO .• ""'" will> p,,,..-oe) ds\tl point may help as son,e Plltients te1ld to "v"c_ ilJat.<>." around the border 1.0,,93" "oor-"--I ,ooef-t--t--t-,! 'boo t I r-;-- r-i;/ ~ "'" tt::::::l=' O\2J.706=O~2~SO:=~2!"~~20'~'~-:29~2~C29~6 OeNERALCARE 1.4 . Fl!,lids aod Electrolytes " Wa te r d e p ri vati o n teet If JIilI \lPelear. the diagn(llliliorO I i. QIlnfirmed by a WB1.er deprivation \olin! . CAU. TlON: perform only unde, clOle .upem..ion ,. rapid and p!I~nlially fa tto l d~ hydniliM maye".ue in 01), 'nI.. Wt .. t'BJ'ely neceu.ry ifllef\lm namnl.lrlY> 2911 mOsmILA Stop rv. and make th e patie nt NPO: ch eck urine OIImolal;ly q II • . L a mtinue the ~t until \)ne orth" foll.owing OeruJ'lll: A. normal response occu ..: urine output del:"'~lu. and urine na'nollllily..ue. t.o 600-850 lfIe>.ntIL B. 6-8 lIounlllPIi4! o uri...., (ll molelily pie lnul (i.e. clUlIlge. '" 30 m(fflm In 3 ~on~("live hou ..' O. peli~t to.H 3'1& ofbod)' weiJht 2. If patient rai,. 10 demoost.tllte the norm.l ,up!lnH. then: A, FYI emsel\()UI AllH {5 U Ioqu~~ Pil .....,inSSQI, which nnnnllUy lhere • • • .. uri ne o.t .noltli ey to > 300 mO.o::v'L B. chedc urine ".molallty 30 and 60 IBinutu late r C. tampa ... highelt urin~ OIImol,· lily .Iler P,I.reUinG'J to the 0&. mola lity jUlit ber," pic..-in® B«<lniinll to Tobia J.lJ TREATMENTOFDI J.g .nd 1'abk 1·10 rOl'doII,", rOrml . nd duration of ection (J/ ",.,.,... _ ~1'obl. pressln p re/N-I'1II;M • . Teble 1-9 A,,~IJble " eaOprtlllln I " I A. B. OR 2 . ADH enhanan, ....h .... lions (worka primanly in chmnk pertilll ADH deficiency. W,lI nol work in total /obaence of ADH) A. dofob, al.e (Almmid SIS) 600 ... , PO QLD B. .hlnrpropramide: increelel...-mol HIlI,tlv; ly 10 ADH C. hydrochlo..,thinid. ; thi."id. d i",.tiQlIO"" act by depklit.l, Nt.' which In. ere_ rn.t-rpt ion in proximal tub"l. . .nd .b1ftin, flu:d aw..,. {fOIl] ru.t.al t ubul" which it when! ADn won.... Rr. ~.I Oyaxidc$1 PO q d (m.y IncrellH up to 2 per d .)' PRN) I.n ~Qll.I ambu.l.a tory pat ie r'll wi th Im painld th irst ole eb ll.Qla m. Ifthint mechllli.ml .... lIIlI. in Ulct in CODKious emb"hl1.ory pIItl~nt, lMy run \.hI risk or dehydlll tioo II, fluid .... e, l... d . For th.,.. p&tienU: L have r-tw,nt rou... ", UO and daily "'li,M" balat10Ce fl"id IDUIU and ... utpul ...in« A " in ~"""ID .......oI,1,Y It -..lllwly 10 bt. ....."woo ....,t.p ..,II>.........,... 1.4. Pluidu...:i Electrolytes GENERAL CARE an~idiun~ic rut'dication u needed to keep UO reaS(Onable 2. check serial laba (approxi· mately <t wHkJ.y) includin( Ta ble 1-10 Meantime H nun .odium. BUN , III n o n ·arob uJ a to.-y, co ma· toaeJat u pon>u 8, or braln ·d ead p at ie n t (also leo! MonQjJrnunt o{ftr brain dUJlh {or organ doILotion, page 169) I . follow 1'1 &. O's <t 1 hr, wIth urine ,pedro. iTavity (SG) <t 4 hr. and whenever urine output (UO):> 250 mlth. 2 . lab" Hl'\lm alf<:trolytel with OImolality <t 6 II .. 3. IV fluid management.: ~05112NS.2:0 mEq KCUL at appropriate rate (75.100 mlthr) FLUS: repla« UO above Mile IV rate ml for ml with ' " NS ~OyAMolclM . M:IMI. M. O~ _..;u. ....... ...... aI.,.,..~aI"" .. _ ...... »45 minuI" 1oIoMrIg ............ (e-.,. piI<Noy PIJIO'dIr NS, for post.op pat.ienl-s. if llloiI~_2-.rwslO . .n~) the patient rece ived .iilliIi· . ....., .a'V!tam poUeoot 10 ~ tIt.oI ... ......, cant intraoperative fluid., \lOrIIIi8Itnlin"'~~ then they may have an Ik _ , lliQ 810 01 dHmop...... .. at ,,*,,,,,, at 4 1iQ Q ~p<>IIklpdi\U'""is.in t lI.tIt.oI-*I-.sIyoe_.--... this caae use 1fl NS to replace only ~ 213 ofUO that exceeds the basal IV rate 4. ifuneble to keep up with nuid lou with IV(o. NG )replacement {ulually with UO > 300 mllht), then EITHER :; U arginine vasopressin (aqueous Pitresain®) IVPIIMISQ q 4-6 h ... (avoid tannate oilnt'pension due to erratic. absorption and variable duration) OR OR vasopreni.n IV drip: aLan at 0.2 U/mi.n & l.ilnlt.e (mu: 0.9 Uimin) desmopn'Sllin i.rl,iection SQJIV titrated to UO. usual adultdoee: 0.5·1 ml (2· 4 1'1) daily in 2: divided dose.s 1.5. Hematology 1.5.1. Blood component therapy PLATELET'S Nonnal platelet count (PC) ia 150R-400K"'. Bleeding (lponLaneOUS 0' with invasive pl"O«dures) wrarely I problem with PC:> SOK. SpontaneoWl h~morrhap i, very likely with PC < ~K. I unit conUlitll 5.5 II: tOI' (minimum) to 10 X 10" plateleta. The volume or 6 W\ita'" 250-300 ml. Plal4!leta mIIy be .tored up to 5 dlY • • Recommended tl'1l1ll i'u,ion crittri. o.: I. thrombo<:yto~ni. due to I production (with or without increased destruction) (the molt common cauletl Ire IplUlio: a.o<!:mi. and leuumia) It. PC < 10K IVln if no bleed.ina: ( prophyl~ t ... n.r... ion to prevent bleed ins:) B. PC < ZOK and blee<iinr C. PC < 30K and PfltMnt at ritk ror bleeding: complainta orHlA, hal connuent GENERAL CARE 1.5. HematowIY " (d. scllt~red) pete<::hill/!, continuo ... bleed;"1 from II wound,llIer.. ;nal heOlorrhage ,;n, ~t­ D. PC<SOKAND I. m~ lu rrery planned within 12 haul'll 2. PC rapidly f"llinl 3. pata nt < 48 bou r . pcMIl.-op 4. patient require. l.. mW . punctu~ ~. acute blood 10111 of > I blood volume in < 24 houn 2. platelet tran, f\lliol'll have limited utef"lnttll wilen thrombocytopenia I, due to pia Ie let dfttruction (e.g. by antibodie ••• in fT1'P) or co",umption (ifproduetkm 1.ltIIequate or Incte.ued, platelet traosfu.;on usually will not be useful) 3. dO(umen~ plaUletdyaru.netion in II p' t len t "h~u led forlurgery or in .. patient with advanced hepatic andfor renal iNuflidency (con,ide r pharmacologic l'lInancemea\ o( platelet fUnction, I.g. desmopreasin f ') Other inOic:ation. for platelet t ..n.r.... ion, 1. ptltiente have betn on Plavilc®or upiri n who nee u'llenl , urgery U, IILclln not be poatpone<! for _ $ daYI to allow new plateletll to be synthesized wno """'" Approximately 25'10 ofplateleUl are losljU.t with transfusion. Peel., I Ull'I)l rsi_ PC by ~ 10K. UlusUy give 4 Ulm·. Adult: 1 U raise. platelet count by ~ 5-IOK. Typical dose for thrombocyklpenic bleeding adu lt: 6-10 U (UIUa! order: '8-paek"). Alternatively. I U of plleresed pl ateletll may be given (ob~ined from a lingle donor by apheretlH!, equivalent to 8·10 U of pooled donor plateleta). Cheek PC 1.2 h .. after transfusion. The inc ..... ue in PC will be leu in DlC, ""pllis, splenomegaly, with platelet ant' bodie., or if the pIItient is on elwmotherapy. In the abIfmtf! of intreau-d cons\lfllption, platelets will be needed q 3·5 dsys. P LASMA PROTEINS FFP {FRESH FROZEN PUSMA} 1 bag. 200-250 ml lUlually ..... ferred to 110 'unW, oot 10 be confused with ivnit of {odiN ,,"'ivily which isdelined II I mll FFP is pllllll1ll separated from RBCs and platelets, and contains aU coagulation factoMl and natural inhibito... FFP hu an Dut-<late period of 12IllOnth•. The risk of AlDS and bepatitis for each unit of FFP is equal to that of a whole Wlitofblood. Recommended trans fusion criteia (modi fied"'): I. history or c1ini(al course s,,""li ve of eoquiopathy due to tongenit.al or aequired coagulation factor der~iem:y wilh active bleeding Or pre-op, wilh PI' '" 18 sec or AP'n' '" 1.S II upper limit ofoonna l (usually'" 55 sec). fibrinOCel!. functioning normalLyand l"el '" 1 gIL. and «III(Ulation factor aMaY < 25'10 activ ity 2. provenooagutatiol!. factordeliciency willi active bleeding or lCheduled forlurgery or other invuive pt(l(:lt(iure A. QOo&enial deficiency off..,tor II, V, VII. X. Xl or XU B. deficiency offactor VIII Or [X ifufe replacement faclOn unavlil.bl, C. ¥On Willtbraocrs di!leue unreapOnliv~ to OOAVP D. multiple «III(Ulation factor deficiency as in hepatic dysfunction. vitamin K depletion 01'" Dl C 3. /"tve,...1 of war1arin (Cou.madin®)efred (PT > 18 He, or INR '" 1.6) in pati.n~ ac' tively bleedioa-or requiring emefJrency surgery Or prooedure with insufficient time for vitam in K to COrTect (which u.ually requi .... '" 6-12 h.no) (Nt fXJl' 24) -t. delicier'K'y of antithrombin Ill, heparin cofactor II, or protein C or S 6. mauive blood tnnsfution; replao;emtnt or> I blood volume (~ S L in 70 kg adu lt) within leveral hou ... with evidence ofcoaguJat ion defK'ien~y II in (1) and with continued bleedin& 6. treatment of IhrombotJc thrombo<::yt.Optnic p!.Lrpura, hemolyt ic uremic ~ ndrome 7. • beclUMofauociat.ed haurd. and suitable al!.ernalives, the UI8 of FFP a.a vol. u~e O!OI:pander iI retatJvIly QOntraimlic.ated Do.age: Ulual.t.artina dose il2 bop orFFP(400-600 mI). IfPI' ill8-22 aeca or AP'n' i, $ .70 aeca, 1 ha, may suffiOI. 0-. as hi,b a. 10-16 ml/kt may be needed for lOme patienUl. Monitor PI'IP'IT (or specific factor ....y ) and clinical bleed in,. Sinoe fatlllr VI [ ha. a shorter half.life (~ 6 hn) than the othe r facto .... P'l' may become prolonpd before 10 I.S. HematolOfl)' GENERAL CARE APIT. R&mernbtr: IfpaOent I•• t.o re.x>lvlll( pl.tel.II, thaI for every 5.6 IInl1.1 of plal. leu the JMltl.nt I•• Iao reallvi ng coagul,tion r8~tONl equivalent I.(l ~ 1 bag of FFP. ALBUMIN AND PlASMA PROTEIN FRACTION (PPF, AKA Pv.sMANA TE®) U.ualiy fro,n outdated blOC)(!, I ...led to inllttivau hQpatitia 0 vim • . Ratio of .IbuTII1n:,lobulin P4'1'Drnt.ll,! In ".Jburuin" illl6\1U~. in PPF it .. 63'11:17Ilo, Av,ilabJ" iu 5'" (OO(Oliul!, ..nd otmotlcalb O!quiVilellt to p18ll"'8J aud 25'i11> (contraindiut<!od in dehydrat.ed poIti.!nt..,. 25'" albumiu n..,11 lot diluted to Mil by mUting 1 volu me of25'il. albumin to 4 VOhllDH of rx,W o r O.9'l NS (_ caution: mixing with I teri l. water will result In a hypotonk 8OI ution that can ( II""- hemol)", , and poai bl a ,-..nQ] fallllJ"eJ. E:cpeMive for UH .imply u . volu me "~paud,,r (- $6Q.&O per uuitl, lndica\.ed only "'Mn IOlaI pr()W:i n <: 5.2 1PlI'Ilo(otlw!rwISl!, uncrylt3 l1 01d which i •• quall)' effective). Rap· id influiOli (;> 10 celmin) has \)Mil ~pGrtcd to UI\1141 hypot.>na;o:l, ld ...... to Na 'ac~late and lielemBn r~Ot r'~ ilMn""). Ute in AROO iI controvenial. In "euros .... g;cal patieQI.S, may be <:QNlid ... red .. an adjunct I'or vol ... n>e expan sion \a101lg wilb crystalloids) ror hy. pem)'llllmic th,rapy CH.1IfI.P 197) wllm the hem atocrit Is < 40'lI0 fQUO'Wlng SAH wh~ tMllI I. cOIKIIm about irlen!..;ng th. ri.il of rebleedi.JIr e,g. wilh the U5l! ofh.etl1llt.~r~1I pagt 781). c.m CRyOPRECIPITATE lrIInsfu!liGn mteri e; I heonophiJia A Rfoeom~nded 2. vOn Willebrand d isea .... 3. documented fibrinog~nfr.dor VIII deficienc,y 4 docwnen~ di55eminated inl.rll~allCUla r t'OIIgulation tDI C~ alonl with oLber m.odeoI oftberapy 1.5.2. Coagulation 1.5.2.1. Anticoagulation AN~GLt.ANT CON51OERATIONS IN NEUROSURGERY Contralndication l to beparin tberapy Many U'adilional contraJndkation.aalll bein, r~nlIidered and challenced. M"';Vf PE producinghemodynun itO)mprom iH should bI! treated witlli nticoogulalion in mOll~ dupite in traut.nial rUb. ContrRindiCl tillnt to h,~rin include; .-..cent !leVeR hud injury te«nt uarllolomy: ..e IMI"", palj..,ta wi th roIIplopa thia hemorrhagic infarct ion bleed.inlulcer or otbu ,nllcc85.bl ... blH.hng si te 'Hitolllrollto bl" hypertan5jon Vvelll hepat ic 0. renal dr_v immedia tely before inv..ive procedu .. (au ~ for ar.riocnphy 0. my~IOI"T" phy) b... in tu mor;,"~ cue.I 10 pati~lltllwltb unM.lphu'-ed (l ocide otal) ce rebra l ane u rylIm , Nllioo.l\IlMion 111&, no!. ilKrN'" the rillil of he,""rrba~(i .e. r upturtl. hO'Wevt'r, . hould nrplu .... occur, 8111ticotJUJItion would most likely inl!l'fue volumeorhlmotTh.~e. 'lid o,u. ;nCff'a. morb'di\,)' and mortallt,. In plltieou wic.b braJn tumllr Sonw au thora are .... Iuclanl \0 adminil ter heparin l(I any p!!Iti~nt with a brain lum~. , Itl\ouih a numbr!:ror.tudJ. found no hi~u ri.k in th .... patientawhm treal' f:tiwi\h her-rin til' DrIII.nt~ lat;"" •..·(PT.hould be follO'We<l yery tlo..el),,_utwiy r«:Oll\IMnded m.i nUinin , f"I' _ 1.2:5 • ""ntm!"). POfIt«JpertltiveJ y rollowill' cra niotomy ReQuil'8S individualiu.tion baaed nn the ruaon fOr et'lltIiotDmr (I.L luruur . AVM , an· eurya-m, e~ ). Howe ...... , most n. uro .... rgeon. wou ld prob. bl, not fulb' antioo.gul8t.e pa- GENeRAL CARE l.~. HematQJogy " tients <.3·$ (laya followingCl'lUlictomy", and soma t~:omroeJld at lean 2 We6s (one itud]' found no lncfea8udlncidence "rhll!f!ding when 81Iu"'8g1.1latiol1 W8$ rellun,ed 3 day. POIIt craniotomy"'). S afe le ve lll of PTIINR to pe rform o e urosurgicaJ p l'Of,:edures Patienb on warfarin who mUllt be anticoagulated .... !,,"g·u po!<!IihlB (e.g. roedl/m i. cel hllllrt Yalv~a) nred \.Q be admiU"d to tlul h0i5pit.allll\d converted to h~parin , Moet eIIn stop warfarin at home, ~lId theD be admittotd 2-3 d ..~ later and ~t.arted on heparin lUI PT begina to normalila. Pat;enlJl with 1"811 critical nee,h for antio:o.gu lation (a ,g. chronit." lib) can usuAlly ~ takM offofthe ""arfann at ]Il""t 4·5 daY" before the procedure, and .. Pl'IlNR is (nlln mecked on admission to the hoapilal. Pntienta ~ to be aware thatdlJr· in,s the time that they are not antit<)agu lated, that they are at risk ofposslble romplica" lion8 from !.he lvndition for which they life !'eC<'iving the ",ana ~ rlo k for meehaniclll nlve iA . 6%, for .·fib it i. ~ 1.5,*,). In p a Ue n l.ol n eed ing IlDgi o gra ph y or myelo grap b y. In 1111 pllti.. ntB, hn pnor ro ~tudy. mil ~top h"pllrin 4 For non·em.e rgcn L n e urosurgical proced ur.llr. For procedUnlB where posl.-Op maSli effect !Tom bleedIng would po6e ... rious ri~k (whioh ;ndudes llIost neuroourgi~1I1 o~ ... • tiona ). it ia recommended tlllll. the PT . h u uld be _ .. 13.5 sec (i.e . .. uppe r limiUl ornarmill ) Dr the JNR sb o ul d hOl - '" 1.<4 (e.g. fur n!fe","CII, thlB INR ',s ~"Onl.id"rN ~af.. rDr performing II percut.llneou. needle li ... er biopBY). To r .. v"rs .. antieoagulllllUl.1U JXl8f 24 . F or em erle nt ne urOHur]i(ical p roced u ..... For eme'JencYlitulltiolUl, giye Ff'P (Bl.lln with 2 urnta)lInd vito",in K (10-20 tug N Ilt" 1 mg/miD) II !lOOn s5 poe.8,bl" (u:e ~e U far fIl ..... rsal ofantiCOllgUIBtianl, The timing of . urg.. ry;8 th .. n ba~o~ the urgency of the .itUlltion Ill1d the nature of the ptoCl!dure (e_g the decision might be til evacU8~. spinal "pidurol h.. matomll in sn acutely »3r11lyzed ""tient befo", anliC08gullltiDn is fully reY~rsed). ADtipla tele t drugs a nd Deuro!lurgical procedures Plov\x®(clopidogrel)($tt pagt fJ72) and 8.IIpirin cause p....mAnent lnllibition ofplatelet function tn.t pel"lliats - :;, days al'le!: diloontinUlltlon oftbe drug and CDlI ;~""Ul!- the risk of bleeding_ Fl>r elective callOlll. 5·7 dl\Y1l offthesa drug5 il1"8<'Ol1IUlended. For e,oer· galley Burge,.,. platelets may be given (art ~ 20), howeyer. with Plavix the drug ~r' ,ist5 in the lytLem for up to a couple deya lifter the last do:oe. and can actually Inhibit platelets given o{t.r the drug is dificontinued rthe half·1ifeoraaplrin ia lower IIIld ahould not be an iuI,I« after I day). [n cas... wilh contioued ooling in the fj"t day or !to afUlr w;,,",ontinuiog PlaYi~. use tb.e following regim~n: I . retOmbinanlactiyo!ed coagulation factor VII (rFV1h,J: even thnugh the defect ;s in the plateiett. rFVlb ...·Iltluo:. via a rnechllnlsm not mtdlated by protein clotting factor.. Very exPl'IUI ..... (_ $10.000 per dose). but Uti, mU5t be billanced againBL the..u.o\ Ilfrepeatcraniotomy, increased leu Slay and additional morbidity A. initial do"': 90-120 m<.'g/kg B. Bamedole 2hra11lter C. 3rd dOle 6 hra lIf1.er initial dos8 2. platelo;lS every 8 bouN! for 24 hour8. ~ A. 6 U Ilfregular platel,ta B. 1 unit ofphe"'"",d platelets (ifpt. ill on nuid or volume ~atrictiOD ) or ANT~GULANTS ~ heparin \ I OROO Iff0 \, ilJt: Administered a. TV drip or luh ·Q bolua. To antil"OlIgulat<! "'erage waight pa· tient. giy~ 5000 U bolu" TV . follow with 1000 UIhr N drip. Titrate to therape-utic entitaBgulatioo of APn" ~ 2· 2.5. control (for OVl'. Stlme recommend 1.5·2. conLTQI"' ). SID'~ (""eA"lkoog~lclllj consuumfWIU tn lIeW'O$urgery aboye ): hemor. rh ag~. thrombolii611O (he]>llrin activates ."tl·lhrombin lJIand can CUU$e plateletaggrega· tion ) which caQ rEDult in 10111. CVAs, OVl'$. PEa. etc. Thrombocytopenia: tranSient mild thromboo;ytop.tnill i& (airly common in the 61'11t few days "fter initiating heparin therapy. however se>'1'rE thrombocytopenia IK:CUr8 in L-~ of Piltients l'eCf!iYlng hepQrin " 4 dil)'ll (usually has a delayed Dn5l!tof6·12 dilY~. ilDd is due 10 CDlUlumpt;on in heparin·induced thrombas" or toantibodill!l rottlloo. ~g3il1fit~ hep$rin·plllteletpTOu,in ooltlplllX I. Conijider LIM-of l~pjrudin (",~ tHlow) iD thrombocyr.openic patients. Chrollk th4!rIlPY may cRUle OIl· teopOrlI6~ . II 1.5 Hematology GENERAL CARE Low mo lee ular w e ight be pa ri n IJ"" Low tnQlec:ular wei,hl hepl.rinJI (LMWH) (.v~llIge mol~ lar weight .. 3QOO.OOOO daltorwlare derived rrom Wlrractionllted hepllr in (IVlrIlPMW", 12,OOO· 15,OOOr:\altoM). LMWH. dllr•• from UnrtllCI;onnted Ileparin becaute th ey h.v • • higher ... 1;0 of IInli·flll<.. tor X. 10 11I\t!·flIc!or n . (antithrombin) aetlYily whleh theurelicnUy . ho\lld producor .,, \iIhrombie 'fTKI.I with fawer heODorrhaljlc complicatioN, aealiutlon orth~ bene6t tI.. been ..... .,. minor In clinical trialt;, LMWH MV11I.ellt&t bioIIIvailahflily .ner aub-Q inJec· lion luding to more p."dlcillbl. pl .. l.ma l,,,.1II wh k h eliminatq Ihe need to roonitor blo- lo';'c artivit)' (au ell •• Af"M'1. LMW U have .. lonller hllif-lif. and t1011U pt. rl~y. thl!fffo~ require few!!\'" Oruglo'inctude: da1teparin (Fhopinl»); Rx 2600 ~ntJ·Xa U SQ q II eno~.pllri.n (1.A.o .....nodl): & doSll,~ eslllbli.hed foll"wini bip replacement u- 30 mg SQ BID JI 7-14 day•. A1tetnatlve: 100 Ulltg SQ BID ard~parin fNQnnlflt4): Rx 00 1ll>1!.x. UiKc SQ q 12 hn • dllnllparoid (O~tHrlOn®):. i'w!paring,d. E~n hither IOnli·X,a:/lnu .lla MIllo than LMWB •. Doe. n6l require lal.,u111O')' moniloDnna. 1U 750 antl.Xa U SQ BID tinnpario lLoaiJlOrinS. lnnohep®); notav.iJ.blt in U.s. ~ 176 antJ ·Xa U r-erk( SQII"ced~ily S pina l ., p idurlO! b~ .wma.: 'l'Mrr have lIMn. num~r of aiR repgrW of,plllal ep'· dural hlln'atllmIUI oecurring in p"'lien ~ on LMWH (primarily tno.apatial ... ho 111110 U"'derwent spinaLlepidurnl .. ...,.lhpi. Or lumbar puncture , primArily in rlderly "'.,/flal undergoing urthopedic lurgef)'. Some h.ve bad signiflc.nl naW'OlO¥ic Hql.lelae. includ· ing permantM par,IYlilI". The risk .. further incrta5ed by Ihe Wie orNSAID., pl.telet inhibitoR, orothe•• nt;ooaguhUl~.lIl1d ... il h Il'8umll'(I or rePfated@piduralor . pina.! puncture. Fondapal"iow: (Ari ll:t ra®)"" (ncrealle!l ractor x.a inhibition ",ithouta(fectint: racto.r Iia (throlQbiD). UnCraetiunllt· eli &. l.MW heparin. bind plalellOl fac:tor 4 and caO UIWI ;mmUllftomediat..d heparin.,n. dueed lhrombaeytoP"!'ia (HIT) . FondaparlnllJ' don not bind plal4!let ractor 4 , and h ... not caUlled HIT. May be. mo.... effective than enoxaparin (r.o-.·e~) for pn.·lI!nlinc pilat · op OVlil. S IIICD'f1«:'1'S: BI@ed;ngillhemO;!llcommon!lidedfl!Ct lm..,.boJincreauo;tbyCOfl· current NSAlO u",1. Rx: 2.6 '"i SQ injection q d. lWPl'Um: 2.5 mg Ilnglwose.ayringes. Lepirudin ( Renud ~)-" A direc:llhrombin inhibitor which blocks the thrombogenic .... tivUyofthrombin. and, IInlih heparin. lleo "'1-11 on dot-bound thrombin . II is rnA IPJll'O'I'ed for a nticoe.f' walion in puJenu wi th heparin-induced thromboc:ytoopenia. IU: loItding d ...... of 0 .4 t:IJIk, (up 10 44 mg) rv, followed by «)nllnUOlJl; inr.... ion nf 0.16 mifM;Wh r fer 2·10 days. 'llIedoae i.e tilrated to sl.3rgl!t aP'M' rlItio of1.5-2..5. __ ''LIW' I lilT .. iall eont.lllnlnt: 60 mi. / ,---J warfarin(Coumadin®) \ / OIIUQN'O \ ~L_ _-----'''--" 1'0 Int;eo.,rulate 'YI!rajle wejpt pati~nt. rive 10 mt: PO q d.2-4 day., lben . 6..,.q d. Follow ~gu"lion 1OI.ume., ti\t1lte to PT. 1.2·1 _5 ' -cunlrol (or lNR . 2-3) for most «lndil ion. (••,. OVT •• incle TlA). Hillier PT r.tiOi of 1.5-2 I control (lNR . 3-4) may be IIHded fot m:unenl.,.,temk tmbGiirm, lIIethsnieal Wart utves ... (th, recommended rlln._ for th, Inte .... ation.l Nonn atl i_~ Ra ti o (INR) lte.b.own io T"b/e l · /J~ NB: Warfarin lhould nO! be started until /I tl\,,,'lp;!utic: PTTb.. been achieved nbte 1-11 Recommended INR , '" on he~rin to reduce the risk oC"Coumadin I\II('l'(IIi • • " Ourin, l he li nt _ 3 da,.. of ...... filrin therspy, I*tiellla .. re I>t.tua lly hmu: colII!ulable ( _ d i l l ' to rl!<iul.'l.ion of v;lamin· K dependent anl.icc.oqul.,ion r.otoR protein C .. nd pt"O~ "S). tMrefore, ODntlnue he.,.rin durint: the lI ..u few da,... 8UPI>I.WI: K'OJ'ed UlbI orl , 2. 2.5, 6, 7.5 lind 10"", TV form: 5ml!ilMal GENI!:RAL CARE 1.6. H""lIto1"1l' 1.5.2.2. Coagulopathies CORRECTION OF COAGULOPArHlES OR REVERSAl. OF ANTICOAGULANTS For recommended norma! yal"u (or coagulot,on a tudil!!l in IM!lJrO$urKary."" Me 22. Platelets S.t J>08' 19 (or 'ndicatior,e alld administration guide!;ne~ , Fres b froze n plasma To revetH wlllfari n an t itOll/{llIBtion. u lW!- the (ollowillg 91 II sta rtin!: point a nd tt!che<;k PTIP'M' IIft.erwBMS' wh~1\ pat,ent is 'th&tlI!)eut;C/l Uyanticoagulated· s tart .... ,tn 2-3 unit. ITP rapproximatf!ly 15 mUleg i, usually nlll!ded ) for ~verely pro\o"ged PTIPTT, start with 6 uojts FFP Prothrilrubin complex cancentra.te Warfarin indu.~ u.r,jeollgulaeilln may be revt rsed up to ~ Or 5 iimo mono qui.kly wi th prothrombi" com plex con ... ntTat~ (P CC) (conr.ains COHg raclonl ]1. IX. and X) thon wit.h FFP". P"tient may become hyperthrombotiewith th is. ,--/ vitamin K (Aquamephyton®) \~--,-I--::c~"""-,--~.~ro,----:c\ ,;--c To reveTae elevated Pr fr:llJ) l\'ru1arirL give. "'1U ....U8 eo!Joid al lolulion orvitumin K, (phytonadione. A'IuarTU!phyto~). Dc.sea", 10 o.ng produc.!- warf,tr:;n r~5isUo n~ for up to I week . FFP Ill.y be adminls!.I>1'I!d oonc urrently for n,ono .opit\ 'orredion (see obo~). FOT noeammended levels of PT. see page 22. Jtx adult : start with 1().-)5 rug 1M; the err"" takes 6-12 hl"lliin abAell«l Qf l ive~ dia· ease). Repea t d0&8 if needed. 'I'iuo llY1! re~ tot..] dOH needed to reverse theraPj!utlc enti · c:oaguler,jon i. 25-35 mg. rv admini,tration hal been assc>ciated wlm &evete . eaction. (possibly 8nephy lae-tic). including hypotel\ll;on lind eVi!n fataliti" (even wiOl proper precaution.l to diluteand e dmi n;. ter slowly). therefore rv route i. reserved only (0 • • 'tua tloll$ where other routes are !lOt fell.9ible and the ~riOU5 risk isjustifi\!d , R.l: rv (when lM route not feal;' ble): 10·20 mg IVat a rate ofinjeetion nollo """,,«I 1 mglmin (e.g. put 10 mg in 50 ml of D5W and give ove r 30 minuteal. ""'Y ,--/ protamine su lfate \ / OflUGlNFO \. 1 mg revenell apPl'Ol[imlltely 100 U ~ (gi've slowly, not to exceed 50 mg in any 10 min period). Therapy I hould be guided by coagulati on studIes. ~tam,ne can 11180 r eversE! _ 6lJ1i, afLQven ox. ,--/ desmopressi n (DDAVP®) \ / DROOIHI'O \ . Cau&etl lin inerllase in fsetar lIT coaguleut activity and vo n WiUebrand fact.o. which help$' OOODgu)ation and platelelaClivity in hemophilia A and in VQll Wi1l~brand·. di&eDfIeTyptIJ (where th e factonl are normal In makeup but low in oonoentration • • but may c.u.~ thromboo:yloOpc"l1i. i,. ....", Wlll~ brand'a d'.t a.>e Type liD wheT" faclOT$ may be ab· normlll 0. miMing). R.o; 0.3 OJg/kg (u8fl 50 ml nfdiluentfor dovl ~ 3 OJg. usot 10 Ill] for :loses> 3 11K) given over 15·30 minute.o 30 minu\.(,s prior 1.0 a s urSica l procedlJ,te, ELEVATED PRE-oP PIT In a palient with no h'i tory ofOOllgulopathy. a $,gnlfiCB otly eJevatc(\ pre-op P'IT,5 eommon]y d ..... to I!ither a foetor deficieney o r to lupus ant,eollgulan~ Worku p: I. milting study 2. lupus coagulont If the mixins s tudy cor,..., .... !he el"v8U!d P'l'T, th"'n there- ia probably B factor defi. ciency. CoNU! t II hemalologi8l. Lupus anticoagulant: I flh~ test for lupUJ pn t ieuagula n t ;5 ~ilive.lhen tM major risk to tM pa tient wi th surgery i. o.ol blllEdin" rath~r it i. thromboombolism . ManD!:ement reNlmm~ndBtions: " 1.5. Hllmlltology GENERAL CARE as soon as feasible post-op.SLart patient On heparin (Met page 22 ) or LMW heparin (_ page 23), e.g. Love nox 2. at the ume time SLart warfarin, and maiotain therapeutic antiooagulation for S· 4 weeks (the risk of DVTIPE is attuaUy highest in the fint few weeks !X'et-op) 3. mobilize ft8 soon as p08.!lible post-op 4. ronalder vena-tava intelTUption filter in patients for whom anticoagulation is contraindicated 1. THROMBOEMBOLISM IN NEU ROSURGERV Deep-veiD Ih ro m ~i 6 (DVT) is of ooncem primarily because of the potential for material (dot. platelet dumps ... ) to dislodge aod form emboli (i ncluding pulmonary ern· boli. (PE» which may cause pulmonary infarction, sudden death (from cardinc arrest), orce rebral infarction(from a 8()o.called paradoxical embolus. which mayoa;ur in tbe pres. ence ofa pateot forameo ovale. see Cal"diOllfllic brai" ~mbolirm. page 773). The reported mortality from OVT in the LEs ranges from 9-50%"". OVT limited to the calf has a low threat « 1%) of embolization. however. these dots later extend into the proximal deep veins in 3Q..5O% ofca5es", from where emboliutioo may OCCur lin 40·50%). or they may produce postphlebitic syndrome. Neurosurgical patients are pa rticularly prone to developiog DVTa (estimated risk: 19-50%) due at least in pa rt to the ..... lative frequency of the following: 1. long operating tillles of some procedures 2. prolonged bed rest 3. paralyzed limbs (e.g. in spinal oord injuries or stroke pa!ienLl) 4. alterations in COlIgUlation status A. in patients ..... ith brain tumors (_ below) or head injury'" I . n)'lated to the eondition itself 2. due t<:l releaM orbrain thromboplast ins during brain s urgery B. increased blood viscosity with concomitant ~sludgi ng" 1. from dehyd ration the rapy sometimes used t<:l reduce ce ..... bral edema 2. from volume 10M following SAH (cerebral salt wasting) C. use of high -<lose glucocorticoids Specific "neurological" risk factonl for OV'r and PE indud ....: I. spinal cord in,jUl"J' \SU page 705) 2 . brain tumor: autopsy prevolenceofOVT ., 28%, ofPE., 8.4%. Incidence using 1261_ fibrinogen" : men in ..'ioms 72%, malignontgliomo 60%. metastasis 20%. Risk may I>!! reduced by pre·op use of aspi rin" 3, suba rachnoid hemorrhage 4. head trauma 5. stroke: incidence of PE = 1-19.8%. with mortality of25·1{)()% 6. patients undergoing neurosurgical operation PROPHYLAXIS AGAINST DVT OptiON includa: I. general measures A. passive range of motion B. ","~u1at.o ~"ptup riat~ pati~" ts as ~'... Iy .... pob.ibl~ 2. mechanica l te<:hniques (min imal risk of eomplications): A. pneumatic compression boots" (PCBs) or oequential compression devices (SCDs): reducea the incidence of DVT. and probably PEs. 00 not use if DVT. already pn)'sent. Continue use until pat ient able to walk 3·4 hrs per d., 3. B. TED Stockin~ : (TEOS) ap plies graduated pressure, higher di8tally. As effective as PCB. No evidence that the benefit is odditive". Care should be taken to avoid a tourniquet effect At the proximal end C. electrical stimu lation of calf mu.s<:les D. rotating beds anticoagulation B A. full anticoagulation ;! associated with penoperative complications" "- TE~ JI' ",g;,,~~ t,..d.",o.rk. "TEO" .\.O nd. f... th"''''boomboli<di . .... B. for.Olllrl;ndkations ond ton.id."lIionl ofull_gulltion in Dl!ut'OIurge'Y. ___ 21 GENERAL CARE 1.5. Hematology B. "low-dose" an ti_gutalion" ("mini-dose" heparin): 5000 IU SQ q 8 or 12 !In, .tarting Z hr$ pre-op or on admi..ion 10 i>olpital. Potential for hazardoua helllOJThagt ...[OIin braiD or . pinal canal hll! lilllited ;1.1 "10 C. low molflCU lar weight heplll'in. and heparinoida (He pogr 23), not a homoCt~u. group. Err~cy in ~u"""urFcal prophylaxis has not bHn dete.mined D. upirin: role in OVT prophylw. illimited becaUIM! ASA illhibl!8 platelet aggregation, and platelet.. play only. minor role in OVT 4. combination of PCB. and "mini...:!..." he~ri n awtinlll on the mornmg of poat-op day I {with no evident<! oraipificant comp\icatioosJ" Reeo mm enda tion. RecomD>eod«l prophyluia ".rie, with the risk ofdevel· oping DVT. a • •Uu.- Table 1. 12 Rl,k & p. ophylaxl a of OVT In neu rosurgical pa118nl'" trated in Tobk J·12 -. AJIJoO I « pogr 105 fot det.aig orprophylaxil in cervical . pI. nal cord injuria. DIAGNOSIS OF OVT The clinical di agt>O$i. of OV'l' ill very unreliable. A patient with tha"d,uie liJ'lI" of. hot. awol· leo. nnd \.ende. enlf, ora poII itlyt Homaou' . lgn (calfpll;n on dor • • inexlon ofthe a nkJe) will hpva. OVT only 2().50% of til." tim ..... 00·60% o'f patienLl with OVT will not hav" thesa f,ndiop. Laboratory testa abOrn.tU. : Ovr.LIMI'_~PC8 _ -,,*_ tion~. TEOS . T"EO \~ _ ...)SIad<irIgse.ICH ...... Ir_M"'''l'Ionl\age. SAH _ ~~ _ " . 70510< speciIies '19l''*'!I OVT ~ .. CWWQI SCI ri". oontra8t venography: the -gold ILtandard", howeY1l r it is invasive and earri"" ofiod,ne reaction. occasionally produces phlebitis, not readi ly repeated Doppler ullrasound with B'mode imaging: 95% ",nsitiYe and 99'Jlo _"""ilic fot" proxi ma l OVT. LesseffectiY<! forealfOvrn. May be used io immobilized orea.sted LE (unlike IPG). Widely accepted a5 the non·inyasiY1l test of choice (or OVT" impedance plethysmogra phy ( IPe): 1000 for reduced electrical impedlnc<l! produced by blood now from the calrfoHowing relaxation ora pneumatic lOunIiquet. Good in detecting proximal DVT, not &elll itive forcal f DVT. A po4itive Itudy in. dicates OVT tha t should be t reated, a negM;Y1l5tudycan o«urwith non-oeclLllive OVT or with good 00llate ral5, aod should be repeated OYer a 2 week period '''I·fibrinogen: radiolabe led fibrinagen il iooorporated into the developinll thram· bus. Bet te r for calfDVTtban proximal DVT. EKpeol ive, IlIId cnany false poIIitiyes. Risk ofHIV tralllmiuioo has resulted in with d rawal ofUM O-dime r (a . pecific fibri n degradation product): high levels are uaociated with DVT and PEn TREATMENT OF DVT I . bed rest. with elevatir:m. of involved 1eg(1) 2 . unleu..,tiroagulation ilcontraindiea ted (_ pog~ 21),ltal1 heparin (as outlined in AfIlit:oogulaJ.ion On page 21, aim for API'T . U.·2 I oontrol) or fuLed. dOH of t...MW heparinoidl (e.g. tinuparin (LoFparin®"', or in tha U.S. • nonpari n U..ovenOlL'®lt~ JIG6f 23}: ~ initiat. warfarin thenpy . Heparin can be stopped after _ $ days" 3. in pIIotien~ whtLre anticotlfUlation i. oontuindicattd, eon,ider Inferior venl elVo interruption or piaeement of a filter (e.g. Greenfield filter) 4. in non·paralyzed p"tieo~, Clutiou.ly bertn to ambulate after_ 7· 10 d lYS " GENERAL CARE 5. wear anti·embolic stocking on affected LE indefinitely (limb ill always at risk of T"<!<'urrentOVT) 1.5.3. Extramedullary hematopoiesis In chronic anemias (especially thalassemia major, AKA Ox.ley'a anemia), low he· matocrit "'suit!; in chronic ove r.stimulation of bone mprTOW to produce RSC,. Thi, reo 8u lt.s in systemic bony abnormalities, cardiomyopathy (due to hewochromatosia caused by increased breakdown of defective RBCsl. Perti nent to the eNS, !.Mre are three aites wheN! e~trBmedullary hematopoiesis ( EMIl ) can call.'lll findings: skull : produces "bair-<lo-end" appearance on skull x·ray vertebral bodiu: may result in epidural cord comp re ssion" (Hf below ) choroid plexus EPIDURAL CORD COMPRESSION FROM EMH The exuberant tissu e is very radiU6ensitive, however, the patient may be somewhat dependent on the hematopoietic capacity of the tiuue. Treatment Sw-gical excisiun followed by radiation therapy has been tlle recommended treatmenL Repeated blood transfusions may help udure EMH and may be """ful po$t-op in· stead ofRTX except for reft-actory cases" . Su rgery on these patients is difficult because 0(: I. lowplateletc:ount 2. poor condition of bone 3. cardiomyopathy: increased anesthetic risk 4. anemia, coupled with the fact that mOllt uftbese plI.tien:" are "iron·toxic" from multiple previou t transfusions 5. total removal of the maBS is not always possible 1.6. Pharmacology 1.6.1. Analgesics For a discussion of types of pain and pain procedures, H' pagt 376. GENERAL PRINCIPLES The key to good pain con!.rol is the early use of adequate levels of effective /Ulalge· sics. For cancer pain, &eheduled dosing is superior to PRN dosing, aod "rescue" medication ~hould be available". Nonopioid analgesics should be tootinued 85 more pm..nl medications an d iavasi"e techniques are utili2ed. ANALGESICS FOR SCM: SPECIFIC TYPES OF PAIN Visceral or deafferentation pain May sometime. be effectively treated with tricyclic antidepress/Ults (ou pag~ 33). Tryptophan may be effective (8# pagt 33). Carbamuepioe (Tegretol®) may be useful for paroxysmal, lancinating pain. n:u~ta.8tatic bone d i sease Steroids, aspirin, or NSAIDa...,.., especiaUy helpful , probably by reduciog prostag· landin mediated sen9i ti!.lltion of A·delta alld C ftbeno. and therefore may be preferred to APAP. Pain !'rom GENERAL CARE 1.6. Pharmacology Nonoploid analgesics 1.6.1.1. ACETAMINOPHEN '", ,....Iic 1OO>C\Iy '..".,IJ''''' ~wiII'>_l", 101jl'1'lllaY, '... 111_ c ~OOOmo, _ _ .~ , oa:urM .... __ C-MI'IIQ!\ ...-'*_)IrI~,"'S1lt1g l>/l r.....'I. .xl!l'ol&l~'ng ~ ""'SO ~·rncIldrlgQt. . N ONSTEROIDAL ANTI-INFLAM MATORV DRUGS ( NSAIDS) Tho! anU.i nfl&m",atot)' propertiell orNSAID. i. pri"" .,.;!), d"e to ; nhlMt'on orth~ ~n· ...,. ..... eycl_y,ftlHe (COX) .. hlch part,cipalell;" the !lyntheslll of pl'OIIl.I,!.nduul ond thromoolu. nu'" . Chal1lc~ri.tic:5 of nonwlective ""'ISUlroid al anti·;nnalJto'latory drug>:: .n a~ """n 0 . .11)' eao;ep4. Mtorol • ., t rornethDmine ('I'oradolol!l . (Ut below ) no dependence develofUI addiliveeffKt imprOY'fllhe ptlin reHfJwith opioid anal,esies NSAlo.land APAP) deruonnf1lte a "",mD, ened : a maximulIl dOlt! aboy" whlt h no fU rthe r llIIaJaaiio ilobta.lned. Foraspirin and APAP, Ihi, lor " l ua lly bf:l;'ween 650-J300 me, and ia ofLen higher ror oUt... NS Al08 whkh m.~ alllO IUIYe a longer d"f1Ition 0( ""lion ri>; k or Gl "PMI;& ..,mlllOlI . 1I>Ore .."rioua rho of hel"'totox.idty"", or GI ulcer· al iOll. hemotTbaee , 0 ' ;:>erlo .... tion Irt! I/!!!$ """mmon lIking medication with mu la Or I nl.lcicb hal not been pI'1l'«'A effective in reduo-IniGi sideeffKW. ~ti~p fO$toI ICytotd). a pl'OIItagiandin, maybe "ff'« tiye in mitipling NSAlD·U\d.lUd pamc el'Ollioo or peptic ulm I'. Colltl'l'nrlical.ed in p. ......cy. Rx 200 Ili PO QID willi food as lone ... patient Is on NSAlDlI. Ifnol tolenled. w;e 100 1-'( • • CAUTION; an .bwtjrjlCl~nL Should not be ,""en tCl preg. nant womt n or women Clf clli ldbearing polen till most l'ev",..ibly inhibit pI.telet runction and Pro1onl bl\'lO'd;nll tim .. (nonaceil}'llted .alkylal.ea hIve Ies& antiplat.elet action, e.l . • al ..late, trililli~l.te , n.b"lIIet.onle) ...... pirin. unlike all nthll' NSAlDS, irrflvtClibly bincb to c~IOOXYleniH and thUll inhim .. platelel ruocUon for the &·10 day lire oflhe platelel an c...... MkliuOl and .... leI' ~ntion and ca ny ~ rloI k ofNSAl D.lnd u«<i nephrtltolrieity"' (raial JMul"fWie~, intelll titia l nt phri lb. M phrotk tynd rotM. hyperkalemia) Table " l ·a No nl1e rold .1 1.6. Pbarma..,logy Tab'- 1-14 NOII.le.oldal _ . . . . , _ " .... \I"'Mo ... , t "'..-.aIIe$I IftK\i.. __ Sfl. _ .. _;EfI •• <lerCleo ._ : OOC.d'UQ~cI-Oce ..IW\!I: MS...-.. I'/ItoLlheotp IrI ~"Ir_ borI. mela_ ibo'Pr"..",os ... r~ l00""'llml: dOSll IOl-'''''IT'O$!O 12~-sIII ~OS ~ loS-l0 110<;lii0i ,,~ : -w."._ ~WI\i\. ~ III 040~, (I>aI FDA _ _ ~-,s.,..,.."....) ~ ....... ""'"INSAIOs. _ _ _ _ ror_... ~ III pouIbI. ..-._piIo~luflCl.oCt'l ketvrolae tromelhamine (Toradol®) n .. only p" ....te,..' NSAl.D appnw!td for ua in pain cont:ol ;n UI~ U.S. Anar-ic .11'«1 iI mon! potent !.hili anll-Inflammatory .1T1ICt. lIal(·li r".6 hu. May be uurul to control p&ln In the following . ituationa; 1. wh~1"f the avaidance afHdlltian ar I"flPlfll\.aly depTIIMion ir; critieal 2. when conlupatl(JolI unnot be tola..1.ed 3. for patienu who are ,",uaeated by nlrcotiCi 4. wher" narcotic depeadene," alWlnoul co~m 5. when epidunl rnorphin. has bNn u...:! Ind furthr anallft;" i. n~ed without ril lt of rupi ..wry dl!pn!ilSion (Igofllet tn>e nll'ODtiQlllnl ooovailldiCited) 6. Clu t (onr. A. no~ indicated for \1M" 72 hn; (complication. haYI been r~ported primarily with pn)lonSed uw olthe onll (onn ) S . u.... wi th aoution in posl oprl"ltivi .. tienlll.",ce (I' with II'I(M:t NSAlo. ) bl~inc lime ia prolonled by platellt function inhibI tion (rialt orGi or ap.'te helQUlThl~ il.mall, but -. lMf"IIaHd in palllnlt > 75,.... 01(1, wMn used .. 5 daye, end when used in high", do6et"'l C. t'Vfl1 thou,h 1M dOlllnl n rCW\lYlnU ~ 01 Iyuem.I'llnI: mlKOll.l,rT;ta_ IIOn.net ef'Olrionl mil)' 0«11. N with all NSAIo./DYOld uR wilh PUDl D .. with ell NSAlo., \1M WIth c.ulloo In pltI~n" .l,," rorrtnal.idll"fr~ Rx Parentl!ral: For anal" dOlll!lIdminJlttalion: 30 ma rv Dr60 maiM In healthy .dull. For multi"l. cIooIill(: 30 me rv o.r 1M q 6 h!1l PRN, Masimurn donge.: 120 mgldllY. GF..NERALCARE 1.6. PhinnaoolOC)' z<) For patient wright < 50 kg. age > 65}'n. or reduced rena l function (ereatin lnedear. anea < 50 mVlnin). aU ortheabove dosag:es are halved emu daily dose; 60 mg). Pa .... nt..ral UBe ~hould not""Cf!1l/I 5 daY" (3 dllyB may be a beUer guideline). It% PO: lndica t.ed only ... II continuation or IV or JM lhaJ:llPY. not rOf routine USIIaa an NSAJD. Swll.l:blng (rom 1M to po, Rtart. with 10 mg PO Cl 4-6 hr~ (combined PO and 1M do~ $hould be" 120 nlg on tM day ort"'Mltion). SIIPI'IftII: 10 mg table~ . 1.6.1 .2. Oplold analgesics Narcotics are m09tc:(]mmonly llSo!d ror moderate to !levI'.... acute pain Or Cancer paIn (sorne ""pert.s cha racteri ze canoer pain Il!I recu/Tt'nt acute pain nnd not dlronic pain ). CharacU!rist ics or nan:otkr. no ce iling e fte(l t {1I«{}Q{ft 281: i.e. iMreasing dlI,~g" illc rea&e!i the eife-cti"e,uSI (although with welk opioid. [or moderate p!lin, aideeffecta INY wuil d05llgel to ralatively (ow level,") with .bronic use, l<llenuJee d~elop!l \ phyaical and pay<:hologiral ) overdm.e po$I!!ble, wi t h the. pOteRtI.1 for respiratory depresllion with all. and fiej· "lU1N with som@. (u~ pGNII151) MILO TO MOD ERATE PAIN Some useful medIcations an! ~own in Table /· J5. Table 1-15 Weak oploicls lot mild 10 mod' falll pair! CALITlON· ~n. can CilUW dio"l/OfOUS .... ""~ 01 CArba .......OI>I"._ Codeine and ill! OQng\ln~~, p!"QpOlQ'phl!1le aod pIIntllzO(:in~, are usuBlly no IIIDre ~r· recliv~ thalASA Or APAP and are usually Olmbined with these dl""llp. ,--/ I. tramadol (Ultfam®) \ / OfItIG I/¥o \ 1 All oral oploid agonist thatblnd$ to I'-opioio;l recapton, and is alMa centrally uting "".. I&,,~ietbot inhihil.8"'''pt.ak""rl)o"<'pi''''phrin""no;l """,<onin. FOF 0.<01.<> poi;', 100 mil comparable to codeine 60 mg with ASA or APA.P""·"'. Th~..., hO$ be~ n nn report or ....... pi ratory depres,ion whell oral dosing reoommendations are followed. Seilurea '/.Ild opio· iel·like dependelWt! have been reported" Rx 50 to 100 IDg PO q ~ ·6 1m; PRN pain up to II maximum of ~ OO mg/day (ar 300 mgfd roroJder PlI\ientl) ~OT moderately 8e,·~re acute pain, Oil initi.1 dose of l OO mg fol. lowed by 50 JOg d06es may suffiCf!. S<lPI'LIED: ,;0 mg tabo!. 1.6. P hlltmllcology GENERAL CARE MODERATE TO SEVERE PAIN ,. , ,, nel '" &i<Gftd <0000 ~ 01 ~amor.opl>enl2~ hI'S I.... (001""'.'" r _ H3.., \Or "$00 ..,ly In oploicl·l<lIe-..,l poII"en,. ~ 2fII SEVERE PAIN Table 1-17 ~ doses lor SEVERE pain, AGONIST oplold. (pa renleral roule I, rflerenced 10 10 mg 1M morphine) Ta b la t !M:I'O poIency ,a;oo ,'" ~ Is "B 10< $I'lllilt _ " . but tiIar'9H 10 1:2-3 wf~ ctvDnCdoslnsI ~ _ ' " 1Ong' !M>lU$oI "1lQI '~ mtpIPI"KIiM is mtrI.ool.M<110 "0..,''''PII'oII..... a . limul.nr.,.;th . I ~20 hour ~ .r.~,,,, . !11101 may accumulatt """ o.use agi"'!ion "'aiM< C~S t>yp.'1IC1iYIIv (IrcIucIIng "",,",Ulll _ _ U'K), ....... '...., ".."iJeOi _given nl~<l1IIg5 ~ ""'I' OIl"" """"" se_era ,~"Ihy 8M dNl/O given .. \II ~ "'" 10 /<>nIl nail· Nit. '''IlHled ~ can "'~ 10 .a:umultrionlll<l eNS <l8p'8""" (muSl rad<JDe 00.. • ~tor _ 3 days. ""on IhouCIh "'. anJI9ftIc hall·'r, _l'Ot I;I'ItI¥), osr:tedally In .,.. IIIde<Jo,o 01 ~II"'" !)alieni. u.. _ De "",iled 10 ~ ....", ...1>tfItr<;e using _ drugs _ """"'i.... w""" t INIY ""1M pta<;licIIJ 1<>, Il$e '" U!iIm ~II\ sinoD I T)'IO!OIl <.01'1 ....... only 5 mg ,,",{COCIOM I'''' ac.14mlrIOI)I\en llmlra 1M M<~). UN OxyCotoIlrill'''' nlOner <lOI.II5 or O>yOOllc>nt ~ • s/IoUICIn<M De used Q"""UneP)<t ·",,~( r,.o;oI ,esg;l&lOIydepf85$lDn1 ,o.pp!y r 1"'\CI>louppe' !O<SO. ~_ ~ n N., PAN rTIlI' Avinza® (extended release rnorprune) \ / \ Onre daily oral morphine fonnulation ,,~inB 11 s philr\olll oral dru, a tlsorptioD. syswm ISOoAS) (numerous ammoll to-ruethacryl8w eopolyrner bead$. _ \ mm (Ii • .). 1U: !K>liallll;s titruled baud on pD~ient·. oploid tolerance Hnd d<'gTf!e orpain. Taken lUI I capsule p.o. q d. Not to be t.a.ken · PRN". Not fot post-op fIlIin . • CAUTION: 1'0 ptevent pot.entially 'aUlI doan of morphine., capBuln Bn! to be swallowed whole. and are not III be~hewed, ~rushed ordiSS\llved. Howe""., the oontcnUrofthe <:apauJe(the beado) may be sprinkled on epple-s .. uce for thaw uMule u. 6Wallow the eaP'llllei. but the bend~ an! not to be ehl'wed ru'(rURhed. liIOC ~ Ou, to tlle potentillly nephn>t<OOc affeet off,,nl8ncacid uaOO in SODAS, the maximum dOlll'of Avin,.., is 1600 mg/d . Doses .. 60 milln! fnropl nid u.lerant patienUr only_ SuPl'UI<D: 30. 60. 90 "" 12.0 mg ""p"u le!; . / ,-/ P.iI,lIad one® (extended r elease hydromorphone ) \ / ORUO INFO ~L_ _ _ __ _ \ -->'~ Once daily .,,,tlmded rel ell8e bydromorphanl! HCI (imm"wate reit&S1I fonn" includB Oileudld®). ~ ... misyntlleticrongener of IllOllIhine Md HCtlVI'. metabolite of bydroo>done, Risk for abua.e 0. lllco:idental a.·,.,rd01lage by viol8ting capsule Or ccmcII:ren t "" of eleohol. Recommended only for opiaid tolerant pelienbi who have, failed other therapiea" . Rx A lJChe~hde 1J dNg. Por oploid loh•• Iln\ patienbi only. ~t.rt with 12_82 mil" PO" 24 hOU ri. Titrate UpWArd by 25-60% incrcmCnL8lvery 2-3 d8Y$ PRN • • Capsulu are not u. be opened . b~n. chewed, d.is$olvoo 0. c~ed or taken wilh al",bol. Do not use if SlIve r<! hepat ic in.uAidency. SIII'PU£o: 12.. Hi, 24 &, 32 mg CIIpfiull!ll. \.6. I;>hannacolcgy ..""" Tabl,1-18 Equ!,n. lgu!c dOlle. lor S EVERE pain , AGONIST/ANTAGONIST opIoldl (relerenced 10 10 mg 1M morphine) Drug 01l1li: genetic ... 1101,1'1 (!Iroprlel.r)8j ~(Supronexe) 'M Sl MIX 'M "'...... ... (Nubm"f) """", (T'twIr0f;) demcina(~) -- " "POt 'M, ~ ,. '.3 , .... ",., "" (." , O.S. I ,,.>,.• ..., 10 I~O~ 1&0 ($1M 0 SO) 1.S.2 10 . "'~ ..,••. •• .,."",.,. !)Ir1iI!J9OAI" I 1'10 $Igm1l1C1j1101 .....~t ,..., .. ..... lItfICIdIIte _8w.1'~" pI'lente pIIySIC8lIy rill"",,,..,, on ~ 1I'0OI ~ "'''''. ~ oIg<twI ''''''114'''' (St.ocri;O ~ N~lint ..1IrCh ,n.~ c,"" 1....., ....01_ (lGf 1M _Jc:cn_onIi' ~,.,.. T'''''".~ I_II''''''''''' "'S'O"_bPlig/lPO-._ T. - N...,."",ccnI_nol<SAl..... r _ ", -\ -"" 1.6,1.3. Alpha-2 adrenoreceptor agoni8t8 .... lphll·2 ' Iloni,IIo ba"'l IIOIlI'leda tivs and '.lla1Ilwe pr(lperti811 aod dram~tieally .... du~ thl rilir. o r "'pi nlt.oryde l'l"fiIIlon , nd Uulllmountorna ...... ti~ a nl1ll""j"" r~quim , ~ Precedex~" (dexmedetomidine) \,~/,--_ _-__-_ _ _\ -,-~ Rr: ulUlIlloadi ng d_ it I mq1q \lVlr 10 ,gjoute., followed by CGlIlinuoul rv infuaion of 0.2·0,7 U1~glhr Utra!ed 1.0 delired effect., nul to ~ 24 houn. SloE vncTS: cUniell lly aignilicant bradycardill s nd .inUI arnt!It hlsVII ~ in )'II\Inll. hn llhy "ol un ~ .... ith i~..ed vlllial tone janticholinergics IUch IS atropine 0.2 mg IV or IIlycopymll.~ 0.2 m,r IV mly help/. U. with I:II lIlIon in patienta WIth ad · hu rt block. sllt'....,.....:2 m! "ill. of 100 mq:Iml for IV u""'. ",nee<! 1.6.1.4. Adjuvant pain medications Th, following ."ay have efficacy in _hIIncing the.efTecti-.- of opiold llnalglfila. land thercby may redu{'O! the reqllitOO dC>H) 1'ric),elle a nl ldepre ..... n~:.~ ~ 376. 'rryptop b"n: an emillOlrid e nd • pl'l'CUrIIOI" ofwrotonm. wly work by illCTUti", .crolonin !eye I,. ~u'"" high d(l<ellllnd luu bypnolH: ~ffectll , w....,fo.... 1.t..2 gro giv"'n usually q hi , MIIII gi"c daily MVI U" chron ic trypcophln thel"llP1 depleta: viWoin 8.. ADtlhlelaro!netl: ~,II\.Aminel play I role in oociception . .... ntim-tamine.. wkith ant ,lao I nJUo!ytk 'ntillmBtic, and mildl y hypnotk Int@fTecll"eB. Bnll!ge8i.-or uadj,,· "lints. HydroxYline (A(oIra41, VisLaril®): fU . tart with rx> mf PO q AM .nd 100 mg PO q hi. May incre."" up III _ 200 mg dllily. AnliconvulPnll; tlIroa .... zepine, c!onazepem, plMnyt.c>ill or flbilpttnlin mly he effKti"e in ncuro{)ltthlc pa in from dinbel;t neuropttthy, lrigemin&l ".U".lgil, pafl. ""' .... petie nlluNllgil, gl_pharyngeal ne urll!gill , lind neuraJgi". due t.o ne,,'e Injury or intil· lration with C8nurOO Phe'lOtblui o u : Inme cause mild reduction in nodoc:a pt;on. Mo .. are t".nqu,lldng Ind IOliemetie. Best Imo.... n for tbis U~ ia fluphlJluinl! \ Prolwn®). usually given with • lricyeli~ I ntidepresunt for n~uroPl'thic JNlin, .e.lJiI:JM/;t tl.f ~rop<1lhy, 7nalm~nl On pap 556. PhenothillZUwa mlly NOdu .... th •• eilurl! thru hold . CO l'\iOO$le ...... idl: in addition to the reductiou ortoxie efTKu " f .... dill t;on or chemo- GENERAL CARE therapy, they may PO~Qlj.~ nUCOl!ean.lgeaics. Ther~.~ .1", a numberllfoonspeci6c benefici,l t lTIM:tI· men,8M appetile. Hme "r w,-II belnl. IInt;e,lIetie. Sid" I!fT<ICl3 ms)' limit useruineM (aH Pou(bI"deletuiolU aWl tffn:1I of".r'OIds, pave lIl). Catfeln.: althourh It no intrinsic anwge$ic pl"Openie., dl>Sl:a 0(65.200 IDreo.l!'r>ee ."alp.ie ,ir.." of APAP, ASAoribuprofen in HlA., Ofllliutpry pIIill.nd post.-partWll pIIm. u.. 1.6.2. po-.._. Antispasmodics/muscle relaxants 0 ...1tf'nlI"llUy·aclinll mUlti/! n!laxan18 have. Md/lting ,-Ifed. On the c:ent.raJ net'V\lU5 a),litem, a nd lben> I. little e>'ideuce of any othu beneficial f'fTO':(t. Elfa:acy ofu5e in~­ tienta WIth Mut@lowblockproblema r. dubioUl'" (uo: /XlIl!l291). Only d<)118 are h.r;~ btlow Be: f,mili.r wilt! appf'(lyed indication. nnd precautlonJI ~ cydobenzaprine (FleJleri1®) \~.....I./~:-:-_ ~;-~ ___\...>..~ R.r Adult : 10 mil POTIO-QID. IIlu.n, 11011.0 uc:et!d 2·3 wtoI!ka. \ / \ ~ RobllJtisal®: i8 a combination ofmRthoearbamol400 ITIi: ... /.SA 315 mg. methocarbomol (Robaxin®) Rz Adulloral dose: inilial dose. with 500 lI.g tab.: 3 tabs PO QID 11 48-72 htl,.nd thell 2 tabli PO QID. With 150 mg t.atNI: 2 tab. PO QlD 11 48-12 htl, alld Iheo 1 tab PO q ~ h ... Or 2 tabs PO TID. With Robax.iul$: for RYe", 'IlUmlpai n 'ta rt at 3 tab. QID If pll.t;enL eIIn tolerate Ihe ASA, tlHm drop down to mlin~nanee dOH of2 labs QlD & Adult IV mer.hocarbarnol: 750 mil: IVPB Q 6-3 hrl ror _ r e 'p.II51JU_ SUI'I"lJ.EII: IT\ied.8ble 1 ,ill 10 mI . 0 ..1: 500 mil: tablet . Robnin$-150baI1SOm, methoeal'bamol . chlorzoxazone iPara.(on Forte®DSC) \ / \ Due to riak ofoeriou. "rwI p<'I5I;ibly fatal bepetoloricity and quutionabll e"ecti ..... neu lUI a muscle Alluanl., tb""" Is little indication to uM thia dnJ'" ~ diazepam (Valium®) \ / DRUOI'IFO \ l R.t: Adult dOSll for muide lp&SlNI: 2-10 mg PO TID-QID. AIaa •• pog.. 368 r"r mo", lnrOI'lllBtlon and ror use In ~j':lalltidty_ ~ carisoprodol (Soma®) \ I DIMlIHfO \ \ Caution ' IlOl. a true mU1IC1e ~"lIt \ more of a sedative). M8J' pnldu~ euphoria wilh ,""ulltng potenlial lOr abuM. & Adull.. 350 rug PO TID arwl q .... ~ quinineiulfate \ / ~-o \, For "oi,hr crampl-. Over 10J0 of people> 65 yrs old uperience noc:tUn;laI crtlmpl at -orne time IUluaU,. In 1M l~, _I~;n the han(II,. No weU-cnnlrolltd lrial' todoelI"",nl efl"ertivlllllM_Mda -aMl,ysl. luggesltd Ihlt lhe frequency ofCfDmp5 C~II be ~ duUld by ~ 2MI. _ r 2 weeks of trealnltlnl, and by InOT1! ",,"r' w ...1u. bu~ Ih"re WM 110 challie in ....enty o:r dunoo ...... Avoid in pr~n~ (aborti facien t). CaUlion: even low dose can cau.. 'I'TP In stn,itive palienta_ re~nted doae&call cau5ecinchoism (watch for tinnilus. HfA. NN, hearillj' Iou)-_Rulf:-out uremk neuropnth,. bero~ trl!(ltinl't-po,gt' "",. R..r Ad"l1 200 o:r:roo ..... PO 'I lis f'RN (better ..tficac;r seen wit .. n!t(Uhlr lI"";nl). 1.6. PhannacolocY GENERAL CARE 1.6.3. Benzodiazepines Alto!1!e &dilfiliU & paralyticl, page 36. All are elre-c:tive for \.reating aru<i~ly lind inllOrnni ll, and \'ary onl,. in phlLrnlll«lkinHice or lIite Gfmetabali.m. Those with ",harter du:ration ofaction are ItS!! likely to 5ed/lI.e, but are 1tIGl'f! prone to tIIU!le rebound depru.ion "" withdrawl ayndrome (may include taehycllrdia, HTN. tremulouanes!l , dillpho.re.is, dY"phonll , confusion, mll""]" twitching, /loll $e;1urea) upon ~Iln"alion , TbDA<! with hmg duration of action On! mGre likely to teIIult in cumul~tive sed ation. and Impair- ment.of paychnmotor aDd iDtelleduw function". Lower doae8 are used for ~derly pa- tients. May be ",vel1!led with nUlYIIUeniJ (Ii'!! IH>/ow l. SmK~' v.. ntilatory dep..-ioo anti hypowo,s.ion u"cer1l.t&d by opioids, w,,'ee in palien"" with COPD. AlI contraindicetad in fin! trirn""ter orpre~lIn<y h:auseoongen. ital malfomoation')", 1-19 oxazepam (Ser.tX®) \ I Thought not \.0 be metabolized in liver. Ib: Adult: 10-15 mJ PO TJD·QID (increllse, to SO IIr severe anxiety l. ,-/ alprazolam (Xanax®) \ IIIgTl~ro fnr EtOH withduwl \~c:"-/_-.,.-~'_~ -""' -c:--\ -"-' May hav" antidepressant eff~ ijimilar to tri~y<:Ii <:6, with ,l1li", rapid Oll8l!t . Rx Adul t: nart ItO.25·0.5 mg PO TID. tittato! to mllll'of4 mglday dividoo; come.! in 0.25,0.6 & I mg tabs. ,-/ .. midazr,lam (Versed®) \ I OfIUG INPO \ 3 to 4 timet 113 potent lIa dla:repam (VaJiumGll). DiQolves in a qut!<lua solution, \ thu~ 11'&8 burning IUld phle bi t is tho d,iaupam. M physiologic pH. i~ lipid soluble and readily ~roeel BBB. Gl'1!lItat amnes tic elT'ed. thlUl diuepBm, Excotllent anticonvulsant proper· liea. Given 1M. on!l-et ooeul'll 8t Hi min, peak at SO miD, duratiioo 1·2 hrs"" . for e oollCiou8 ileda li!> D WQJ!t lVP): 1·2 mgoyO!r2 min (do not uteed 2. 6 rog with init.i.al doore), wait 2-3 mimi, IlOd repeat up to total ofO.l-U.16 mg/kg. Reduce by a t lellst 2~ if opiaid,8re 11&0 being u.;ed or in patient.s ,. 60 yrs. To mai ntain seda· lion , "'peal dOBl' a of25$ ofinitia] . Clilltion: mida ... br.m has been associftted wilh rtspiratory arTen (even in young ppt.ient.d. Monitor palientwntinll0U51y, II&(' e.· Il"a caution in eJder ly !!. ror 1M p .... o p : O.07.0.(N! n,gIkg (6 mgf70 kg) about 1 h. p",""op. 3. ror ind uction for geneul anesthesia: A.. initial dose (.slow lVP) of: I. for u"premedkllt.ed average adul~ age. '" 55 ynI : 0.25 mw'\<g 2. > 55 yfll, ASA Oltt'"S I or II: 0.2 nw'kg I. GENERAl- CARE 1.6. Pharmacology JS 3. ASAlI l orTV~ O.J5 n'f'9 B. t.o m.inLaIn: "'peM 25'" ormi t;.) delft. Miduol.m dnp: DilllkW mg llIiduol.m In lOOct: IV fluId (only ilLui boltJ'N<'OllIllIended,'5 plnt.ic .deo r~ midB.lOlam); Itart lI.l 1-2 mg/hr .nd tilrHta 1..0 desired level orled.tion. BENZOOIAZEPINE REVERSAL J flumuenil ( R Ofl\UicQllil)) I \ DRUB"*<> \ CtImpetl tively inhibilll b.1l,odiuepi nu (OOZ) lit , _p1..ot lita. Sinw dllntlon'or IIcllon i. shorter thn mo.! BD?,,". reeeillltion 1lI8)' o«ur. elpeci.lly "'ltll hlT", dOlift of B07.& glv.n OVl!r , Ions: \)r·OC!tdllni. BOZ,nLaton;,,,, ~I < 2 mi ni Il\fr TV dOlI!, pub in 6_10 mini. end IA~lIl . /lO mini. l)o!dlOtioll i. only parti ally re,.. nad ;0 80m. palienl.l. Rev6ran l of BDZ illdu""d t.pi'lIU,ry deprHll ion if partial or oil". Con traindicated In pDtienu ~htonka lly Irul.ed with B07... (ro' II!JZllrI!II Or fGrothe. indicational whAt . a ntagoni sm ma.)' prO)Voh. withd rawal Iyndrome and/or Hi~ u"". May Pl'1WOlr6 a panic lIu.ack. Not approvlld. fDr liN in pregnlllt)'. &To ...... eral! BD7.... u... d rOt(:On.cloUf~ation Oflalleral arlNtMlia' O,2 ma(2 ml) over 15 SOK:Qnd l: rep!!& t at I minu~ intenal, ifle.1I1 of , evonal ia inadAq"ate up u,a maximum or I mg (total of 5 dOllU). Ir relNid.tion occurs, I'll'), re~t doMinf at 20 minute iotervds, keeping withlll a m"" lmllm or3 rug per hour. For .tUlpeded ovlP'doeap. civa 0.2 mil ovCT 30 sea, w.lt 30 &ea. lhan give 0.3 meover 30 lea al I minute itlU!rvall up to 3 mg Or I,lJ\til ""lien t aroUlli!" rv 1.6.4. Sedatives & paralytics The modi fied RamlJ./l)' ;oOOlItion !IC.!II~"';' .howll in T",bk 1·20. This is u.seful e.g. for QU llntitating th edl!liil1!d level ohed8tion .. hell pll!scrihlng ~ativl!Ii for an I16itated patien!.. 1,6.4.1. ·· · Table 1-20 Modified R.mll~ sed ... lion KIlt. ,..... .... ,, Conscious sedation IWWous 'flO ~ 01 reess _..... oooperaIioe. orienled and ~ 3 I8SJlOIlIIs 10 CDn'lIIl;II'd$ onIr FIeIponM 10 I/gbI g11lMl11ullp Of 10lI0 IUCII- miduolam (VIlt1'M'd®): M' ~ 35 pMtoba rbiu l (NembuI.llJe): a ba.n,itu. raU!. 1U fgr 70 Jq adu.t; 100 me.dow "" ...... • , ...... ..... <VI' tII!si< 1\!$9OftM.' chloral hydraie-; ledation dOle to 25 mglkg (_ bflow) 1.6.4.2. .... • N ....... Sedatives for procedures thiopenta1 (Pent.ot.ha}®) \ I \ A Ihort Ictinll ba . hi l un!L III d08l C8"1IU um:oDKiOtUlneu in 20-30 _(circulation time), de pt h InCTell.. lip to 40 &ea, du ration. 5 min. (terminated h)' rtdi'triblltion), _iOUf,nea return. O'tIH 20-30 min• . 8mI: DTIICT$I dOl' ....,1.1ed rupirau,1)' depre ..lIIO, !rTit.t>on il ... tran-.ated , intra_ .rterial ln~tioo ~ n~tOti., . git.ation itin,ieeted . Iowl)" lin IIntj.n. !gnic mJOC'/lrd ial deprUlll nl., hypotelWon in hypovolemic patlen".. & Adult.: ini l ie! eonfflltra\.ion ,hollid oot ucae<! U,", giva50 ml lUt d_ nlOdCraUlI)' rapKl rvP, then iftoleral.td give 100-2(1) m.lVPo .... r 20-30 IeCI \500 Ill( m.), be required in I.rp !'fItl .. nt). J methube.xital (Brevital'l» \ / CRUGINRl Mort! potent and ahorU r lICtinr th.n th,oplinul l u."rule.r. for 1.6. Ph.rmacology \ pI!~u"neou, , rhllO- GENERAL CARE where pellen! need. t.o be .edlted IUId I w&.ll.ent<irepeatejly). Last& 50· 7 mill. Similar CIIllliona "'ith thlld ded probl.m that meLhohuital may i.n!I.Y&lta~zlll'fl IU Adult.: I sm':\soluti.on (add 60 ml diluent 1.0 WO mgto ,wId 10 mgl'mlJ. 2 ml tut do. , then 6-12 lOl TYP at rata of 1 mll5~. then 2 W 4 m] q 4-7 mIn PRN . 1.011\)' / fentanyl (Sllblimaze®) ~ \ / OfOUGIIlFO \ -----L-_ _----''--" N.rcotic, pOtency ~ 100 . mo~ine. ]n . mall dos~l. [alta 20·30 min. Unlike mor· phonland meperidinl, doe. not Cftuae hi ltllmine «,Ieul. Low .. ra ICP. Sma D'nIC:J'H, dos~ d'pI'nde nt r IJpiratol)' d~prn"ion, IlIrp dOl" givfln rapidly may c:ause chelt ",.U rigid. ity. Rx Adult; 26·100 III (0.5·2 ]VP, rlo'pe8t q 1-2 hra PRN. SIJl'~L.IJ!D; 50 IIgf.rnl, re· '1uin!1 refrigtraUon. mn ,--I proporo\ (Diprivan®) \ I ORlI(;INFO \ 1 A 'feb.live hypnotic. A1~ ueeflll in high doses during "neury.m IU'll~1")' a. a neW'Oprotectant /tet p~ 808). Protectlon leem' to be leas than wiUl barblturateto. IUt ror sedpl.JoQ : "'lIrt at Ij-IO I'g/k,gIQ:lin. loCI'1'IIM by 5-10 Hf'k.iImiD II 5·10 minULl!S PRN d8sire<! seda tion ( ~p to a IOU 0(500 Wli'kgfmin ), 9t'1'rl.n;:0: 500 mg IUlpended [n 11 60 m1 boUleorfal emulsion. The bottle and tubing II'IU8t be chlll\ged every 12 hOllI'll Sinte it ronLlirll nO baC1.eriolltatle IgenL ~ haloperidol (Haldol®) \ I 0l'II.I0'*<1 \ 1 SmJ: trn:crt rare neuroleptic ItlllilMnt Irndrome. a Contralndiall.ed [n Pl tkinlon', diseu&. An~imolinereic ",recta ml)' ..x_rbata uri ... !), ~lention. Rz For "ra pid ~f!quenc .. U1Inqui!izal;on" (to Rdata "aile!) agiUlted p.olimt): 5-10 mg ha]operidol]M q 150 minutes until p.tientcontrolled. PED1ATlllC SEDATION The following agenla may be u8ed to sed8te pa1.tenl.• (or prut:edu~1 (e,g. cr or MRlI. Ahoy .. 1 ,.,at, anyoflheM mly be "sed. Forchildren < 1 rur 11>'. .... chloral hydrnteat 50 rog!kg C.- Niow). pentobarbital (Nembutlll®~ 2 mg/'ka' IV II ~ hnlPRN OR OR fentanyl (Sublimawe): 1 NIka: IVP di,upam (V.liuum). 0.1-0.50 mglltg« not to ..xefti 10 mg) lit miduolam (V.r-.tIIl 0.1 mdkglVP \ ! chlo:-al hydrate \ Ilk... 30-60 minllLl!S all.er SL'PPUm: . utpenlllGli 100 IIIlVml (_ 500 ~ till wh~h ilMlOmw'eatpoonJ or 500 mg oral dOle to c.~uJ" WCN"t "Dpr (DEMEROt., PHENERGAN & THOI'V4ZJNE) ~ii~~~~;;~'~'~ !!'b!'!""!'!' AKA -lytic r;Odt.lail" Corabine in 1 . ynnp.nd rive at deolp]M ;11- .iac:tion: • ... IIW!peridine (Denu!rote): 2 mlVkf (mu: don 60 mg) pl'OlIlethnina (PhenerganCl): 1 mgllo;g (a COnl rll;lId;clltad;n patient.! < 2 yn age) chlOll'I'OIDI,iI\e rJ'hGradnt«l): J mN GENEItU CARE 1.6. PhnnnlleolollY " 1.6.4.3. Paralytics (neuromuscular blocking agents) CAU'J'ION: "'quirt's venc.ilatiDn (intubation or AmbtJ-bAglmnskl. Reminder: pH ... Iywd potienl.ll may still be~DnsciQIIII.lUld thereforellb!~ to !eel pll.in, th ,imultllneQua use. of8edaliou i, !huJI required fD' cou$ciaus pMienu. Early routine uae in head·injured patienulowens ICP (e.l . f.am lI.uctioning' O') and mon...lity. but doe!> not improve ovenilU outcome'" . Neuromuscular blQcking alente (NMBAa) Ille ch:ll<liified clini~ly by time tQ anaet aodduration ofparlllyaislllOlbown in Tabl, 6·22. AdditiollllJ ioformlltioo for sorueagenb follow! tbO! table along with $OlOe mru;ider1!tions for neuro.urgjcal patienu. Table 6-22 On$&\ and dUr,llion of mUlcle relu8nla ULTRA-S HORT ACTING PARALYTICS .-I succinylcholine (Anectine®) \ I 0f:W'31N.FO \ , The anly depohl.ri~ing ganglionie blocker (the restate competitive blocke",). Rapidly by pillsma pseudoc:hoLine6t.erllsel. A .ingle d.me produces fll5CiculaLions th~n paraly$i.s. On..«et: 1 min. Duratian of adion: 5-10 min . InIl~tiYIl1.ed Indi cationll Due Ul l ignificant side effecta (.Jet! tN!iDw), use is now IIrnlt<!d primarily t.o tbe following indlclltioo.ll. Adults: g>!nelllUy ~llU!Iended Dnly rDr emergency intubatia"" where the airwaY;8 notCDnlrolled _lD child ren : Dl1.ly wben in tubaLion il Deeded with a fulluo"' _ aOO , o~ iflar:yngt>!lpa.m "",,1m! during IIttempted intubatiDn uRing othe~ IIgents. S id e effeds • CAUTIONS: usually increases serum K' by 0.5 mE:Qfl. (on rBre Decaf;on CBUses "",veee bype rkalemia (!K·I up 10 12 m&yl.) in patient8 with nel,U'l)nal D~ mu..:ular pathol. ogy. uu~ing tllTdiac compHt~UDru; which cannot 1Jo:o. blocked ). Lherefcre contraindiuted in IlCUt.e phS$!! of iDjury fDllDwing major bUm6, multiple trauma Dr nt.e1Uive denervatioo of.keletlll mUl!<:le or uppe' motor nwron if\iury . 00 noL use for routine inlubation~ in adolescenlA and children (may couse tlirdillC IIrrest even In "pparen~ly healthy YDUngIt.e~ many Dfwhom h8ve undiagn<llled myDPllthi~). Linked t.o lIlaHg:lant hyperth~ rmia. MAy cau.e dysrhythmia.. Kpt!cially ainu~ bradycardia (INO L with atropine). May get autoDDm;c stimulation from ACh-like aCLion - HTN, and brady- Dr tachyCllld;a (e.._ pecially In pedl with repellt.ed dal es). The fasciculation! may ,n(felne Ie?, intngaatric. t.6 . PhannacolOjp' GENE:RAL CARE pre""UTe. lInd inr.rQoeuL8~pre""ure (wnlTaiooitllted in pene~ra ljnge.y& injury. espeaally to qnterior charober : OK in glaucoma). Pl'1II'urorization with a .pri.ming do.se" ofa n<JfIdepoJllrlziDg bloeker lusua-lly ~ 10% 0/' the intubating dose, e.g. iUlQCu ronium 0.&·1 mg IV 3-& minutes prior to sucdnylch o>line) in pati~ntll with elevated ICP or increa""d "'traoe... l"r p r ...... ure (to am.-.Uornte further pressure Incru$ru! during failCiwlation ph illie) lind in patientll who have eaten recently (c:ont.rovenial lO'). Phole II block (.lmi llirto nondcpolpr. zing bloekerl may develop with fillC\l8S; .... dOllIlll nr in patients willi a hoonnal pseudoebn~nl!l!terll88. Dosing Hz Adult: 0.6-1.1mglkg (2·3 ,nJ/70 kg) lVP (elT on high aide to allow time for procedure &. to avoi<:,L multi-dosing complica t ions), may repeaL t.his dose II I. Rx Ped s (CAUTION: tim recommended for rou t ine use, sunbo<.'f!) Cl1i.ldn:n: 1, 1 mgfq. J.nfanY: (0( 1 rnOS); 2 mglkg. SUWUt:ll; 20 nllVml coneontr&tlon. ~ rapacurooium (Raplon®) \ / OA\IG I!<fQ \, 'fhe ahortalt scting nond epoJ~riJ:ing (coropetiLive) NMBA. DUl1ItiOll of action and hisl amine re leolN! are both d""" dep!!ndeu L, Rx Adult: for intubation. 1,[' mglkg. SHORT ACTING PARAL'r'TlCS ~ mivacllrillm{Mivacron®) \ I 0I!IIQ1NfO \ , Me tDbolillm i$ by pln~m& pSE udn<:holinl!!lter,,"E. indep.mdentofltidM)'W or liver. Po>t ian~ .... ,th pIIeudO)Choline!ltenrse defic,ency may vcperienee prolonged pa ralysilliuting for h"u .... Rx Adult~ (or in ~ub.ll t io n. to avoid hypotension. give 0.15 mglkgover!>-16 sees. or 0_20 mglk,g over 30 sen. Or 0.15 m&fki: followed 30 t;.Konda later by 0.1 mgIk,g. ~ \ ! roc:u.ronlum (Zemlln')n®) OIIUOINFO \ , (n large dOA ..... ha$ speed of on!<!l that approaches sucriflylcholine. Hnv.·eYer, in these dOllea, pa ralY$is ueualJy lo~ta _ 1· 2 II .... E~pe!llIive. Ib: Adu Lt , initial dC08c 0.6 -1 ro""B. May be used os j~Bim of 10- 12 IlWklfruin . INTERMEOIATE ACTING PARAL'r'TlCS ~ vccuronium {No rc u ron®) \! 0RUCl1NFO \ , Nondepolariting (competit ive) NMRA, Adequatto pnra!Ylis for intubation within 2.5-.3 minut"" of pdmini~Lratlou, About onR third mol'll rtent th an plUlcuroruum •• hotter dllI'Dti"" o{netion (huts _ 30 rnmutu "fl..>. tailisl dQlJOl . Unlike pe.n""...,,,i,,,,,, vcry I,ul o vegal (i .~. ClIrdiOY ..scular) err-acta. No CNS .. dive mel.8bolite.s. DOoe'!I not alretl. lCP Or CPP. Hepatically l1lel.8bol i~ed . Due to active metabolite, . partlly,Ca hn been reported to taM 6 hrs to 7 days to recede following diswnt;nuotiOll of the druB Dfler it 2 dll.)'8 uae in pIItient.s with I'f!nal f~Hllr.-.I". MU8L be mixed to use. Doaing BWP .... !(;g: .10 rng freeu-dried enkc. requiring rec,;mst;lution . Uao wit hin 24 h..... Rx Adul~ahd ch ildren .> 10 yeors age: 0.1 mglkg (fOT llIoe~adults use 8-10 mg as ini_ tial dose). May repeo t q 1 hr PRN . lnfu gion : 1-2I'gfkglmin. Hz Pedlatril:;!:hiI.dD:.Il ()- IOyrs) requil'll sligh tly higher dose and morefrequenLdOl!lIng than adult. lofllol.l (7 weeki - 1 yr); slightly more ~ensitive Iln a mglkg basi. thaD adullil. tak"" ~ 1.5 ){ longer to recover. Use in n"'lnet.el and ~ont.inuou~ infu9ion in ch il _ drr.ll i~ in sufficiently studied. GF.:NF.:RAL CARE 1.6. Phannacology " :-./ cisatncunum (NimbeX®) \ / DfI\IIlIHO'O \ , Nondepolarizing (rompetiti"e) blocker. Thi s illOmu of Btrll{:urium does no~ relelllle unlike it& plU"eP l C(lmpOuud (lee ~Iow). Providllll about I bour ofparaly~i • • Also undergoes HofmBM degradatifln. with laudanosine III one nfl1.3 metaboli1.(s. Rx Adult and children> 12 years age: 0.15 or 0.2 mglkg 113 part of propOfoVnitroui hi&tamin~ oxideJWi:ygen ioduction-intubdion ~ ique produ~ mU$ele paralyeil adequllte for intubation within 2 or l.~ min n.es, respedively. Infm<ioo: 1.:1 IIg1kglmi n . Rx Pediatric: ~ (2·12 y rs): 0 .1 mglltg giwn over 5-10 S<!COllda dllMg hnl ",thang II. <>plaid lloeathe6ia. ,----/ atracuriurn (Tracrium®) \ / DRUClINF'tI \ , Nondepulariling (oompelitive) blocker. After IV bolulIl onBft 2·2..5 min&, ptak 3-5 mills , duration 15.20 mins (i nitial d""" may tB~t up 1.0 30 m;nutllll). Uudl'rg<H!" nonenzy mat ic HofmlUl.ll degradation 100 ealer hydroly$i, at normal ptly~iologic pH and tamperIHure, in~ct;"at;nll too drug iD ~ 30 rrunute$. Therefore \Uif!ful in pat~n\$""' ith li",u Dr renal fallure. Reven ible with neostigrtlinl!. C~us~s h.isl.amine release which t~1) produce hypotension (ronliider cil;lltraeurium inst<!lId, I<l'I! abooe!. A mel.llboliw, IAudnoo$ine, is Muroextltatory. lind a!:<'umulation could theoretically cau$eHlzures (no doxume nted ~lISelI)l". Do!:ling SlIPPUUI: S " 10 ml ampule. c.f 10 mg/IDI concentration. Rx Adult & ~hlldren > 2 yr$ age : 0.4·0.l~ mglkg lVP. ReduCOl ~b~quentdDfieli to 0.02 mg/kg Rx ~(I month· 2yrs), 0.3·0.4 mglkg. LONG ACTI NG PAR ALYTICS ,----/ pancunm;um (Pavu\on ®) \ I DAl./GItjR) \ , "Prototype" nondepolari-QIIij (CQm petitivtl) para lytil'- Puk; 3·5miDII, duration up to 60 mins . Revel'9ible with Bnticholineat.erage$lucil as neos tigmine. Renal elimination. SlDI:D"1'ECTa1 usefulnel!s a limited because the drug is ~ and IIUl illliiNctlym· pathOlnimBtic whid> incretlliell cardiac OUtput. pulse rate. and rcp ConsIder "l'curonium II1S an alt.em ative.($n' aoo ... ). DOlling ~ Rx ~(h.ild..r:m: 0.04-0.10 mglkg 1VP (lItaTtwith 3 mg}. Reduce suhsequenldos· to 0.02 mgfkg. Rx :t:i£::Imawl: espe-cialJy Hnaitive. t<!it dose 0.02 mlVkg- 1.6.5. St~68 Acid inhIbitors ulce ra; in oeuro!fllrge .y" The m~ of st,...ss uicer' (SU);$ high in c,; tically HI patienUi w;~h CNS puthology. 17':lofSU. produ~ dio icallyaignificant hemorrhage. eNS risk r""tan. indude inlmen· nial patholOgy: brain injury (upeda Uy Gl asgow Coma scale IfCOr e < 9), brain t\lOlO"" in· tracerebral hemorrhage. SIADH, CNS infection, l~cbemic CVA, 118 ~11 as spinal cord Injury. The odds a re jncreallf!<l with the coexiIJtem:e of extru-CNS risk r~ct.oTII including: Iong·term U!ie orste roidll (\1I uaHy > 3 wlI'!lui), bums> 25% of body turfl1<'1! srea, hypoten· sion. respitlltory failure, coagulopulhietl, renal Or hepatic flIiJure and 8epsis. eNS palho10f0'. especially that involvin,g the dien~ph .. lon or brtlin stem, ""n low.d to reduction orvagal outpul ... hich lead!! to hypersecretion ofllaatrie.acid and pepain . Thm. ia a peak in add a nd pepsIn production 3~ d~ys alter CNS injury. Propbyhlll is for s treSB ulce r .., There illtrong e vidence that reduction OfgasLrit acid {whether by anL9cidfi or agents thatinhibitacid 8ecretion)reducef the Inciden~ofGJ bleedi"l from . tress ultenl .1.6 . Pharmacology GENERAL CARE critically ill pllt.i"nbl. Elevllting gastric pH ". ".f> 0.1110 inactiyales pl'psin. Other therapies that don't in~olve alterationa of pH thllt may be elf~tive indllde ello.ralfa le and enteral notri tion (controver lial),". Titrated antscidl or s lIcralrale IIPpear La be superior to'}l, antaconiu8 in reducing the inddence ofSL·•• RolltJ.ne prophylllJtia .... hen .leroma are used fs not .... PlTant.ed unle" one of the rol· lowing r is!< fac:tors I ' e p~nt: prior PUD, tonCUrTen~ use or NSAlOs. lIepot'c or renal failure, malno urish ment. or prolonged steroid therapy >:1 weeu. In 1.7. References )l OWO J F. fki><h<rll S.SIJ •• ,. f , .. ~ · E>-""",,. ,. 1"'II'I<"""""~I"'d .. ", ........ 0.'<1< ........ ""' ... ·C . ... f<J>O" . N......... ~ ~S C.Co\< ~ · 161·l. \'l~ , OS. "",.1 P M." oJ ~ fOul "". rdnI'i«lI<mI, " " ' , " 1 _ " "ldoOl",,",,""'. , • , _ _ ... """"",,1&1. " ' _ ..... or ,"" •• • '"'" '" 0<"""-1 io~ 1'1 ............,.., Jl' 74~·g, IWl. 5hoplM H M 'I...,.,_,.,..I."",.rIo., ... ~I","" ......Jollijpo" ."... ""'. I.......,.bosI •• M" I<I R D. (..J,) Ch ... ~~ILJ.l'J"""'."'" Yod . ln<l.u" I9!/>. Vol 1. PI> 1ID-6111. ricl"", T E........11<0 E H: TIle ............. ~yp<,. ...........)1'Il.-..1II t.1I 1 MooI 3O'I '16-1. I9!J. ONJ' (Of h}""",~ol .. ~."" ... M<d Loll« 19' UI.. :ZO 11I@1 . R Il . \lla»eo P If M)"I><ri<"' .....,",.... .if> ,od ..,,- . JAMA J5S I60J.II.1981o. CoIueIII E..... <I K, "I'\onoloof lt . "01.: 1CP''''''jQ ilhill· "Kro~",1 ...... 1"""... 1 J'oI<u""" .. "3. Jl9.JI. •• ""fl"_ ,rdKedb)o"""iu"'' '''_''' ''p";.".. .. .It. .... booo I. ')~""< 1"",,'~_' _ lImJ " " ". ". " ''''. ~,"'Z.Spi<c<I .... R . f"...u..Q ."~" 001tyt4 "",~ •• """","'clcaIti<~ion f'"", rn>- • " ,. " D. " " " n. ". " • "",i<d ..,.u.... ~""'.\,.."'" """,101, ...."",, J ~,". ....... ' 1 l!. 60S- I. 1¥ll9 QrIow.U I p. Sb;. ...J' D. llid, OC." 01., Wb.blol 10.......,,1 bloool PIt .."", .... , ran ....."""''' kJ,. "''1 Col, Con M"" 16 lM--t. J9SII . Eornolol AU!cn-iI<Ii"J 1\' Dna~ . M, 4l-t1· ;'9:l7·'. 1'II7. T",,,,l>ie E R. M",,-iu<- J ~ . My... o. I ;5, eo..."~ ..... hy .. rll1 ,... . ..... h<IolI ....b on .... ' .........."'01 ....... P""" .. J ,. • • """'" a2: ~ 7. 1m. Knli<lk>lF."'_" II P.r.<."""PL pol_O<)' .....".· T ............, d o _ i... .N_~ 19' 169·70. IWI Bn"~ R L; WI<.\<I<"o ...1r...", &I_~ ,~ .... py. N EDel J "hd XIS. »? \976s .."" G c .. W;,1lla- S R. WW.", ... I or 1i. _ I. <oOitI iIoo ..r) .n ""~ .... S~ ~.. roI +\' 0l'1Il, 1995 K..... OS, A. oIJQt<do", rot' "...,k...... ,"'" ...;u.. <In ........ FIlm l'II,oJd&n 'J9: ~ .. , 19!9. MmI"IoIl Lf".KI.,J.L.>o&fu<TW: Tho_Ik.'ion ur ,,,,,,,,",,"rom iIIenp, 1. _ _ JI<>I P'o',l<n<o: A \Iud, AM J'oI<u,oI I :101 · J.1917 O'".lbl<t J M. Hall E 0' CUm .. """10"'"'" or . "''''_. IImold ,,."""" r.. Cl'is ,OJ"or. A,.,.,.. """""Il'. J N...... . k 62. !06·ID. \0< N.,,,,,,,,,., J'O'"'..... ",1;11_ """'\I'"'''' .... ,.>oIozl.'" LuW Y. R....... yOIl.l\oIilljl It,' 1I . ,,~r~ A ...·i o" tI: " <ell I""f'h)"ui, I. ,... iro.......... _."M . N<~ ..... 'II<'<)" 41' .16-1&. I~J. W.;"e. H L.Reu,AR.C-, PR.SiI_~'''''' 10:". p<nor.,..... "'''''''''''TI<W 10; h'liHIow ....... ,,""..., ... ,.......... ~"..,. n . 0().}.1991 .1«, "'"''''"'I'''''' po!"." ...., •. 'Z,,;o1" M. M..-. C.Il""t<"'oI~O S. • , !JI: Cot> I' .... ,.!Oi<I 'iI<topy " IO<UIl=d ""'~ lo<hem o<,...,,,," GEN£RALCARE ~. ". • N. • ". ". " , " ~ " M<d 7t. l97.«ll 1'111' . S"'"Y' .... S................ Mold« HI C)o<Ii<aJ <\III .. ..... ......... _Iouol" ... ''''.. ''''''_"''''' 1<",", ,. t.lIW<I~ ..... -... "",I<t." ""'" .... d""""'""","",,".""' J ,'o1«1'l9:l:J~-.Il. I~. "I'l,booItot, M, ,wIdl.," ...._ . R,,~t~ . ~i.."y,.•. - ' _ I tTa/",,_ . I" ~ ......... __ ..1110l0&I .0.....,... 0 L..-J Sol.... w. t.u.). cOn• ...... 1. ,••••""...,""'. WOliiAnlll_ Wjl~'''' Il.r.lli"""".I992. 0'01.5; PI' 19·.I!l D!rio"" M.~ PW.DonIC... ",. SoiIr"," __ ..... c .. fIIl .. ioo;,.. pot_ wi'h ~bnl ~I An:b Noo",1 .0& 921-JO. 1959 ......1f ... . : H~ .< ..... I~"" .. """"""'y ....,."1 .""" .... "..,..-.. b<olr,~.r..,.le<.1i" , ..""" '" '"'"''''~ _ . N [MII J MocI JI~ • 1329·)5. \986 11,-", J C. Kt<>'''>poll! R K. ",!orr" I: Ch."'.... <OftC<1)I, "" ", .. n"......._ '1""""""'"' _y. """..,.",.., Ropil come_ oorj J><KIM< .. I0I0,,,, ", ....... II""'1'"'''Y'"nol)''' ... ", I MocI 7S, I~ \IO'2.I93S Ft. ... C L. " I S,..".. ..... ,'" ~,_""".;o: ""'..,. ..... , """ " 1M .... '0 _ )10/',1 ... m),<l1· ~"'S<III ""'. rvl4. "'I~n.19~. """",,)10. 11"_,1.1 M..... IIEL:C... 'rolpoo'l1IO ,"ydl""4'.i~ " "',""no <Ii ..... ""....- ","'fI """ •• _ ._1>«1 .. ...-I~po! ... " ~5oI..:n,I?~ . ,.....' 011'57<111 .. , II ' Ardl ", •• 1 C. K".....,.,liItK .... rieff II I: T_"" .. or '~i<hY]>Q"'''''''''''''''.' ~ ..... ",11<1 .. <lo"'"'iO.roEu,I J M<dll7 II!IO.'. I'III !krl T- T'Uli"1 L~ponou.""., It,'~" il 011 II>< """" "".t«~ _ 1 ..... ' "'"'' M«I 11):011.9. 1~ _If II n lt,,,,,,,,,,,,n>iIo ..1O<'-l"""perm&DIIDI _<10 ...,... ...... 1-..0 M'" 11· )7j-OO. 19117 t...ur.. .. R. 1C"lI S I: M,.II""',-." d b)poo.irMII • • Ann I. ..... M"" 176.. SJ-6~. .n.""".,,,.,. ,m !UN..... O. R_"" B.lobI_ R•.,ftI ~ /l.apidOOl . .... ,"" of ~)""",,:n:mk> I. SIAOHI M ."."'..,"" U'U) ...... lOhy_., 001;".. ....... 10..". M<d 1.. '"lO·S . ltlJ 1.<*.601 C. III.I_ P B. :<.woIoc""'I • ...."... ...... • _ ..;.,.......... 1lw. ' 1""_ofl"'fII>'OP"'l< ••,<"";... oI ..<id»nnc._. Nell, ... , • ...,. .: 7:1l-00.1'I31 ](<011 M, MoIc').' .li"",,,olm I. Hy_,..."" .. ... <'it Ino" ~I ....... J l nl Mod :131.: 191-1. 1992 H.vripo M ]t; Qn:m.i >01, "'''11' 1 ~ A ",,,,,, ... N<"' ..... l ..,. )8. ISHIO. '996. O<T"'J«II. o."",,,",! c:C""""""'of ...loI ....... -Il, b) N EoJ! J 1.1«1 ~J 91"' • 19JI p.,-•• W It .MoW P.I..,.~LA: 00"",,10<)0. citr,e ",1"'JIII"'IIri'" .0011.,,,,,_ L....", l 14!4. I976t .. ,,~1. r-om-oJN .C.... lo-!.Kon'C. .. ."S"p<'fior.,o( """"'kqoc:li,.., ". _Ito<)oo;l,,,.,,.., II"".,,, on ill< ,......,.", of 1<- .y"d"""" of "'_Io , ~ or ... ejl, . . 1.7. References _,.,ion " " 00. ". 0> ". ". • ... ". -, ... ". ,id,.moo _ .N E» ~ J Mod l98, 17)·7 . 19J! 0..: •• , G. w. «rIo< Y.Gcr.<u< F. "Ill. Tru,,,,.," 01 , ...yl"odtom< of i""PI""!'rio'" le<m ... 01.",,,,· i."" .. """""""" with fu .... mid<. N i:nd J MId 3O<;l:l9·)(I. 19" . ).1. . - 1 c. NeI_ ? S· lIy_l<mb ,n ""... " ",III _Imoodho:""""",,: T_ _ ," ,,,,,,I, • .,.,;.,... N .~""" ~ , y I : 2ll-6 • •m . Wijdick> f F M. v""",.1<n M. lI'jdll .... " 1>1_ lIy· pO<I. lrUIho.nd _ , ",r..,;tioo in pol" .... wj'h ",,".red inln<"""" .....u<)' ......, I. no'" .... Iwmf.I1 ...... N....... 11; 137...00. I98S. Wijdd, E F M. V. ....... Io. M.... 11 . ... 1 .... .. <4' Vol."" d<plo.;"" on<! ""ri.",;, '" ""' ...... "'pout«! i"',"', .. iol • ......-y.... ...... No.",I ),. 111-6.1911' . N. l<",,? S.S<irS M. M"""" I c ... <4_ Ky· p"'''' ',,,,,,. i. i,.,.,." .. • y _ o I i ... ~"' •••" .."""oI ... id ,. ..1I< _(S'AOKI_ J 1'1""<0>.," ': 9) .... , . 19& 1. II .... O.Lrodl.oy K W. Wip",h I: F 101, "~I, : Ef· 1«:10In_""' ____ " ... ~ ..........."h_ .....,~ fIOKI .. ~ . S """' ZO: 11'f>-61.19t9. ~ R F. Hotbo. , h R 1:: ... dtn .... ",,,, .... 01 ,n,"· "reo on<! -..01 "Ii.. lot ,.. "" .. me," 01 byp"n."uni. in ... ""." ..... po1 ic,"", J Ne",.· " <110, 20 1·6 . t~89 . V_Ii. I G. ROI:>I""", "'O. M_ ' " 101 , Po."pef..i .....nd p""·<=maI [< di."",.. insip''''''. fron, H"",, It"" 13: 147·6.1. 1!IaS. ... "" T K.S_ N...... " Lylllpboc)'l'" hy pop/1y•• ,,,C... « PO. · N.~, ..... " ..., J6, 10 169. 199' . 1m... H .N..... K.Sh,ma" . .... " 01" Ly"'P ..... ytic i.I.O(Iiw_"""'ypoph,..'u ... . <.....f 0."",,1 d,Il><,.. i.",""," •. N EnJIJ Mod 319, (1).. 9. I99l. Millt, M.O., ... "'T. M....... R«OI.i. tj.,,-, 01 1""'" <ltr""" ,n ... ,id,. ",'" _ .. , ,,,. '''''' . ... '''' I., ... M«I 7}' 121·9. 1910. Fresh·Fro ... 1'(.."" C>,},,*,,,, , po·~< ..... PI ...IeI. Admini ..... ''''n Practice G<oid<!inc. D<v<lopmeo' T.. l For« .ftheCon.,. or ... ,....., •• Po,toolo","" Proro ... _ ' 0 ' f", tl>c ... of tl-c"'·fro,... pl ... .... <1)•• ond pi..... " . Ji..MA 17,- 7n. 11. 1994. M_ _ i' M. 0.:.....,..,.;0: ... _'...,.r.... "" I..... of ,rca""e." r"'","-ital .l1li ""'l.i,.., hit..,· 1.,di_. 8 _ 12,,449.".1918. SO W. lIug o _ 1I. 1Uc.... ~ 101 T: C<HI"4'iicatioo. of.".....,..I .. ' ' ......., in PI'''''' ... "h kno"" un' .. , ........... yot<lII ........ C." J 5 •• ,26; lSI·). 1981, RoffR._, I: ''''' ...... . I111' ......... "r po ...• m! ,,,,",",,,,,,,, '0 poIi ...... i'" , Iiomo . AM N... • r<>Ill: ))00·6. 198). Olin J W.. y """, 1 R.O<aot R .... Tre>t",.., of de<p .... i. , _ i , ..... PU"' ''"'>'}' oMboli i. ..,... " ... ir~ pri.....,. ond ........ ,," b<oi" ,."""" ...... ieClO' ....... '" ;"f.<\of ,~ n. co., (<f,et"! A.-dI ......... ~.<d 147: 1177-" .. 1981 . F~ 101 .... K. Stlk<r ~ G. '" 01.0 Tho nsJr .....s . m...:y of • • ,icootot.". 'heropy '" the ,te..• men, of "'rombo<mt>alic <ornplication. ,. ""itnt, ,..i'h pn.....,. moli&o",,' b.. i" fWI><>r> . New .. .",,...,.l1. J. -7. 19'IO. S'<nI W E. 1'''''fN'",I.. ...,1.",,,,,,: CM<plk~. , ...... ,.. I, pr~. '~ P<I ".." ... " ,. r. N... """c>.... "" 1<1") . Y........ J.(.dJ . W. 8.Sounrl<n. PhHOdclpl.io.1nd <d .• 19S1. VoI.l: PI' 105 1.. 116. K. wom", T. T....~i" M. K_ O." 01. 101"'&0...., 0( i.' ..... i., _ 1 0 " >o<i...., ... i"' .... '"",",u"" ''''rtpy 5 • • , 1'1 ... "" ...: 4J8"'J. 199, N"".".-. for ...... hemopllili. "'...,,120;' . M«I 1.e""'46: 11 .... '2():")C. Hinh I . 0.1<0 1 E. D< r\:.i. 0." ...: (lraj ""'i<:o>& •. I.. ,,: M«"'n' .... 01 """0 • . el,.ie.' cffccu ....... ,t>eropouti<: 121\&<- C.~ 102 (S"""')' ,io:,_ ,..;0,. i., ..."'....""""I" "'" ,... v._, .M."""""" M.".'. .,.""1"101<. ". " ". ". ". ". ". 0>. ". • ". 00. 0>. .• " " ""..a."Ie, 1.7. References KIwrwI>I. M .... C . _ M I. M.rOO F... aI" Th< """~""., or II"""""",. ,n the ""~ipid· .. ,it>ody.ynd"""" . N r..... J ~ ))20 99)·1. I99S. Ill'<" T ).1 . 11 .11 R O. I G; "'",~""""l>oI" ,ho:"9)' r.. ,...,.. ~_ic dila><. eI,.., 9S·lJ5-5IS. I9i9. ... ,. ,,,,,,,, 1 L 0.5 .... T M. Kumit, F I . .. oIo lie· pori • . i_ _ ]'IOjIO. io_"""m_i. i><h<1Itic """,<. Mo)'<lCu""..,. 6j: lS)-6 ' .I98S. 0.11<11"'" ...... h<t low· molo<.I".""""" ... pori • • 101 ........ '.' )1· 11.1-6. IWS. Al6epat .. ot><I obtooporo;d r", "",_ion '" <k<p "",. ,_ , •. M........... )9(10 11): 9'·S.I997. fO ... P>'bll< hoo"b "" i<o<r. I'00<I ..... ON' ..... • m;.i" .. Ku ~ hSt"' .. < Ro<h il".M O. O«<nIt>e, " . I99J . Fordopari.. . loti" ..) •• """ on'icott. loOI. Mod LoeucT "': 4 )-4. lOOl. Lcpinodio I", .. p.t.r;n-i - " ,"rotnbo<ytOp<";. Mod LeU, . 40. 9'·'.1998 . fr«lri U IOn K. NOfro ins S. S,,,,.,...,\od L G: E<t>«• g<1'<y ~", ... , or.,,,i<o,..,.. iOfl . 1«, i~ _ 1 _ " , . S' '''''e lJ: 912.7.1992. Hom)I"", M O. 11.11 R 0. PU>co G F: V.".,., ,1IfOm. "", ,.001;'111 i. 1'1<\1"".'1"')' ........ U<Olo., ~ . '''n''' ... rev;'w. N....... UIl... y)l: 1flt}.%. I99< . OI>oo J D. K.. fm •• 1I H. MooI.< I • .,DI,: Tho ioci· dtJ>tl oN "Ini r~ "n•• mo_i< .bo",..,.'i,;', i. I'".''''' " ',b """" "'Jorit'. N",,,,,,,",,,"y14: 82)-)2. 1989. S''' '1' R.ll>« .... ,10 M. EI.KalhllJ" 101 : S .. ," ",. ""'" U\d ohromtlo<ml>Ql;sm: CI;oicaI. I\e ..,.",ic. ..... bio<"'mOcol """"I,,,,,,,,. J N, • ..,...,. 70· JI <A. I989( ..... ,,",O . Qutvotlo J F. S"' ..... , I C. Schmidr J L. ".,-, ThrO<nbccmtool i,,,, I. »OIit,"" ... "h tHV>-lo.d< , 1;0.. mi. MoyoClI ........ 1I\I ll9-J2. 19901 . Bloc ~ P M. S.... , M f. _ C P: £o.peri<n« ... ith .... ",.1 ..... m.. '" <olf cO<nfI<U'i"" ... ",uroIot, .t: 11/).4 . ' 9M. S.)"<I<r M. Ro.. o<l'" I: '""oc, ..;" ~ ... lOCi."", ""'h '.uootcoll1"," , ..... 11}" . S~'""C N<~'" 7: )I..o,19n Cern'o O.... , ..... C •• """hr.. Po Deep .... i" Ihrom· too<i •• lllllow._ bepa-i. proph".,;, ,n _ u r · , .... PO' "'"". J No-u .......... '9: 1J8-", 1m. Frim 0 M. Bitt« f O. I'ole"i CEo .. or,: "",,-,. "".., ..... _ ... pooi"~""'"""""_or: w.o, ,,,,,,.I'Iobl" " " "'" "'.roouttt'Y.No. '."'IO')' " " ". """'!II .... ;..,. i. "''''''"rV<oI palio ..... ""' ..... lO. 130-1. 1992 . R.... S C.Z .... <II<I W I ,M.""". L E." 0/ ' ..... " . .;'i.i,yol «>lor Doppler no... i"",,", r", <Iet..,_ of """ecolf d<ep ~_. ""","booi. in ",.."pomoI. .. pO""I,." "i.. po,;" .... J V_ I....... R... ... . , ""V'}' " .,1>1" ". ". " "'" "1''''''''' " )'~26.1992 . 00 111 _7. !9'Jl. " n.. o. Wei" PS ...... "'..... 0 R. RornwoilrJ. .. ..s. Vo/u< of ..........,.. of proboI)' Ii'y of do<p-'""'. ,~;, .. <lini<., ....... , .......... (..0.0«1 no1M -I. 1997. O...bel1;1 s. "'olt. P S. " _ C ... ,,," St'';';'"y on4"""iror:ilyol. rap;,: wt.o~_ ...., fo, 0d,me, ,. ' .. d",""';,olpul ...... ')' emboli.,".A,," r."", Mod 129: IQ06. I I. 1991. H.II R 0 .R " ~ 0110 E.P;ntoG F........: S.b<:ut .... · .... Iow .. "..,r_I... wel.," hepori. coml"'1"l ""h """,io_ . i.".......... !t<ponn ;,. , .. pro.,.". I· .... ;" ' " _ . 1'1 """ J Mod 1.16: 97'· 12.1\192. KuU R O. R..l ob 0 E....,...bloom 0." oj" Kep. orio r", ~ .... d. " u ccmpoted with te. i. ,he i.itio! ,,"'""' 0' of pro ..n01 .. _ . tItr\ltnbO:r<is. N £"" J M«I J22: 1160-1. IYiIO. M.... K S. Yu<C P.CIu. K K... ..s, ~It", ""e 'o.,," IT-.e<toolloryh< ... '09Oiui.;. 'hol ....",i.· eo.. ",pon . J N'.' '''''''I ~ 9)1...00, 1987 . pre"'" '_'Il1<0, '" ". 0> da,. GEN ERAL CARE Sl. SO . 35 . 86. 112. 811. 89. 90. 91. M,o",,', "'''''or MAl>l\>JI K A' poUo' a.... poo;lIci· pits "'" ;nv.. i.. ,... tnxo~ M. yo CliD !'ro< 71, • 72-1.1996. CcI..",..,blorOltbrili •. M«I Lelltr 41: 11·2. 1999. 11<111"" S M.Sonolbo".coot J. Z.I"m D. «<>Ie 0;. <lo[. ........,.",i.olalk<p""'.,.ici'y .JAMA :!601 : 2660-2,1990. 1k"; ' ~W L: An&i&Gic nephropo<hy. AnoJ />I.., S<t m: 56 1·!. 1m. 8mmf<na< I.......pi • . 1\1.., LeI .... l'/: 9J .... 1991. S,"'"' B 1.. . 1I<~ ' o I A, Kinma" I L .,dl, Par<n,«>1 k.lOtOtooI: .nd rnk d. C.woln<e"ln.ll ond opo<l<i'< "'. ble<\l'"I . JAMA l'J': :)1~1I2.1996 . Trunadol · A"" ... or ...... ,I<'>' •. :.1 ........ ' .... J7: W·ti(I. i 9'), . ONI' for pai" . MOll U ..... 010". 79-&4. 19'11. 1'Ill1_f<>"h,,,,,,<poln. />I..,unorO.l l .J. '. dd<~ y poOpl< . 8 MJ J 10:. IJ·7 . '99~ . Qtioin< 10< "n,JIro cnmpo'. :.1'" ..... ne. 28: 110. 96. Choice of b<.rodlaup>nn. M ... Uuo. XI: 26-1. BiCO>S._)'<"fO. II,..G.« t>I, .... ~ .. Io.. _ p.obk .... 10 odullS . O",ical p", 'kc I" i~tli .. no.14. AHCPR publitalioa ' 0. ~2. A _ lor H«ltlo 1'01;" ond !l<.. "",~ . ""1>1;, 1-Ic.ltIo S..... i« .U.S Dc,..""",., oflt",-,,,, ond Itu",," Scr· "ice • • ~O<kv i ll<:. MD. 1994 . a.kno'UOD<h<po,", •• io:i'y. />I.., Uu<.J8; 06. c...: 9J. ,~ . to . M .... So!:o. !i,., M.W.,IoG : M..... ao.rJY' .. or.lliu<y 01 "" - . . for , .......... "' <>I ...".ma! <nm". GENERAL CARE 1<, , IUS. 91. 98. 99. lOG, 10 1. ONp IO'1")"C ~ ~ ' ri< di_ " _ ........ 21: 99· 100, 1986. MidaiOlam. M«I un•• 2.: 71... . 1986 , f1u ..... ".I. Mod t.ert.. J<I; 66-I. 1992. ltam>ayMAE. S.v<" TM .Si _ _ I RI . .,t>I_ c.,.,' rolloO oodatioo wir~ l1I'lw_"lphodoIoot. Ir Mtd J 2: 6S6-9. 197 • . W.rbaA. W. I"".~ C .I'rtr' '''k W,"dl.; V<,<utOn'"m ptn'< ... ;"'<Uf<.;n ...........'" p ...... .. d",· i"'_"'lt"O<_~",.t><IioIti ......"oqi<oI poe" .... A,,-tlot' ... 4(1: J2t·JI. 1991 . H"... ~) K. Cheon., II M. C.iIjlCD • .,,,," Early. ",",i.. "....,Y' .. :or i. _,..;a! _~ """tIOI i. _rn: IIoOld ;"jII.ry: I. ~ """....".1 C ~, ca.. i'I'" 11; ,.71·6. '99<1 0101;"1<' M I.R"-1 0 H: No ............. i.vblO<k· I", ...... i~ til< i....,.;.. eort ..~ Surs N........ . 9:217·21. !m. SCS'- II. C"d,,<1I1 E. M.""", M A, .. 0/.: !'or. 0;, ... , h 'rilic:' Uy ill pot;"'" oro.,. ""',. ..no odm' ........rion '" -.-""",i.m. N Ecolll J Mod 311: $24·1. 1992 ••'" 102, ~, . 92. .. ~~ 10), !()O , "_iUI """ysi' 1.7. References 2.1. Dementia Definition: loas of in~llert ... al sbilit,.,. previl)tlJlly ellai ood (me,,,,,ry, judgement, abo itract Lhought , and other high~r co rneal fuoctiona) severe enough to illt.e rfere with 80<:;111 andlo r occupational fUnclionillg' . Memory deficit i. the cardinal feature. however, the DSM·rv definition reQuires impairment in a~ least Dna other domain (langue!:",. per«ptiM , visuO!Ipatia] function. calcu lation , judgement, abotrodion, problem.Bolving 8kjIl8). Affe.:ta 3· 11% of community-dwelling odull..! '" 61> YI" of age, with II grealer pruenoa among institutionalized reaidetlLs". Ri sk faeta ....: advanced age, family hialor)' ofdementia , II.nd npolipuprot<';in E-'I ,I· .,. IMlerium: AKAacut.econfuaional atalf. Di.Gtinctfrom dementia, however, patients with deD1Mtia lI.e at increased ri$~ ofdeveJopingdeJerium"', A prima')' dlSoroerofot1.entiOll thalaubsequently &iI'!'Cl.$ all ~theT aspect.; ofCOjfllition'. Often repre$ents lir..·threBt.enjog illness, e.g. hYl"'xia. SRp.oi •. W'emic enCi!phaJopa thy ralllO;«< poffe 64), eJectrolyta .. bnonnality. drug into"ica tion. MI. 50'l0 ofpatienta die within 2 yr8 of t hisdiagnosia. Unlike dementi., delerium b•• !H'ute Onllet, nlotor slgnJI (tremor. myoelonU5, "". t.erw5). slurred speech. alterEd conscioualles& (hyperalertlagita1.ed o,-lethBrgic. Dr fluctuatioo,), hallucinations may be florid . EEG - proDounced diffusti a\()wi,ng. B rain biopsy fo r d e m e nti a Clinical criteria are .. aually .ufficient for the diagnosis of moet dementiaa. Biopsy shouJd be res..rved for calle!; 01'11. chronIc progreulVe cerebral dillOrder wi t h an UnU!U,] cli nica l coW'se where all other pOOlSible diagnOlitie method$ have ~o eKh ...... ted lind h .. "e failed 1.0 provide adequate diagnostic certainty'. Biopay may d.iscl06e.CJD, low grade 9St.rocytoma, and AD .mOllI: olhen. The high incideme oCCJO among pat.ieoUl.elected for biopsy under the .... criteris ~es5italeflllppropri&te pn!C&utions (IIH Creu~reld'·Jokob dr_if. page 227 ). In .. repon of:;O brain bioplllH p&rformw t o _ progreo;aive neurodegenerative dllJease (If unclear etiology" the diagnC)l;tic yield ........ only 2{1% (6% WeN! only Hugguliv~ of. diagnosis. 66~ wert! abnonDal but nonspecific. B'l> wen! normal ). The yield wa5 lIighHt in thoae"With focal MRI obnonulities. Among \he 10 potienl.i with diagn05ticbiopsies, the biopsy rHult led \0 a meaningful therapeutic in te ...... c!llt;on in on ly 4. Rcoommend a t;on a, B~ M tbe above, the follo .... ing recommendation. are made for patienu; ..... ith an olllerwi5c uneJeplained neu rodeg.merati.-e dis-em;e: 1. thOlle ...·ith a focal abnonnality on MRJ, stereot.llrtic biopi;y :l. t h...... wltlloul foc",] abnormality (pouibly including SPECl'o. p£T ...,.n): b.ai.o bioplly /lhould only be perfonned within an invntigative protocol 2.2. Headache Headache (W A) may be broadly categorized as foUows: I. chronlc recurring headache. A, vasculsr typE! (mig.-a.ine)' ... ~ bdo'" B. muscle contraction (U!nrionl headachall 2. hudache due \0 pathology A. systemic p8thol~ B. intracl1lnial pathology; II wide variety nf atiologi811 including: 1. aubarathnoid hemorrhage, Il!J12~Q onlie!, severe. uaually with vomit-ing, apoplexy. focal deficits pos$ible iM'e poga 7ff2lilr diifel"l!lItial diag- 2.1_ Dementia NEUROLOGY I'M" of paroxYlmal HlAJ inctewaed intra","n ;.1 preMure linm a ny CII\lItI (tu mor, almmWlica l~ 2 In, hydr1lOeph"I\I5, inna mmati on, Jli!IeudoluJ>>ur cereb ri .••) 3 4 irrita t ion!W Inflammlltion ofmeningel! m@ningiti. tumor: with Or without ele~aU!d ICP (no. JXlIt 4!l.S) C. lou! plIlhoiolD' oft~ eye, nuopha ryr\ll:, OT utracn.ni"J tiRuea (;"duding ~U"lt <ell artenti.,.- pagt. 58) o following head t ' II"llIa (~tcor>c:uU;Y" ayndrorne}: ~~ PfJ~ 682 E. f.lllowtllg ainlolllmy t".ynd rome 01 th. trephIned"): 1ft pagt 6J2 A ,,,!Yere new HlA. (It. chaos , in the plltI\!m oflllo"8.tarulinl,: Of' rKUrTenl HI" ( in~ eluding developing IInoclllt.l(l NN, Or ~n "lmormal neurologic enm) w.rran~ (.. r1MoT in· Yt$tiption with CTorMR I' , 2.2.1. Migraine Migraine attacks ua uallY'ICCLlr in indiyicillaLt pr.dilpeud IA'l ,h"condition, lind mly be activated by factorl alleh a.\ urill,lli,ht, Itrfla. diilt ch, npll. trauma, adminiNrillioI'I ofrttdiologic contrast m~i. (eJpedaUy 8JlgiOgtIlPhy) and vesodilalol'l , CLASSIFICATION See aJfrO indu under HtodQl;/u" e.lI. [or; crash pogr 782, pOIH,.. myeIOjfraUl headache ptJ~ 46". migr~ine (thundndap headachel COMMON MIGRAINE Ep;Booie HI" with:;.lN and photopl:lobil, w;thoutllu", or fleurologiedelkit, CLASSIC MIGRAIIII£ migrai~ ~Ive comp1t~ly ... aur. , May have HlA with occuional foelll neuro\orlC dt:firiuI ) in .. 24 hra . Over halfofthe Ir""delll neurologie dilturblln~ ~f'It vilUll\' and uluan,. _no!" poIIitiyt phenomena (lpArk photoplil, ,Ian., IXlmplu 1000metrie pIIuema, fortifiCAtion apectra) which mllY leaye negative phenOOltl\a (goloma. hemianopia , monocular or bin. orular yjauplloQ , .. ) in their wake. The HlCond IIIlXt malloon symptOma a,.. .amatoRn.. frOry involving the hand aod lower rac~ ..... fn!quently, defldu may (:QIUI\1t orapha&ia, .... mipa ....,is. or unil,,~ral elu"",;n ...... A slaw mardl·like progrnllion ofdeficit i. Cha rllllVlril'itk. Tho! risk of ~Iroke is probably inatlaMd ;" palientll wilh mign,,""'. Com mon Ihlll COMPLIC.'o TEO MIGAAIN£ Occuional IIll.8eU ofdaJ.4jcmigte;ne with minimal or no auociated HlA, and comple~ re&Olution ofneuroJorie deficit ..... 30 dap M/OAAINE £OU/VAL£f'/T Nelll'Olork 'ymplomf INN. visualaLlrJ.. etc. ) without HlA (_phaJg.e migraine), Seen mc:.11y in childnn UsuIII,. dev&lopll into typical migraiae with I~ Au.. lIIay be ehorVlned by opening and _an_inl contenb of a 10 IIll!I ni(ed,pine capw]e'". HEMIPLEGIC MIGIM/Nf lilA typiC*lly pr-'eII hemiplegia whkh may penlSt eve" Il~r HlA t«olves. CWSTER HEADACHE AKA h;'l.8min~ mllTlllIl.. Actually a neUl'OY8ICUIllt ""tnt. di$tincl from true mi. IUrne. RtcutTtnl unila~tll altacks ofseYeN! pa;". Ulually oculoCrontal or IICulolempGfli wilh occuional radiation Intothejaw, ulu_Uy r«Ilnin,on theslme , id"of the head. lpe:ila~ralautonomic: UVl~ (UW)juntliyal injectIon, nau.l conlle~tion , th ino rrhea , lacfllUlltion, fad.1 nUllhin,) .... comtll(ln , PBrtial Hamer'aayndrome (ptoai. and ml .... \s) _ellme. o«u,.. Male;f~ale ratio U. ~ 5;1, 25~ of pat ienlll hay" a petllOllal or fami ly hi.tory of m igTIJM. H"adache. ch'''doI'riu~Uy h.... no prodrome. I.t SO-SO minu\.O$, and ~r one or mote limes daily u...al\y (or 4- 12 wHIu, often lit a .imila t time day. following which ther. is typieally, remillion fat an average of 12 month.", or NEUROLOGY 2.'2.. Headache BASILAR ARTERY MIGRAINE Essentially restr icted to adnlellc~nce. RecurT~nt episod811 lastln!: minutes to hours oftral"llnent neurologic ddidu. in distribution ofverwbrobMilar system , Defioil& iru:.iuu; v~rt.igo \ moat common ), ga;~ ataxia, ..,pual disturbance(acotD,Data, "'Ialoeml blindn_), dysarthria, fo1!owad by ... veu HlA and DC:C8IIjonaLly nausea a nd vomiting". Fami ly his_ tory of mrrrBln~ is present in 86%. 2.2.2. Post LP (myelogram) HlA AKA "poatapinai headach e" or "spinal helldath~·. MaY·IIIIG folio .... proc:edure. other than l P/myelogmm, such 811 dunil opt!ninc (..." pa/le 308). Can alro o.....,ur with 5pontane· O1.Ir intratrauial hypotension i!eep"'¥t 178). CllDi ca1 rea tures Important distinct ive cho.ract.eris t lc: HII'. (Ittt.ITS .. hen patient is e~, and ia corn plelely or partially (but eignifitantly) reliev..:! .. hen recumbent. May be lll!wcisted .... ith nsusea. vomi ting. diuiness, or v;"'uaJ dioturbances. Tim e CO~: MO$t pD6t_LP headachea IPLPllA) hav"-,, delayed OM~1 2" ....8 hl"l after the LP, and although they may octU . ....eek~ poet-LP. mll&tal~o develop within 3 day". The duraliao ofPLPHA varies, with a mean of 4 dBY"''', IUId r eports of dumtion of mon t hs" IlIId even> 1 yeB. '". Pat b o pbY!lio logy Thought to be due \.0 continued CS F leakage IhrQugb the hole in the duro " . which redUCN the CS F ' cuahion" of the brain, 10 the uprigh t po.9i ~iM\. the pull of gravity on II ... bmi n produces t m clicmon lh~ blood veMelaQ nd any .trucluu s tetherinR the brlli n to t he pain-sensitive dura. CSf' may sonleti mu be.delllon~trabl~ in the tl1id.w:a.I.pacc. Ep id e mi o lo gy ro llowiog LP Reported lnddenct: " ng" is2-40%(typically ~ 2~). bigheraftudiagnoatic LP than for epidural anuthuia". For variobles in LP tl1at impa~t upon the ri$k ofPLPHA, Sef' paMe.617 T REATMENT FOR tvA FOLLOWING LP Ini(ial 1, 2. 3. 4_ 5. 6. 'cOIlservative" me:saurea include!'.at in bOO for at leat1l24 hI"!! hydm tion (PO or [V) analgeuCii for lilA ~il!:ht abdominal binder de,oxyrortiaone acetate 5 mg 1M q 8 brs" colTeine lodiwn benzoate 500 mg in 2 ~c IV Q B hr. up to:l d mllll (70% of potienlS had relief with 1 or 2 iqj.,dlo~" 7, high-doae .teroi,a, report ofsuccK8ln 8 case orinll1lUao.ial hypoWlls;on auoeis led witl1 "ponllln&OU8 Blit ventricles tapering down from a MArting d05l! "rd",,amethasone 2{j mgldayll 8. blood patch if refractory 1_ below) E PIDURAL BLOOD PATCH For refractory PQSt-lumb.o.r punctu r~ or poll-myelogram HlA. W-oru in one a pplica_ tion in over ~ of caul. mil)' ~ repea\.ed ;fine lTective" . Theoret.ital ri8q: inflKlioo, caude equi na com prcasion, failure \.0 relieve HII'.. Tec hn iq u e ACCl!uing epidurall1pace (one ofuvera! techniquu): prDC:etId as rouline LP. When ligame4Ls a re Itavened. and lleedJe tip iB neating apiDel cane!. style!; is renwved. Then. either plllC.l drop of st.erile u line in hub (hanging drop tE<:hnique) ud advance while wa\.chi.ng rOt Jl Ie be. d ......... n iM" n~e at epidural apate if entered, or gtonLly try it\je<:tinK a lr with small !l.Yrinlle(prefera b!y glSMjwhile advlltlclng, wben the epidural space Ii entered, rui.t aoca Ie ir\ie<'tion disa.pp8Q r~, but CSF cannot be aspi rat.ed . A venlpunoture site. i~ prepared a.eptlcally, 10 IIlI oftl1e pollent'. blood is .... ith· dl"lwn. After verifyiog CSf' c:annot be aspitaLed through the ~pin w l needle. the blood i. il\iected i.n\.O the epidurelapa<:e. Afte r 30 minuw supine, patient m~y ambul.te ad lib. NEUROLOGY Parkinsonism 2,3, PArkinaonjsm may be primll ry (irliQpath ie paralytis .gita", (IPAI , cllllllical Pa rki n. \OOn', niUlle) or lW\:onrlaryLO olhu con dillon l. AU lUu lt from I Il!IaUVf; laM of the dOp.llmine mediated in h lbltioo of th .... necL\ C>f acetylch ollne.n Ihl! b. , a! ganIl:1i,. I DIOPATHIC PAAALVSIS A01TANS CI .. ¥icn l Patkin!.On'. rlilellae. AKA ! lIaking pa l.,.. Table 2-1 Cla sele triad 01 C lin ica l Parktnlon'l dlHalll Aff«tA: -l'*'ofA,mt n canl>apliO)'f'I". M.le:remaJ. I': - :"= , ~1'*<nt) .... 1 flItlO i. 3:2. Not clea rly l!:I'I"lronmentllJ!y o. , enedeflUy in. duted, bu\wu)' bo! Infl uenced by th~ f.etart. The donie triad i, shown in TIl"~ 2· 1. Other .igI.. may indude; pos tu ...1 innabill l)', micrographl. , mask-like raae.. CHltl;'On&i.~ or ..... n. J tlUffiin, ate"" l mll ",h", ' per.i lf; p,,) or feuinll!inr i.it , C lini uidly di~l ingui8hing IPA from .ceond "..,. padtin..,nitm (I« bfiout): MI.1 be diffi cu lt urly. IP" IIfInflr.Uy uhibia ""dl.l"l on... 1 ofbr&d,yk.inell. with trelnor lNot i. of'Wn lt8ymmetrica l, .nd initi a lly rH porKIl wen too Iev(ldopa. OIM. di_den! are .""",11. ed with rapid progre..,OJ! of iymptGmll, ",bee the initia l rupome loCI .... odopIl n ~u;vo­ cal , or "'M!n U",rel. u.rly tnidli,ne 'Y!'lpWlII' (lluo1ia or hnpainrol!nl or ,ai t and blilel>Cf!, &phiocter di!tl.lrb&r>«! ... ) or 1M! pl'l!Hn ce of oUlu fe.tulU .ud'! .. earty demen ti., H n_ 1io01")' findinp. profol,llld orthOli talic h)1lOten!lion. OJ' .bnonnalitin: ofutraocular m",,~nta"' '' . Pa tb opbys iol ogy Degeneration prim&rlly of pi~nted Ineuromelanin-Iaderl) d opaminel'(ic: netU'on. oflhe pIIn! eompatta of the lub&Ulntia niera, <Qultmg in reduted levall ofdopernine in thenOOHlriat l,lll\ (ca udate nude uR. pUL/unen. globu • .,.UidUII). Th i. decre&lfl the U t;vi ty ofinhibil,ory neurons with predomimUllly D2 dUll ofdoparnine uoeploClMl which pl'OJftl directly 1.0 the internal i;~nl ofthe "lobUi pallidu. (CPil, and al$o illttell~es (by lou orinhlbilion) Dttivity of r.t'u rons with pndominanUy 01 ft'Ct'PlOf1I whil'h project. indifllOl:l' Iy w the globui paJlidut exlllma {G Pe) .nd .ubthlllamic nudelU lI , The oet relUlt i. inCTt'a-' "c:tivi!y in GPi "'hieb hat inhibitory prq;..,tion. loCI the thalam~ "'hil'h tlMln I UPpreJSel aclivity In the . upplemenl.l'll molDr cortex llIJIoul other locat.on.. HiJ.lologically: Lewy bodies (eoainoph llic int raneuranal h)'lllinoe indllSlOlil Ire tilt' hllimlrkoflPA. SECONDARY PARKINSONISM The dift'~r tDt ;' 1 dl~OIiJ loeludell tht' following etiologiH or Htondary pa rkinMlnilln gr ParkinlOn-like «mditi01U{IOme. rmlTt'd to a. -ParlLlnlon plus"): 1- oli vopoDIcx:ereb~Jla. dege.nuel>Oo (OPC) 2. I lriato-ni{fal d~lI4! ration ISND): more .",!!ISi... Ihan parkinsooi.m 3. .-t.enoephaIiLie pIIrkin$oni,m: foliowed.n .. pidemk oft~PNoU lil ~tharg>ca (von £,;onomo di~lI) in tIw 1920'" VIctim, I." no kmll'~r livir\i_ Distinauiahing ruwrea: ClCulOC)'ric niail. In!mllr involv ... not only elItremlli ... butlllso trunk and he.d, uym llletriclll. DO Lt'...,. bodi" ... progreaah'f. IlIpr'lDuciear palsy (PS.W): iropa ired v@rticalgne (eu0600» 6. m"l tiple .,stem IItrophy {SilY-Orager .yndrurne1. '" tHlc>w 6. d"., induced: iDdudn: A. p~riplioB drop (alMdy females _m III~ I UlIOepllb ll!) I . anllptycbolict (AKA neu.roleptict); hal0pen601 (Haldol*) whi<:h work! by blocki", ponayn apuc dopamine receptors 2. phf,nclllillline Inliemeti~: pnxhlorperulne (Com pll1inl4) 3. me!odgpramide t~anll) ... . -rpinl B. MPTP (1-methy l·.... phenyl · I .2,3.6-t.eu.hydrupyri"in~); II commert:illily a ... iLable c:[email protected] illl.gaby-productofthe.ynlheai l or MPPP(I rnependinll "",Ioel tha t w . . .ynthfll.ed lind ae lr·injeo:tl'li by II NEUROLOGY 2 .3 Parlunaonilm 7. S. 9. 10. II. 12. 13. 14. 15. graduate 6~udent". and later produced by illicit drug manufac~urers to be sold as 'synthetic heroin " and unwittingly injected by some IV drug abusers in northern Cal ifornia in 1983". MPTP was sul»equer.tly diacovered to be a potent neurotoxi n for dopaminergic neuronB. N! a rule , the reBponse to levodopa is dramatic, but short·lived C. there ia an aa yet unproven assertion that metbylenedioxymethamphet· amine (MDMAI AKA Ecstasy ( on the street), may ha"""n the onset ofP ...· kinsoni sm tox.ic: poisoning with carbon monoxide, manganese .. . iscbemic(lacunes in basal ganglia): produces so-called arteriosclerotic parkin· 80nism AKA vaso;u!ar parkinllonism: "lowe... halr pIIrkinllOnism (gait distur· banee predominates"). Also causes paeudobulbar deficits, emotional lability. Tremor is rDre posttraumatic: parkinsonian symptoms may ocCUr in chronic traumatic encepha· lopatby (dementia pugilistica, _ JXJlI~ 68."l). There Dre usuD l1yother features not nonnally present in IPA (e .g. cerebellar findings) nonnal pr~8ure hydrocephalus (NPH): urinary incontinen(e ... (& .... fKlH'l 199) neoplum in the region of the substantiD nigra Riley·Oay (familial dysautonomia) parkinson·dementia complex of Guam: dauic lPA + amyotroph.ic lateral l cleroais (ALS). Pathologically ha l festure. of parkinsonism and Al~heimer'1 disease but no Lewy bodies nor senile plaques Huntington's diMase (lID): whereas adulu typically show morea , wben HO manifesu in a young penon it may resemble IPA (8 pontaneous) intracranial hypotension may present with findings mimicking IPA\.-page178) MULTIPLE S YSTEM ATROPHY (MSA) AKA Shy· Drager syndrome. Parkinsonism (indisti nguisha ble from IPA), PLUS id· iopa thic orthostatic hypotension, PLUS other , igna of autonomic ne.-voU$ system (ANS) dysfunction (ANS findings may precede parkinsonism and may include urinary aphincter disturbance and bypenenaitivity to noradrenaline or tyramine infusioWl). Degenera· tion ofpregangliQnic latenll>om neurons of thoracic 'pinal cord. NB: classic IPA may eventually produce orth(l8tatic hypot..-naion from inactivity or 8$ a result ofprogresaive autonomic failure. Unlike IPA, mO$t do not respond to dopa therapy. PROGRESSIVE SUPRANUCLEAR PALSY (P$NP) AKA Steele·Richardson·01alGWski syndrome"". Triad: l. progressive s upranuclear ophthalmoplegia (chiefly ver tical Caze): paresis ofvol· untary vertieal eye movement, but atill moves to vertical doll·s eyes maneuver 2. i>*ludobulbar palsy (mask·like facies with marked dysarthria and dysphagia, hy· peractive jaw jerk, emotional incontinence usually mild) 3. axial dystonia (especially of neck and upper trunk) N!sociated finding" sutCQrtical dementia (inconstant), motor findings of pyramidal, extrapyram id al and cerebellar systems. Average age of onset: 60 yrt!. Males comprise 60'1>. Response to antl.parkinson drugs i, u8ually very short lived. Averagesu ..... ,val after diagnosis: 6:1 yrs . Differelltiating from Parkinson·s disease (IPA): Patienu with PSNP h8ve a pseudo-parkinsonism. They have mask facies, but do not walk bent forward (they walk ered), and they do not have a tremor. They tend to rail backwards. Course I. early: A. mDny fall., due to dysequilibrium + downgaze palsy (can't !lei! noor) B. eye findings may be normal initially, subsequently may develop difficulty looking down (t"Specially to command, l~ to following), calories have nor· mal tonic component but al»ent nystagmus (cortical component) C. alurred spe~h D. personality ch!lllges E. difficulty eating: due to pseudobulbar palsy + ;nabili~ to look down at food on plate .. 2.3. ParkinsoniBUI NEUROLOGY 2. I .~ It. eye. fIXed ~utTaUy too response to oxulocepbal ic. or otulovullbular1); OIl1.11 •• ImmotiU ty ill due Lo f. (Hltlll lobe laio n. 8 """k atiffe ... in "",ten,lon l. etnK'OIllI) SURG ICAL TREATMENT FOR P AAKINSON'S DISEASE BerGn Ih .. introdudion or t..dGp. in til- I. te 19&0'., .te' f'Otactic tblilemo!.Omy ... n widely used fGr Park ....... diteaae. Tb .. loaItlon ullimll.ely targelN for lel io",;ng"'u the .... nll"Ol.III,...1 o"deu •. Th .. p.-lu...... Q1'ked better for Nlifl.vinr the t~mor tbflll for the bradyllinUla. however It "'1\1 the lillie. lympLom tbllt we.. mOll;t.diubliog. Thi s ~ tedu ", eanoot be done bihllllrfl Uy ... ilhoul .igni licunl rislJ to 'PH\:h function The p.ocedun. f.1I oUt GfflYOr wh.n more effective drop ~lIme IIvIIU.b!e" See SW-I,",lll'WOlm,M 0( f>Qr1ti1lWll', di __ 0"' pap 365 !'or rurther lofonnation. 2.4. Multiple sclerosis A derllYlLlin,ti.Q( dlll,",_ (Iffecti", "nly while malto.r) IIfth. al1!brom . optIC neTVl!II, . nd s ploaJ mrd (espec:i.lI". oorti«llp!nal lUlU .nd the pOIIl@rior 'JOJumru). Ptod"Cftmultiple pl.que. of VII no ... ..,;n dilfu ... loxe~1\II in tl!ll CNS. eapec:illily in th" poi"riv~ntri.,. UID r white maUer. LHiolalniti,lIy eYOQ a", innIR'ma~ response with monoqteo and ]ympl»cyllc pl:nvucul., ""mnfi;. bllt with 'g~ fedle down to el ial SClil ri. EPIDEMIOLOGY Utili] IIp.of onMt ; 10·59 yell,..., " 'i lh lb. gTellli'!lt peAk bet.... een agell20- ~O y,",,~. Ma le 10 femal~ I'Itio: 1.J§,1. Prevalence v.nOM __.th latitude, e.nd is < 1 peer 100,000 rtf:1I r iheequator, lind if - 3Q80 per 100,000 la Ihe north*m U.s. and Canada. CUNICAL Cauj;eS exac:erb.a tioRa.n d ~rnis­ T.ble 2-2 Cl1nk:aL MS l ions in variou$locationJ In the eNS (diuemioati~ aDd liIDfl ). Com· mon Iyrnploms! visual utu rbantu (diplopill, bl"rring, fielcl :U1ll1I• .,.,1.0. mil. ,pastic par.pa res;lI. and bJ,ddp... distllrbllntK. N01'llf:11t1l1turfl for tbe. tima 1>'1,,'$11 o( MS if. . h ...... n i", 1'bbh: 1'. 2"1. Re1~P8iDg-rem'lting MS i, the IOOiit com· mon pattem at OMet,.nd hal 1M beat I'f!Sponlie to therapy, b,,~> 5~ of cues ev"ntually become semn~al')' pt'<IgTeI. slve MS. OnlY 10% have pri mll')' progrl!e$i,"~ MS. and tllKe ~ .. tienll tend to be older at OUMI (.0-60 yea •• land (~1I""ntly develop p.ogrt'"ive DlyelopalbY"". ProgrHsiw I'tla~in, MS if. vel')' uncommon De fi cit.:'! preHnt " 6 months "Iua lly penlllt. D ifferentia l diagnOll is Th e pletllora of possible sign. and lympl.oDll Ul MS taU5H tha di fferenllli di~ to e~t.ond to almost,,11 tOliciition . ",uli"i ~l or diffuac dyJ: fW>Ction ofthe CNS. Condl· tiou. that mllY t losal)l aunic MS di nio:slly and Gn d iagnoltic to.lt;1\I include.; I !\C1,ta d.i~rnin .t.ed en<"flpb,lomyeli lil (ADEIII); may alllO Ila>'e CSP-OCB, rener· Ally monophasi c 2. eNS Iymphomll . ,u ~t 463 3. other flonly Nll B~ demyalin.t,"g diuaJeS: a.g. Dewic ,yndrome,,"~ ~ 90Jl NEUROI.OCY 2.4 MultIple f('!ll'OIil .. Signs 80d s ymptoms Visual di s turbances: Disturbances of visual acuity may be csuaed by optieor retrobulbar neuritis ..... hich ia the pTflSenting symptom ofMS in 15%oftllSfls, and ..... hich OCI'UTS at some time;n 50% orMS patients. The percentage ofpatientll ..... ith an attack of optic neu· ritis and no prior attack that will g<I on tode~elop MS ran ges from 17-87% depending on the series". Symptoms: scute vi sual l\lfIs in one or both eyell with mild paln (ofum On eye movement). Diplopia mey be due to internuclear ophthalmoplegia (INO ) from a plaque in the MLF. INO is an important sign be<:ause it ra rely o<xurs in othu conditions b<lsides MS. Mot-or findings: Extremity weakn""s (mono, para, OT quadriparesi s] and gait ataxia are among the most oommon symptoms of MS. S pasticity of the LEa is often due to pyramidal tract in~olvement. ScalUling speech results from cerebellar 1.... ions. Sensory findings: P05terior column invol~ement ofWn causes 106S of proprioception. Paresthesias of extremities, trunk, Or face oc:.:ur. Lhenuitt<!'s sign (electrie shock-like pain radiating down the spi nl' on neck flexion) is common. but is not pathognomonic. Trigeminal neuralgia occun in ~ 2%, and is mOre often bilateral and occurs ata younger age thsn the population in general" . Me ntal dis turbances: E upboria (Ia bellI' in · difl"e.-enea) and depression occu.r in ~ 50% ofpatlents. Refl e", changes: Hypcrreflex.ia and Babinski signs sre common. Abdominal cu· taO!!9ua reflexes di$apPl'ar in 70·80%. Table 2-3 Diagnostic criteria for MS , GU SymptOIDll: Urinary frequency, urgency, and incontinence arecommon. lmpotence in males and reduced libido in either sex isoften_n. ,. D IAGNOSTIC CRITERIA No single clinical feature ordiagnO$tic test i~ ad· equate for the a<:eurat<! diagnosis of MS. Therefore, clinical information ia inl4lgrated with additional data. Diagnosing MS after a ";n· gle, aoute remitting clinical. Iy isolated syndrome (CIS) is ~ery risky . 50-70% ofpa· ti~nu wit b "CIS ,u88~s tiv. ofMS will have multifocal MRI abnom:>alitiell charae· l4lristie of MS. The presenoe of these MRJ sbnormalitiell increases the risk ofdeveJ· oping MS in 1-3 yellNil (with greal4lr prognostic signifi· cance than CSF-OCB). The mOTe MRJ lesiOl\lj, the higher the risk"'. Criteria for the diagnosis ofMS" follow$. The l4lnns "dinieally ~ definite MS· and -clinically probable MS· are no longer recommended. Preferred terms: MS. possible MS (at ri5k " , A. ,. 9 T2Wl lesions on MRI or C. D. lId<IiIionaIlests no! required. " MFlI Q< CSF tesIs ore dane and ar. ""9"'ive. aPlOl\l e. lreme cautIOn In dlagr<>sing loiS I"I'IU$I ","I cril<tr\ec In r _Z-f POSillve CSF sI>owing o/IgocIc>nalt>an<lS."" d'""-ninaUonTn ~on t.!FlI T.,. U must mM11hil ttIIeria in r.bleZ·5 aln)<mei Ykuol .....ol<od pOI",, ~ ol 8$ _ in loiS (IeIay wilh ~I· p r e _ w..... lo1m) for MS but diagnosis is equivocal). Or oot MS"'. 2.4. Multiple 5tlernsis NEUROLOGY Diagnostic criteria ate shown in Tobie 2·3". Ddi"itions" I . attack (exacerbation. relapse): neurologic disturbance lasting> 2:4 hrs" typical of MS when clinicopathological studies de· termine that the cause ill demyelinating or inflammatory lesiaM 2. typical of MS: sigruo &. syrnpwms (SIS) known to occur fn-quently in MS. Thus excludes gray matter lesions, peripheral nervous 6ystem lesions, and non·specific complaints such as HlA, depression, con· vulsive .;eizurea, etc. 3. separate leaions: SIS cannot be explained on bas;' of singI.. lesion (optic neuritis of both eyes simultaneously or within 15 days represents Bingle lesion) Table 2-4 Brain MAl criteria lor MS 3 althe loIlowIlI9 4 cr~erit· I. 1 gadollnU:!l-enhancing Iasion or, d no gado5nlulI1 enhancing lesions, theo 9 T2WI!esQns 2. ,. 1 intratenloriallesion 3. ,. 1 jultlac:onicalleslon (i.e. lnYoMng subcor1iclll u Jtlers) 4. ,. 3 pefiol .... \rio:uIaf lesions 1 ~ CQf(j lesiDn car!be- subs ~lu'ed 10, 1 bra i n _ Table 2-5 MAl criteria for d ieaemlnaUon ollesillns In time MRI MRI i. the prefeJTed imaging study in evaluating MSI> and can demOlI9tl'at& dissemination of Ie· sions in time and space. Recommended" brain MRI criteria for diagu08ing MS are . hown ill Table 2·4"'n . Le5ions are normally" 3 rum diameter". M~R[ shows multiple white matter abnormaliti8$ in 80% of patients with MS (compared to 2:9% for CT)'"· ... LesionJI are high signal 011 T2WI, and acute lesions tend to enhance with gadolil!.ium mOre than old Iesion a do. Periventricular lesions may blend in with the tignal from CSF in the ventricles on T2WI. these leaioll8 are shown to better advantege On proton density images as higher intensity than CSF. Spinal ~ming hOI cri1ical. buI 3 mont/I$ b cord lesions normally show little or no .welling, should be:it 3 mm but < 2: vertebral S<lgments, occu· ,~py on a portion of the cross·section of the cord, and must be hyperintense on T2:W1". Spe<:ificity of MRI ill _ 94%"', however, encephalitis as well as UBO. _Il in aging may mimic MS lesions. Focal tuweractive demye lwatillg lelioo l {TOLl may ()(:Cur in isolation or, more commonly. in Tabif! 2-6 CSF c.iterla 10. MS pa\.ieots with established MS. TDL way represent 1. ~,1alilative assessmeM or IgG is tt1e an intermediate poaition between MS IlI!.d ADEM". mas! inlormatiYe aroaIysis TDLs may enhance, al!.d show perilesional edema and !hUI be mistaken for neoplaSIIllI . Biopsy resulte 2. analjosls should be pi!I100ned on ~Irl\ted CSF al'lC! musI be may be confusing. MRS may not be able to differen· c:ornj:ilIed to sillu1taneoosly run setiate from neoplasm". rum tampIe in Iha same assay 3. qua~·jtali'le aroalysis shook! be CSF made in termsol one or Iha 5recogCRF"n"lysi8CS1n IUPf'Ori.the di~E"'""i9in lome nlleCSIalnlng pauems lor cell cases, hut cannot document disaeminatiOll oflesiona ~. alO!I'1e, lestspeflooned on!heCSF in time or space. The CSF in MS is dear and color. r~ wac, protein & glucose, less. The OP is normal. Totel CSF protein is < 55 lacfale) shoUcI be I8lwn iI1Io considmg/dl in - 75%ofpatienU, and < 108 mgldl in 99 .7% e.aticn (values near 100 should prompt a search for an al· 5. Hcm.cal suspQon is high 001 CSF ternative diagnosis). The WBC e()unt is" 5 cells/Ill res.jIs are equivocal. neoalive 01 in 70% ofpatienu, and only 1% have a count> 20 show on1y a single bar(!, conside, cellslpl (high values may be seen in the acute myeli· repeating the LP tis). 6. ~'.~a!WelgGisaCflr1lllemeota'Y In _ 90% ofpatieoUl with MS, CSF·lgG is in. teS!, but Is no! a S\bstitule lor qua1itreased relstive to other CSF protein., and a chara.,. tative IgO t\1sting teristic pattern occurs .... garose gel electrophoresis shows a few IgG bands in t he gamma region (oligo;>clonal band. (OCB» that a re not present in the serum. CSF-OCB are not spe<:ific for MS, and ean ooeur in CNS infections and lI'IIs commonly with eVAs or tumors. The praNEUROWGY 2:. 4. Multiple selerosis " dictive \l81u8 of tile ebtente oflgG in a potient w;tllauspcctcd MS lias not heeD satisfactorilyelucidated. Recommended ~rilerie llavlI been publi, lIed", m~t of wlli(1I pertain to apecifiea of laboratory analy.it. pertinent cliniClI1 e~wrpta ... e allown in Toblf 2·6. 2.5. Amyotrophic lateral sclerosis · I t Key fealur .. a mi~ed uppe r an d lower motor neuroo di_an (UMN - mild lpaltici ty in LEI; lMN - atroplly And f.w:icullllion i Ln Ur..) • rw co~itive, .. ruory, nOr autonomic d funct.ion • e/lu.ed by degllneration of ne...,...,n, in t),le tervic,,1 .pi ne end lD&duU. (bulb) In llle U.s. emyotropllic iatflral sclcowi. fALS) i. AKA Lou GeIuig'1 dilellM. EPIDEMIOLOGY'" Preva lence: 4·61100,000. Incideote: 0 .8 · 1.21100.000. Familial in 8·10'l00fca_. Familial ca$U Ulually folio ... autDtomal dominant inlier. ita nte. but oecasionally demonstrate a r_ive patl.olm. Onact usually aner 40 years of age. PATHOLOGY Degeneration of anterior 110m alpba·lDotonlluron. (io tho! lpi nal cord IIlli In brain ,tern motor nucllli) and cortioospina! tl1lCI& (lle/"lfle AKA motor neuron diseue). Thi, produces a mixed upper and lower motor DeuTOn discue, ... itll a great deal orv,ri lbi lity de. p"nding on wllicll p""'om;nate, at any given t;n:>fI. The etiology of ALS illtill not known with certainty. CLINICAL Involvement il ofvoluotary mu..:I.., eparing tile volunury ~ 1Il,,"lee and urinary ephincter. Classically, presents initially with weaueIII and auoplly of the hands (lower motor ncuron) witll l PIIllicity and lIyperunexia of 1M lower extremiti"" (upper motor neuron). However, LEI may be hypon!fleltic if the Io"'e r motor neuron delicita predominate. Dyu.rthria and dysphagia a ... cau..sed by a combination of upp"r and lower motor neuron pathology. Too,gue atroplly and fasciculations may occur. Although eornitive deficits an! generally considered to be abosent m AlS. in aetual· ity 1·2% ofca_ a ... auoc:ialed with dementia. and cognitive changes may occasioo.ally predllte tha ul ual fea t ura of ALS" . DIffERENTIAL DIAGNOSIS It is important for the neurosu'¥e<ln to be able to dilrtinguisll A1.S (rom cervical .pondylotic myelopathy. SeepG6t 33J for a di..:uHioo. of differenti.ting feetur"". DIAGNOSTIC STUDIES EMG: Not abaolutely I1«t'lS&ry to make diagnoei. in moIIt ca.&eI. Pibrillationa and posi· tive I barp .... Vel are fouod in adva nced _ (may be abRnt early, "pedally ;fu pper motor neuron pathology predominatel). LMN findin p in tho! LE in theabRnceon .. mbeor Ipine di.."c. Or fibrillation potenti,l, in t he tonaue are luggestive of ALS. LP (CSF): May have . lightly elevated prol.ein. TRE~ TMENT Onpng trial. with riluzole (Rilute14), whicll inhibita tile pruyn.ptle ........ of glutamate, indiClitol that dOH' or50-200 mgld inCrf!8MII trach_tortly·free survival al9 &; 12 months, but tile improvemeot it roortlJ>OOkott Of" rnay be non-eJ.ittent by - 18 month," ". At tile tima of thi. writin" the d"., it aVlilabLe onLy for prema:rkl!tln. trials. and cannot be procured comTOCTcially. Much of care i. di~ted tow.rd, minimiain, diubility: I. ..pintion may be treat$;\ witll 2.5. Amyotrophic iat.e!'al lCleroai, NEUROLOGY A. Iroch"""IllIllY B. gtostroslllllll' tube III allow cootinued fceding C. voce] eord ill,jedion wit h "(!f1on 2, a paslidty thaL occun wh(!11 upper Illntor neuron defrcit.s predomin~~ may ~ trea~d (usually With ! hort.· UO'ed response ) with: A. bsdafen.: alM! may re~eve t.becommonly oc:currlng cramp. (,el': fX18t 368) B dia~epam PROGNOSIS ~IOlIt patients die within 6 years oranset (median Bu,.".i"al, 3-4 yrsl. "h ... e wIth prominent or(lpharynlfulsymptol1t$ may haO'e 8 . harter lif....span usually due ta compJi. ClI.tio"" q{ IIspinl.lion . 2.6. Guillain-Barre syndrome t Key features • acule onselofpenphet a! neuropathy with pf'Oll"l!Sl ive .... uscle weakne.u (more BeVe~ Drol{imal!~ with arefleria, Teaches mllll'lmum o"e r 3 dllYI t.o 3 waeu cranIal neuropal : 8 180 conunotl, may include fadal diplegia, ophthalrnopltlf;ia little ar nose.uory invo!veml'n t (paru thesiu lire not uncommon) onset often 3 dayo.·6 weeki fo UowI,IlB" "ira! URI. Immunillltion, ar s urgery p&thol~: foeal Rgnlental dem!eli nlltion with endoneuria1 monocyl.ic infll lrat.l! elevated CSF protein wil.baul p eocytosia (albuminocytalogie d,s6Ociation) AKA BCUU! id iopal.blc pol)'TlIdiculoneuritiB. "he IIlQIlt common acquired demyeli nat.ing neull>\>athy. lncidenoe is _ VIOO,OOO."he lifetime risk forar.y one indlvidulIl gettin!! Guillain·Barri &yndro"" (GBS) is _ VI,GOO. Mild cases of CBS m8y pre&ent only with alllJ<la, wh"reaJl fuhn;nllnt _ may u _ ""nd to pllrslyu .... apirowry muscles and cranial ne~. Frequen t (but not euentjal) p~ing even Ll: vinll ;nfKtion, &urgery. immuniu· liM, rnycoplnma infection. May follow onfection with C"Il\P1{obod~r j(j.. ni (. 4 days of Intenae diatThea). Higher frequen<;y in th" fo\lowing conditions Lhan ,1\ genera l popula· tion : Hodgkin's disl!8se.lymphoma.1upu~. The a<:tua! cauae i. not known. May be due to antibodies to J'l!ri pherllimyelin . DIAGNOSTIC CRITERIA'" I , fealuree requiNd for diagnosi s: A. progT"'I'Iive motor weaM OlI!s of mor.. \hlln I limb (from minimal weaJrnes>o ,,-ataxia W para]yai~ , lJIIIy include bulba r or facial or EOM palsy ). Unl ike mO&t neurO;lllthieli. proximal muule3 .re affected more then dista l B. arene";. (usually univenal. bul distal Brene~ia WIth d .. finiLe hyporenexl a of blCf!p5l1nd knee je rks suffices if other fellLUrei consisLent ) I!. featun!S strongly 8upporti~e o[diagnosis: A. cHnicol featu res (in order ofi n,l'on.ance) t. progT"e,jon: mowrwe3kness peaks aL2 wksm 60'll>, by S wI\! in 80%, and by 4 wu in ,,9Q<I, :l. relat!vellymmetry 3. mild sen!lOry sympt.mn;uaigns (e.g. mild pa rea\hesia8 in hands Or feet) 4. ~ involvew&nt: flW;l weak geH In 60%, \l.Wally.lilla!&uJ. GBS ~nll initially in EOMs Of other Cr. N . in "6" of C3$eS. Orop~,eryngeal mUlw:]l'lI may be 1Iife<:t.ed 6. ",cova ry usually by 2-4 wka aller progn!!IIIion stops, mlly btl delayed by \WlnlbJr(mo.t pat ienu TOOoYer functionally) 6, ll uLOnomiedysfunction (may nucl uale): lBch~eardin and other a rrhyth:nias. poeturo l hypClten:DOIl, H'l'N, v8SomolOr symptoms 1. afebrile al onset of neu ritiesym ptomB 8. van.uUl (not ranked): a. fever at onset of ne uritic symptoms b. !J<jver8 MOSOr)' loss with pain c. progreuion wu d. ~es6Btion of pral>"!ssioll without T«Overy 8. 3phin~r dys function (usually spared!: a,e. bladder paralyalo! >" NEURO/..OGY 2.6. Guillain.Bam; syndfOlD8 " f. eNS involvl!ment (controversial): e., . ataxia. dy!l8.lhria, Babin .k.i aigna B. CSF !indings: a lb" m ,nocytolog"i<: diSllOCllltion (elevated CSF protein witholll pleocytosi. ) 1. protein: elev'l.o!d I wk or aymptomt, > 55 O'Igidl 2. cell. : 10 or fewer mononuclear le ukocytHIml ant. 3. ".nanta no CSF prol.ei n rin 1·10 ... ka afW r oout (rare) b. 11-50 mooocytulmi c, elec t rodiagnolti~.: 8~ heve NeV Ilowing orblock atlOmetime (may take several weeu in lome). NCV \auaUy < 6O'lt of no .... •. l,Ilal, but not in all nerve- 3. fealu," cu tin, doubt on di egno. i.: A. marked. peraiat.t!nt, lI)'lllrMtry of_aknna B. pertiaUlnt bowel or bladder dy.funttion C. > 150 monocytesltDi CSF D. PMNa in CSF E. _hBrp sensory level 4. features that rule out diagnoei l (findinga that . uggeat 1M! preHnoe orone ortha conditionll in the dj([ert0tjl l d jlR'm!Ja. e., . ' " Myck>pq.llly. pap 902): A. current huacarboo use: volatile IiOlvenw In·hu.ne. methyln·butyl ketone), glue anilftng D. .cut.. In te.rmita .. n l porphyria (AlP): a diliOrder of porphyrin metabolism. CS t' protein is not elevated 10 AlP. Recu rrent painfUl.bdomln. 1 eri. &ei ...... eommon . Ch~k urine delta ·aminolevulinic scid or porphobilinogen C. r~ent diphtheritic infection: diphtheritic polyneuropathy bu a lonCCr la· \.ency Dnd •• Iower cresa!odo of . ymptomt O. lead neuropathy: UE weakneu with wrin drop. May be uymmelrical E. purely sensory syndrome f '. poliomyelitis: u,ually uymmet.rn:, hat meningeal irritation C. hypophosphatemia (may OCCUr in ch ronic IV hyperalimentation) H. botuJi~m: diffi culttodis tioi'Jish clinically from CBS. Norm. l NCV . od . f• • cilitating .-.sponse to repetitive nerve stimulation on electrodiagnoaliCl I. toxic neuropathy (e.g. from nitrofU."ntoin, dapsone, thallium or arsenic) J . tick paralysis: may ca. ...e an ucending motor neuropathy without sensory impainneoL Careful eumination oft.he scalp for tickC.) K. long time coune: mey indicate chronic im ... Wlc d .... yeli n . tmg polyra· d icu lon .. uropatby (Cl OP) AKA chronic relapsing CBS, chronic rela psing polyneuritis" . Similar w C BS. however symptoms must be present> 2 mOl. CIDP produces progrellllive, symroetric:al, proximal &. diua l weaknes.s, depre.. ion of muscle atretch noflex .... and ,·.riable soellSOry laq. Cranial ne""es are usually spared (faci al muades may be involved). Balance diffi· cullin are common. NHd for respiraWry IUpport i. rare. I'l!ak incidence: age 40-60 )'TI. ElectrodiagnOltjCl lllId nerve biopsy findings an!' indicative of dem~lination. CS t' findings .r. aimilar w CBS (_ obow). Most respond to immun""uppnuive therapy (npeciaUy predniliOlone &: plasmaphereaia) but relapaea arecommDn. Refractorycuea may be Ina~ with IV gamma. globulin , cyd"" porin ." ", tolal body lymphoid irradiation or inu.rferon-<>." The MiIle, · t ·ilher v.nant of CBS indoo... ataxia. an!nexia and ophthalmoplegia. TREATM£ftIT' LoununoclobuliNi m.ybe helpfUl. lnKIWc.....,ea rlyplaamaph ..... is haa\.eM!.he recovery and reduaoa the ....id""l defici L Its role in mild c:aaea Is l,In«rtain. S\.erOids . re not. helpful". Mecba\1.ical venlilationlJ.>d meuu,"" to preven t aa piration , ... used .. a ppropriate , l n e. 1IQ of raci. 1 dipleril , the eyn muSl be protected from eXl""'ure keratitis. CNTCOME Recovery may not be complete !'or H veMl I montlu:. 35'" of untre,led patienla have .... id""l wealtn .... and atrophy. Reairreneeor CBS .lUr achievina: maximal recovery DCronl in . 2... 2.6. Cuillain·a. ... . yndrome NEUROLOGY 2.7. Myelitis AKA acute transverse myelitis (ATM). The terminology is confusing: myelitis over· laps with "myelopathy". Both are pathologic conditions of the spinal eord. Myelitis indicot<!s inflaounotioo , lind includes infectiouB, post-infectious, autoim01une, and idiopathic. Myelop9thy is generally reserved for compressive, wxic, Or metabolic etiologies". Er/Ol..OGY Many so-called "causes" remain uoproven. ImmWlologic response against the e NS (most likely via cell mediated corolX'Dent ) il the probab le COmmon mechanism. An.iroaJ model : experimental allergic encephalomyeliti s (requ iN!8 myeli n basic protein areNS. not peripheral). Ger"~rally 1. accepted etiologies include: infectious and post-infectious A , primary infectious myelitis I. viral: poliomyelitis, myelitis with viral encephalomyelitis, herpes ~OIIter • • abie!< 2. bacterial: including tuberculoma of spinal rord 3. !pi.ro<:hetal: AKA ~yphHitit myelitia. Causes syphilitic endarteritia 4. fungal (aspergillosis. blastomytosis, tryptococcosis) 5. parasitic (Echinococcus, cystiterl;Ollis, paragonimiasis. schistQf!omia· sis) 2. 3. 4. 5. 6. 7. 8. 9. B. post-infectious: including posl-<!xanthematoU$, infiuen2a po!IHl"8umatic physical agents A. decompreSll ion sickneas (dysbarism) B. electrical injury ' C. post-irrad lation para neoplastic ~yndro me (remote effect of cancer): mos~ common primary is lung, but Pl"Ol!tau!, ovary and reclum have also been described" metabolit A. diabetes mellitus" B pemiei",'! anemia' C. chronic liver disease' toxins A. creayl phosphates· B. intr8-arte";81 contrast agenta' C. spin al anesthetics D. myelographic contl"8st agents E. following chemonuc\eolysil" arachnoiditis autoimmune A. multiple sclerosis (MS), especially Devic eyndror:"ll'l ($« page 904) B. following "lac:ciuation (smallpox . rabiea) collage n v8sc ular diaea/le A. systemic lupus erythema- Tabk! 2-7 Presenting sympto ms In myellti' ~". connective tissue B. mixed disesse I~", . _ .ted . . WIth .. u ~ti.k "' .1 be ""Or' properly ro th. , u... o>y.M;. ilb. my.lopothy _ CLINICA L A: 34 ~nIj ";'~ ATM'" W/lf$ B: 52 ~nts .,ijh OCU"' OI subaCUlfI tran ... _myeli ~s"" PRESENTATION 34 patients with ATM ": age of On· set ra nged 15-55 yrs, with 66'l1>occurTing in 3rd 8nd 4th d"",ade. 12 patienUl (35%) had s Nt'UROLOGY 2.7. Myelitis " "iral ·like prodrome. Pruent;ng symptoms are shown in Tabk 2·1, with otherpresenting . ymptoma of unspecified frequency including"': fev .. r and rash . Pr elHlDling leve l The level . at pretentation in 62 pationu with ATM aro shown in Table 2·8". The thoradc le"el is the molt common ten · sory le~ l . ATM i. rarely the pre.enting.ymptom of MS I_ 306'11 of patiMtI with AT M de"elop MS). Table 2-8 Level of MnSOl'Y deficit PROGRESSION Pro8l'usion i. usually rapid, with 66% reaching maximal deficit by 24 hn, however the interval between fint . ymptom lind mlllUmal deficit "aries from 2 hn·14 days-. Finding. It th e time of maximal deficit a re .hown in rabk 2·9. EVALUATION MY.florram CT &..M.SI: nO characteri.· tic finding. One pape r reparts 2 patients with fusiform cord enlargement". High ...... olution MRI with thin CUtl may be able to demonstrate al'8S ofinvol~ment within the cord . Patient.hould hIve imagi ng to IUO compressive lesion. C5.E: nonna l d ur ing acute phase in 38'11 ofLPs. &roaioder 162%) had elevated protein (usually:> 40 mg%) or ploocytOS i$ (Iym. phocyte$. PMNs, or both ) or both. Tabl.2·9 Symptom' " time 01 maJlk mald.lell (62 patieotl..-i l h ATM"') , EVALUATION SCHEME 10 a patient developing acute myelopa· thy/paraplegia. espc(:ia lly when ATM is considered likely. the fint uslof choice is an emergency MRL Iffl()t readily available, a royelogTam (with CT to foI!ow ) direc:ted at the region of illesensory If!>'e l is perfonned ICSF may be sent in this ci rcumstan« once bloek is ruled Dull. T REATME NT Suggested efficacy ofhigh..:lose s teroid treatmen t in 1 patient .... ith ATMG (methyl· prednisolone 250 mg IV q 6 h,.. X 24 h ,.. . 125 Ing IV q 6 h,.. .. 24 h,.., 125 mg rv q 12 h1'$ I. 48 hrs. then 30 mg PO q 6 hno. Ulperilld gradually. Rc>&imen sllould probably be individ· ua liud baaed On ..... ponsel. P ROGNOSIS In a $eries of34 ATM palien U willi" 5 yrs follow·up (FlU)"": 9 pal iellUl 126%' had good rltCOYery (amb",1ale well mild urinary symp&o ....., minimal $eraory and UMN l ign l ): 9 (26'110) lIad fai r recov ....y (functional g. il with $Orne degM!! of $p8sticily. urioary u.rgency , obvioua .. ntory '[1"5, par' pereaill; 11 (aN) poor (paraplecic. a btent sphiDcter fIOIItro\); 5 (15%) died wilhi n 4 ..- or illn ...... 18 palientl (62':1. of survivorsl becama am· bulatory (in th_ cues,.1l c:ould walk with support by 3-6 ..-). In a Hri " 01'59 pllienU-{FIU period unl pl!('ified 1: 22 (37'11) ....d ,ood recovery; 14 (24") poor; 3 died in K U\.a stage (ru pinotoTy inl ufficiency in 2, Hpli5 in U. R«overy oc· curred between 4 weeki and 3 _ after on$et IfI() improvement oc:curred .fter 3 rnos). 2.8. Neurosarcoidosis SI.rcoidosi, i • • gran",lon,atou. di _ that il ulu,Uy I y, terni.:, and may indude the CNS (_ lied neuroaan;:oidotl ia). Only 39& or cue. have CNS fiodinp without IY.' temic: manifut.alion. ... The ('8uHorthe diM_ i, ",nknow n. An infeo:tiou l Igeol il pot. NEUROLOGY .ible. Organ~C(jmmon ly in~(Ilved indude \ulllP. ~k1n , lymph nole.. bones, eyn, mUliClu. IlIld parolid glands'". P ATHOLOGV CNS lall:oid().9ia primanly InV()lvl!Ii the lep~omeningea, however parenchyma l invpaion often occu.rtI. Adhesive a rachnoiditia wilb nooule form.t.iOD may al-o oco.:u r llloduJ~ have" predil~iOll rOT the pc., nerior £(658). Oiffuse. meningitis ~r roellmgoeneephalitis may occur, and may be 1II011! pronounced al the balll.! oft bl! brain {bR8IIl meningitia l Bnd in the aubependymal region of the third ventricle (including the hypotbalamwo ). Cons tan t min"Oll~pic featW"1!5 of neurO$&TCoidNi. in clude n~a;,eati ng JlTllllulomilS with Iymph<l<:ytic infil trates. Langhans giant .,.,lIs roay orm,y not be prelieM E PIOEMIOLOGV Ineide ",:., ofs.ar(Jlidosi6 Is - 3·50 "'IsesllOO,OOO popu lation; neu rOlla ra)idotlb O«UTI in _ 5% Or(;llM1l (reporud ran Ke: 1_27'1» . In one • .,ries, the median 1ge monset of neuro. l"(ie symptoms was 44 ~arl. CLI NICAL FIN01 NGS Clinlcallindings incl ude m ultiple cranial lIe .... e pal&iea, pl!flphe ral neuropathy, and myopathy". Ottasional1y the le8ionl roIlY prOOuce mauelfe-c:l1'. IUld byd rocephalW! roIlY res ult from adhe,,;vB basal ara~hnoidili$. Patiant>lUlay have 10.... grade r.. ve r. lntr&CrBoi. al hypertension i~ common and UlAy be dangerou s. HypolhalaJDie invol vero!';n t may produce dillorder~ or AD" fdiabetl>5 tru.ipidU6", disordered thirst). LABORATOR Y CBC: m ild leuk~i. IltId ",,,lnoph.llla may o<:cu r. Se r u.D;l ang"iotenai n·co nvertiPi eo~ym" fACE): abnormally elevlto!d in 83% or patienu with active pulmo",,!), aar<:oid08is, but io only II % with in8ctivD diJlellse"'_F~llle posi tive ral.e: 2-S'IIio: ma) ..180 be eleval.ed in primary biliary cir:h08;s. CSF : similar w any 8ubacuto! menlogitis: elevated p,et;SUN!, mild pleocyt.o8"ia ( 10200 oe:llslmllll ) IIIO$tJr.lymphoq'tu, elevated protein Cup to 2.0!lO mgfdl), mild Il.ypoglyc· orrha~hia ( 15·40 mgldl), CSF ACE is eleva ted in . Or CaI" with n eU'0$8rcnidoai. (nonnal in patienu .... ith lIa",oidOllis not involving th6 C NS)"' . No organislllS are /"IIWV· e red on clll t uTto, gram 'tain. 5-5" DIAGNOSIS Oifferentiati.nij ¥NnulolllatoUll8ngiitil (GA ) Table 2-10 Oltfe. enllal diagno- froUl rlellTosarroido&is that invo]"1!!1 only the CNS ClIn be dane 011 histologic &riteril: the in n ommatory rail¢> lion in l,rt"Oid08i.t! il nat limited to Wle region imroed.i· sis 01neurosareoldosla au.ly ~uN"Ound;n G bl~ V_18 "" It;8 in CA, .... he ro ""len6;v8 disruption Qrrne vueel wall mayo<:cur. Making the diap"";5 is relatively BII$y when systemic involvement occurs: chara cteristic ti nd",~ on CXR. bioPIY of ak.iu Or live. n<>dulei . U\ LI.iIele biopey, leTVUI ACE a""y . holato!d neur~lra)idosiI Ul'y be Ulore diffi cult to diagorn.e, alld IOsy requi re hioP")' ($o!"t' bd(!w ). BIOPS.,. In UOCfrt8iO~aH', biopsy mQy beindltated. Wheneverpo$aible, MRl a hou ld be used to localize a SUpl"1ltentorial region ofinV(llvernen~. and biopsy should include alileye" or IJIf!ninges .lJld QBrebro l cortex. Cul tlLr1!S and ~t/lin.s for fungus Ind acid·fMt bacteria ('1'8 ) 8hould be performed in sddiUon to m icrwcopit exalUinMion. NEUROLOGY 2.8, NeUrMOrcoidoo;$ TREATMENT AntibioliCll hB~t not been proven!.O ~ofbentfit. Steroid. ore bc!n!':fidal for 'YI!.emie u WtU •• nellrolo,ic involvemen t. Thtr. py with cycIOlpori". m.y allow a redoclion in lteroiddos"e in r.fn ctoryuIQ". Otbtr I..., well ~~IId.ied trutman tll : methotl'i! "~' eytaun. CSF shunting Ui indk,~ if hydroceph,III,dtvelopa, PROO NOSIS UIu.Jly I bftlign disease. Periphuflllllld CtlUlilll nervli palsl" l"itWVer,lowly. Vasculitis and vasculopathy 2.9. Th. vlkUlitides ora . IJ"lIp of diaordtrl cho ... ~~riud by inflammation and MCrolia of blood v_la. VaKul;ti. ma, be prilllllt)' or IeQ)OOlry. Those thOL n'ay affect lhe CNS Ire lilted in Table 2· 11 , all ofthel6CflUJe WIUt 'Khemla (even ,,/\ar the inflarnma tion it! quitlCl!nt) thlt mlY raup iJI elT'eo:t from nauroprllXi, tQ infa rction Ta ble 2-11 Yueulillde. lhal !(£Y:O."""""""'''' ....._ the eNS'" : •• _''''''''''''''': >-t.'''''''''''''''ICI1 . onIr~_~ SAI-I.~~ _HCIIon".. ~I Iot_tDIlia J>AN" IfIOUI>"'_~......,-...ybt~ 2.9.1 . Giant cell arteritis (GCA) f TKey fuw .... formetll D~" ~fured ta al l.emporal arteritis d ' romc vallCUht it!oflac]{e and ~um celibtr v_la, primlri l, LDvolvlnSeTl' nill b",ncl;>ea of Ole Imnft trisioS from the .0000e...::h age,. 50 yean: atrKU WOme<l IWlet .. otten .. Ultn important poIIIIiblalal.e romplicatio ...: blilldneu, atroka, thane..: IOrtic lna .. ry~m. and aortic di~ioo. temporal artery bioplJ' il rec'Ommtnded (or.1I Pl'Uenta IWll*ted ofOCA rortlCOSl.erold. an tlledl"Ur of choice rer IrflIIlmenl AKA Lcmpo r l'lrteriti. (TA,) , AKA crlltllal.rl.entlt. A chronicJrIlll.. lol7llt.o ... Ir_ I-tribS ofunltnown etioloo In.oMnS pnlUllrily tbecrtlDi.1 brandlftl or lha Ionic IIl'dI (especillly Ih' uterTIal urotid af'Wry (ECA))". wluch Iruntl't'llted , mil)' IeJ.d 10 blind· ntal. Talcay....·' art.eritit it . imill r VI GCA, but t.tnds 14 affect Iltse . rteries in )'Ounr .. om~, I EPIOEIdIOl OO 'r Stan ,lm Ollt e.:dU&i~1y in CauCII.;allt:> 60 '"' &Ie (mean'~ of o....,t it! 701. Ind· denc:.; 17.8 ~r 100,000 paople" M1yearaold" (r.np:OA9·231 Pr .... a1enc.: _ 223 (aulOp., incidence may be much hiKrlIl"rl" MoreCODlOMlll in n-orthtm litiludea Ind lmoll, 2.9 VpeulitiJ and visculopalhy NEUROI.OGr individuals ofScandintwiaa descent". Female:male ratio is _ 2:1 (reported raage: 1.05· 7.4:1). 50% ofCCA pat ients 11180 hllve polymyalgia rhellmatica (PMR) (."" PQHe 61). P ATHOLOGY Discontinuous (so..clliled "skip lesions") inJlammlitory reaction oflymphocytell. pl asma cell s, macro phages, :t giant cells u fabsent , intimal proliferation may he prominent); predominantly in n,edia ofirlVolved arterie~. Aruries plllferentially involved include the ophthalmic and posterior ciliary branches and the entilll distribution of the eKternal ca · rotid system (ofwhith the STA i8 a terroinal branch). Other arter ies in the body mal' be involved (reported invot-'ement ofabdominal aorta. femoral , brachial and mesenteric arteries a .... rarely symptomatic). Unlike PAN. CCA generally s pares the renal arteries. C LINICAL Various combinations of Table 2· 12 Signs and aymploms 01 GCA". T7 symptoms of giant cell arteritis are FreqU8fl1 listed in Tabl~ 2· 12. Onset is urual· j> SO'4 01 ca_) jll).5(l'!{,ol c_) « 1,"- of cases) Iy insidious. although OCCWlliOflaliy -.i$Ua1 sympIQm$ it may be abrupt"". ' ~'-~~ ~alMIlly ~11o$S exlremi!y daudicalion Details afso me findings \Dng~ claudica1ion ,-~ !8'/e( (law gllOe) 1. HlA: the most common pre· prounalmyalgi3$ earpai:l senting symptom. May be jaw claudicalion nonspeciIicor located in One I ~a:ial pa;., or both temporal areaa, scalp lenderlleSS angina forehead . or occiput. Mal' be superficial or burning with parolC)'smBI hmcin ating pain 2. symplQllul relating to ECA blood supply (Itrongly sugge~tive orCCA. bu t not pathognomonic"):jaw claudication, tongue. or pharyngul muscles 3. ophthalmologic sym ptoms: due to arteritis and oodusion ofbranch.es of ophthalm· ic artery Or posterior ciliary arteries A. 6YI"PtomS inclllde: amaurosis rugax (pre<:edes permanent visual loss in 44%), bUnMa$!;. visual field cUtl. diplopia. plOt;'. o<:ullir pain. oomelll edema. chemosis B. blindneu: incidence is - 7%. and once itoccutll, reeovery of'ight is unlikely 4. systemic aymptoms A. nonspecifk constitutional symptom!: fever (may present as FUO in 15% of cases). anorexia. weight 1088, fatigue, walaise 8 . 30'l0 have neurologic manifestations. 14% are neu..... pathies including mononeuropathies and peripheral polyneu ropathies of the annS Or I~ C. musculoskeletal symptoms 1. PMR is the most common (o<:curs in 40'l0 ofpatienta): I« page 61 2 . periphersl arthriti s. swelling &. piltiog edelIlli of bands &. feet in 25% 3. arm wllldicatioo from ,tellOSi. of subclavian and 8lIillary arteries D_ thoracic aortic aneurysms: 17 times as likely in GCA. Annual CXRs are adequate for screening 5. lel3tpo<al otter, ,,,, on phyeical exo.minntion may oKhibit tand .. me ... . swelling . erythema ..... duced pulsations, or nodularity. Nonnal in 33% 6. the presence of systemic symptowscorrelates with a ~ incidence of blindness or stroke Oifferential diagnosis: 1. periarteritis nooOlla (PAN): PQH~ 61 2. hypersensitivity vasculitis 3. atherosclerotic occlusive disease 4. malignancy: aymptom, of low grade fever. malaise and weight loss 5. infection 6. trigeminal neuralgia: _page378 7. ophthalmoplegic migraine 8. dental problems ""....., "'" '"""'" .-. '''''' &"" NEUROLOGY 2.9. Vasculitis and vaaculopathy " E VALUATION Laborlltory . tudi e. I. ESR > 40 mrnlhr (usuIlIy > 50) II)' Wnwr,,"," method llf > 80 IIIm1hr with .bcJo,·e CtUII<:8J ')'IIdromu, highly '''8I!el tlVl! orecAl. ESR i. norlllal in up to 22.5"" 2. C·rellCuVi protein: 8uDther ftcul.ol phllse reactant thlt" n,Ore iII" S;t ;V!!. \hln ES R. Hu th e .dvllnta84' thllt it o:.vo he perfon ned on frozen Olen :1. c a c : ,,'.y I how tn.ild ao,moc hrom;e 8uemi"~ ot . rhe umatoid f.~tor. ANA . and Il!rum eomple.tnent ..... ally oo rmal 6. LIT. I bnomuiJ in 3O~ (usua lly elevated !llk.,li"e phoeiphalll.te.) Ii. 1.e1.1I1"ot rheuma toid ractor and AN A "'" usually "w,lll;v. 7. to!mpor818rtery allglollTlPtr.y not tr.elpfuillngi0lrtlphy elsewMrl! Indicated if Sui· pldofl "flll rgt! aI"Wry ili vo lv,",,<,nleltlllll 8. CT' uI"ally 00\ helpful. oce report dutriberl c..lci6ed area colTlllponrline to the temporal ''''I",riu tJ 9. U:mporal arl.lry biopsy: '"' ~1f>W TEM PORAl AItTE AY BIOPSY Sensi tivity and ~pl!l:Itidty I re . ho... n in Tab/I ,./.1. Indication, and timini rlblcl2·'3 . ~.mpo,''''''''Y Current reo;;ommend8Do .....: IOlmpwII artery biop.sy ill 8IL pa t.ient-J , UBpecloPd af I\avHl8 GCA". Preferllbly. biopsy ahould bto dane bl!fore t retltmenl is inlti nt..,d ... Ho... """• • pAlhologie cha",,,, bI! .....an after mOre tha" "2 weeu ~fthn-I I'Y"', th ....efor-e do " ot withhol d steroid& to await biopIy. Technique of tempora l a rtery hiopsy Bioplly of the coutra lawral .ide if til<" n ..:n side 11 ~~tl.-e III tun when!! ciiDlul lIuijplcioo is high innullell the yield by 5- 10'A-. TREATMENT No known cure . StMnids o;an produ .... ~ pl.o"'atic n!!lidand ueuIUy pr....ent blind. (proc,..:t5ion of DC ul • • prohlenlllU--4a btl! _flu i""titution af . deq"ataateroid.ls rare). Tot.llilyblind pauenUl or t110fie witb louenaodine partial VlJwoJ 10M ani! ulllikely to nI!~pond to any tRUmeot. t. for mo,n. ~.; A. IItllrt with ~n.91tt:. 4().6Q mlfd PO divided BlD-QlD tqild doli", is "I,,· I lly HOt ef'ff!d ive in Initillmanag",meut) B. ifno reapoulI! aI\u TI! bn:. and diap108i. teTtlin, Ito 10·25 nlj QJD C. OnCO! ""'POOBe ....:un (" suaUy ... ithin 3·7 days). giv," ,",,:..n. doH 81 q AM dole. for:l-8 wet!u unlil l ympwoos relOlved and ESR oo""aliz... t~1,U"!! in 87~ oflNltienu with",_ ~ wftOka)or . u.bili:es at < oto..;.G.-nnVbr D. once quiHc.mt., a if1Io\Iual u.per is performed lO preye n: encerbe.tions:- re-d\lee by 10 mgldq 2.4 w"klI to 40 mild. ~n by5 mgId 02--4 wb to20mgld. then by 2.5 mgld q 2""", wu lO 5-7.5 metd ... b~b i& IDIIUll.ained for MYn-1I1 manu, •. fol lowed by I ",gld de(:l':'menllq 1-3 "'1111 (... ulIl .... n~h af tre31""",1 il &-2 4 m05: do ACll 00 llto.roida "~n ES R normaliau) E. If Iym ptomt recur during trtaltn.tnt, prednisone d_ is tf:mporarily in· Cl"tllaed until tympl.OmJ reMlv, (]JQ1.ted riM in ES R is lIot lumcie n~renon to inc..... ltf:.-.idl") F JUlUlflUlhou ld be foUowed clOHly for . 2 ~atl 2. '" .e~ertly III pltittnu: methylpredn1'lOlone, 15-20 mg IV QlD 3. II1ti_l\lllnt thenop,.; cont.l"OVeni.J ... .Cllte blind"... (on51': witbin 24·36 h,..) in Il*tien l with giant ",,1I11rt.eriUI: 11.. colI.lder up lO 500 me aleth,l'tpndnBollllIe IV over SO-flO ",I"" (no eontrolled studi" thow I"e\WNI ar bhndnelMl) B. lOme bave used intf:nnitwnt inhlllatlOn " r MII CII rbon dio,,,d~ and o~an n eolll OUTCOME. Complication. of IW:roid tilen py occur in _ ~ or p&t ientl\mOlltare not lif. Ihlll!at· erunl. Ind loclud. "eneoral DOllI plll!"t5lOn f"'cture.ln _ ~. pepUc "I.... diM... ln " NEUROLOGY ~ 12~, proximal myopathy. cSUlrscUl. exacerbstion ordiobetes: also see Po.9iblt cld~je­ '''''''!litLt tI~t.of,teroids, P~i:" WI. 30-50% of pauenta will ha"e sJ.I(In\.<ln<!OUs exacerbations orGeA (especially dllnt;lg the yea ... ) .... gam.lus ofth tonicosleroid I"<lgimen". . S ......... ivaJ parallels that oftbe ~neral popuIRl;on. OnselafblindneM alter initiation of steroid therapY;1I rllre. finit 2 Polymyalgia rheumatlca 2.9.2. PolymyaJgia Theumat;c:a (J' MR) and giant ",,\I arteritio (GeN i_fXJR£1i8) may be diffe rUlj pointl! on /I condnuum orche ume disease. Epidemiolo gy)' Both GCA & PMR occur in peopl .. ~ 50 years old . The incidence increaaes with age and peMa betw~n 70-80 yeat8 and is higher a~ higher latilud"". Polymyalgia rb e umati cs (PMR) " an inflammatory cond ition afunknow n etiology clinical rna",clenst\a A. aching and morning stiff/ieM in the c"rvical f'<!gion and shoulder & pe!\-ic gi rdles lasting:> IlDOnth. The pain llstUllly increases with movement I . sh oulder pIl;n: present in 7<1·95% of plltients. Radi~ te& t.oward elbow 2. hip & neck pain: :;O·70'!l>. Hlp pain radlat@$ eoward$ 1Lo_ 8. age,. 50 yN1"8 C. ESR., '10 m.mI"hr (7-20% ha ve normal ESR") D. W!ull1!y respond" rapidly t.o low dO!le corth:ost./!roid. I. 20 rng- predn',,'meiday) utlHlow E. IYlt.eIl\lC lympt.olTl5lpl'e6t'nt in . 33<r.): fev"t, malaise Or fatigu~. ano"",.i, and weight lUllS prevalenct': mort' common than eCA A. 5001HlO.OOO'" B. I case per 133 people .. age50'" favorable prognoais TTeat m ec t PMR TespGn<ill to eitber 10 low dosel of sten)id.o;l' ( 10·20 n\il prednisone/dayl or sometimes I<> NSAIDs (Iesponse t.o ate roids ig much nlO"'" ",pia). The in it;lIl dose of Ste· roids is maintained for 2.... weeks. lind then hy. 10$- oftheda;:y dose every 1-2 weeklY' wrule observing fo r , ;gnl "fGCA. 2.9.3. Other vasculitides PERIIIRTERmS NOOOSA AKA polyarteritil! nodol8 . Actually a gl"Oup ofllecrotidnK v~ulitjdes. ineludine; dauic periarterili! rwd0811 (PAN): II multil!yn.em disease with infl:unmatory ne· 0I"0Il;&, thrQm ......,~ ( ocdu.ion ). Dnd hCnlorrh"so or Drt<:riDll and arteriDI"" in ow~ry olgan except lung & ~pleen. Nodules may ~ palpated along medium sized mu&cular art~e •. Commonly produces monooeu';t!. multiple,.. weigbt!""' f"wer, Bnd tachyca rdia . Peripberal nerve mllrUfntatioO!l Ol"l! attributed 10 arterilicocelusion ofvo"" OOrvonirn. C!,;S rnBnifestatlOlIS are uncommon . nd indude HlA . $.ilUTt!! . SAH. felfnal hemorrhages, . nd eVA In - l~ • aJ.Iergic angiit", and granulomlltosi s (Churg-5trn uS!l syndrome) systemic n""rolizing YII8Cnlit;s These pa t;enl.ll do better when t~lIt..ed with cyclophospbllmide rather tban "erai"" WEGENER 'S GRANULOMATOSIS )\, systemic n<!Crouilng granu!omat.ous "flarulitiB Involving the respiratory t ract OWl" - cough/nemopt)'lli., snd/or n_1 airwal'l' - laTosanguinou! no""J d rainage ='"'p. Ull perforation - characteri~lie "i8ddle DO'" de.formity") lind freq"ently the kidney. (no ref"Jrted caBej; of kJdney inVOlvement without 1'f5pirotory.... . NBUROLOcr 2.9. VRllCuliti! and vB5fillop~thJ " Na .... obttruetion and e,ulting ... the ulual initial findill8l1. Arthralgia (nOt true ill present in > 50'1&. Neurologic involvement .... uaUy eon$isU of cl"lUlial oerve d,..runetion ( UIIUIUy II, 111, IV, &. VI; 1_ often V, VlI, &. VI II ; and leal t commonly IX. X, XI, &. Xli) and peripheral neuropathiU, wi t h diabetn illlipi du'(OOX.lionally pt«edingothet8)'ll1ptom. by up to 9 montha). Foealle.ionl of th e Drain lind spinal «Iro occur In. frequently. .rthrit~) Differenti.l diagnosis indudu! "Ia tbal m idline I/Tanu lo ma" (may be similar or identical to Jl<)Iymorphie relic>ulosis) may evolve into lymphoma. ~boy cauu r... lminant loca l dutrud;on ofth. nasal tiu ue. Dift'erenlilltion il crucial II thill cODdilion ;1 treated by radiation; one l hould avoid immune.uppruaion (a.,. eyciophOllph,mide). Problblydoet: not involve troe granulom... Reoal and tTacb •• 1 involvement do nOl. occur fungal dille..e: SpOrothriz fChfncitii &. Cocci dioidet may ca\IM identicallyn. drome other vasculitidu: up«i~lIy Ch ul'1-Stnu.. I yndrome (uthma and peripheral eosinophi lia usua lly _ n), and PAN (,,"anulomas ulvally IACki.ng) LYMPHOMATOID GRA NULOt.'-"TOSIS Rare; alfecu mainly the IUlISI, akin (erythemalOUs maeulu Or .. ndurat.ed plaequet in 40%) and nervOuS Iy,tem (CNS in 20 .... p"'ripberal neuropathiell in 15'1» , Si nuee" lymph nodn, Ind spleen are usually lpa red. B EH(:ET'S SVNOROME Relap!;ingoculaf lesion. and recu!l'entoraJ I nd genital ulcer., with occ.a.ional . k.in les;ons, thrombophlebitis, and arthriti' .., H/A ooeur in,. 50". Neurologic involvement includes peeudoturnor, cerebellar ataxia, paraplegia, aeilurea, and dural linus thrombo.i•. Only 5% have neurologic aymptoma as the presenting c:omplainL 86% bave CSP pleocyto&s and protein elevation . Cerebral Ingio(raphy is ul uaUy nonnal. CT may show focal areal of enhancing low deMity. Steroi<b usually ameliorate ocular and eereb'alsymptoma, but usually have ooef. recton .ki n 100 genitallesionl. Uncontrolled triab ofcytotoxic agentl - lOme benefit Thalidomide may be effective (uncontrolled studies), but carries risk of &erioua adyerse effectl (teratollenicity, peripheral neuropl thy ... )"'. Although painful, !.he disea6e il ulually ben ign. Neurologic inYIIIYementportenlb a worse p'ogTI06il . I SOLATED eNS VASCUUTIS AKA i!lOIAt...:! IniP ili. o f the CNS. Rare (~ 20caaa repol'l.ed" &II of l 983); limited \.Ov_11 ofCNS. Small veeel vuculiti. i. ~ alwlYI praent - segmental inflammation and necrosis OflmlUleptomeningeallnd parenchymal blood v_18 witb lurrou.ndi ng ti.,,,e itchemil or heO'lOrmlp". PRESENTATION Combinltion. ortYA, eoor"lion, dfmentia, I nd lethargy. OccuionIlly WilU' H . Poell and mullifocal brain dilturbanceotCurs in,. 8O'JI.. VifllalIympt.llllllIre frequ.,nt (se.:ondary either to involvemt nt of choroid.land retinllarteriH. or to involvement of villlal cortex - vil ual hlllucinatio.-.). EVALUATION ESR &. W8C COWlt Ire usually DOrm. l. CSF DIlly be normal or hl~ pleocyta.il andlor elevated protein. CT may ahow enhancin( areas of low denai ty. AngiOCrlphy hequ.ind br di'enOl;a>: characteri.mally . ho,.... multiple area' of Iymme\.rieal nlfTOwinll ("ltting ofp"'.rlt" cooflguration). If nannal, it don notuc1ude dilgnotil. Hiltolop:.l diagn06i1 (recommended>: III bioJMY materi.l.hould be cultured. Brain parenchyma biapey ;nf~uently , how. vl.ICuliti .. LeptOmt ninpal bioJMY invariably involvement. .mow. " 2.9. Vllculiti. and vllculopathy NEUROLOGY H YPERSENSITIVITY VASCULITIS Neurol~c involv.ment if not I prominent fe~tl.Ire ofthis gl'j)up of"8MUlitidl!$, whIch include: drug induU:d enel'l1c V.~uli li. cul.neo .... V8KUlill. HrulTl siwOII': rna)' - ancep/llllopolh)" Mbu ...., coma, p!!nphe'!ll l>~urol"'Lhy .nd br8th.ial pluopa tb, H~noch-&:h6nlein purpura D Rua INDUCED VI, SCULms A numlHlrord",i' !l.""".lIOCieied with th"d~elopment of~".ebTl.I vlUlCUlit ia. ,odude metfulfllphellolfline. (".peed"), tOeIIine.{fl'llok vI\SCuliti. ClCCU ..... but is nlJ1!). he .. n,ne oln and ephedrine. 2.9.4. Fibromuscular dysplasia ._i.ted A vnculopa thy (oogiop.thylatrectilll pnm anly brllndMs o(!.he eoTta, wltll reo.1 nrtery involvement ill S5'i11 of caH. (thl. motl IlOmll"llln .Itel.nd eIImmonly wIth hypertM5101>_no" di_1e hI' an i.otldenee of ~ 1'11> •• nd .esulls in mui t ifoaolll ...... rial cO"'l"lrietions ,"d i,rne"""nirlc regiol'l5 of.oeu~,n.l dilatallon, The le<lOud mostllDmmollly involYed ,;UI;5 the c:&n>ical illt.emal carotid (priml rily nenrCI_2), with fibromu!iC1.ll&.r dyspluill iFMD) 'Ppe.rinlon l \t.ofearotid llIriograml, making FMD the &eCOnd molt ~mmon causeofexLr&crani.1 clrol.id 'UI~. Bllaleral cervicnl lCA involvemrnl O«UI'II il> _ ~ or~. SKof pal"nla wi lh Uon)ljd Ji'MD haye renal FMO, Patienls wilb FMO ""ye an Inc:rnted rUk d ontu"ranill I"'U.,.."" lind neophu;ms, ami ~ probably II higher ri&k of tllrotill di56edion ETIOlOG Y The ItCtual etlolo1O' remains unknown, alt.hout:h«lncenital df~ of the media (muscula r layer) and ir.lem&i ~a.tk layer oftbe sr\eria bar bee.;> identified which mIoy prediSpoII8 the arteries to injwy from otlll!T"o<riw ~I-tolel'llt..d trauma. A lulh ramllil,1 rftl~ of strokes, HTN, aDd rnllTai..e have supported th~ ,,,""lion thet FMO is an autoIIOmal domillant lrail"';!h reduced penetranee in mal ...... ANEURYSMS AND FI8ROMUSCtJU.R DYSPlASIA 1'be reported incidenNof aneuJYSln' with Fr.to'" I'8Dg.. from 20-50'11>. TabS. 2· 14 PrevIOU . CI", .ymplOAW III 37 of aQfloc:rlflll' FMD'" PRESENTATICJN M <>It f)l.lielll.f hn,·. recurrent, multiple ftym plOml Ihown in Tabl~ 2-14 , Up 10 so.. of patienta p......,nt witll epiaode. of transient «rIb' ll itdlemia or itlr.,.ctlon, Haw"ver, FMD IDAy also be an incidontal ttndi"l and lOme o:a...Hhaye beenJolkrwed for IS ye.1'II WIthout recurTt"nte oflachemic .ymploml i~tinll thll F MO a,sy be. ",1~livel)' benifn condition. Hud lche. are ronunollly unilat..nllnd may be m;'" taken for lypical mignllne. SynllOpe may be cauoed by illvotw.men~ofth" carol.od .;nUl_ Homet'••yndtvme Ottul'll in _ N ofCII ..... T.waw ehanen on EKe DUly be seen ill up .... on.thlrd olca.sn, and m.y be dUI to i.nyolvemtlllto! the roroo"y arteries. OW;NOS<S The °l6ld·.tandll\l" for the disl_1I orFMO i. the Ingiogram. TIwo th ... a nJiognphic I)'pes of FM D'" INI .hown In ThM. 'J-16. TREATMENT Medical t hHIPY Inc:luding entiplat..11I medicatloll (e." 45pmnl " .. been TeCOmCMndecl. NEUROl.OCY Dil'«1 5urgic~1 trealment;. JW'oblem ridden due to the diffi. tultl_uon (hith ca rotid . rury. nU. the ban of th. al<uU), a nd the friable ~turt ufthe ~Im making anU!luno,,,. or o .teriOI~ my d o.ure difficu lt. TT. ... lum'na!8ngiopl.. has achieved 110m!! degtH of l uo~. Ca rotid c .... mou.linul •• and a rLi!tiall'Upture ha,". been r.ported .. complie.t/OtlL T. bl. 2·15 OlfMO t,. 2.9.5. Miscellaneous vasculopathies " I CADASIL t Key futures clinical. mignllnl!a, deJ;1anua, TIAs. ptyeh,uric d iilurbanc:eI • MRl: wllilt ~t"'r abnormahtiu • autosomal dOI1l",an~ ir.!w.ritllr>Ce • anticoaglliantl controversl.l. ,tneBUy di$CO\l.~ged An a,,",nym enr ClTebrlll .... ulO$Omyl Dominant Artuiapll1hy with Subeorticallnf· a r~.nd Lomkoe,""'phalnpath,.. . .... f.mililll d;~ with onnt in ea r;y ad ... 1thood (meDn .ge lit omet: 45 '" II )'nil, mapped to chroflllMOfDt 19. Clinical and neuroradiglogic fca IU ' " IN!limilarlOlhoIe aeen wilh mullipielubcorticul mro~U from HTN, ucepl t here II no eviden~ofH1'N. The vlISCUloplltlly i5 disti nct "om thot Ieiln in lipO/lyal'nasis. ar1.eri000erosi••nd amyloid lI.IIgiopal hy. and cause.s thiek. ning of the ~ia of lepl.ol!leniniNl ""d penOI1lI,,,,, anerie, m-.uring 11)0.400 "," ," dia.nw!Li!r. Clinical inYillvell>ent: rerurnontsubmnkat io rlln:~ 184~), prawns;v"' .... u"pW'5e dtmentia (3 1"), l1IigTaine "'ito'! li' UI"lI (2'~), a nd depress.on {\tOOIi-). AlIl}'mptomaU( Dnd IS'l\ofUympt.omalie patlentil had prommenuu bcort.ieal whit..·matterand basal ,anlll ill hypennten$it;u on 1'2",1 M Rl. Trutment: Cownadinf>is ua.ed byaome. 2.10. Vascular dysauloregulalory encephalopalhy This H<:tion encol1lpa$5fta IrouP Dftnn!phalopathiet that ma,y be I1'lati!d to dl.". dered vai<'u lar autorqulatioc-. Et.ologies ami find il'll' iodud.: 1. tho~e due IO ,~ ...10Dd prfIMure .~vationa: imqilli "Udlellhow I)Im metric (onnuentiesionl with mild ",a", ~tfect Ind pII t.(:hy "",ha_t primarily in the , ,,beort.iCIII wtul.e matllt" of the awwJJl!!la"' {pouiblJl baaitule of limited .ym· plthetk innervltion in the ~rjJlLcir:tuJ1IJ.lwl} whie'" may "rod"," coniCll1 bhndMM .... hype rlf'n.;"", ""'c"ph.lop,thy j " may Ott'" w.th IIUIl ipant h~TUn.ionl 8 peripartu.,,; lluociauod wit h ferebrlll ed'm.'", on"", t'rnponlry, but (pi"manen~) infarctiOM IllIG OttUr L may p,_n l (' .1. with blindnus) du tio ~ pre",. lIty complicated by p,.edlm pua Or eclampsia" 2 rn.y develop 4.9 dlY" pO:lt.ptt rtum . nd ,n',)' be e_l~tt-d with "._pMm" 2. .. C cyc1Ot1porine lO~idty uremic tllH phalopoth,e!o: imalJl ng iI"ditsshow multiple ..... or.ym~trieede,. rna in the bani ""'glie. with Ie\'ert _ _ devdop11\i (oaollnfam. WIth or ",i lh. 0"1. hemoITha~ 'rh_ diNOl'derf lire asliOCiated w,th elevate:l 6tJN .nd im-tud ..: A. u•• miD 2.10, Vlllnl iar dYliulOregu latol") eneephalopathy Ni:UROLOGY B. glomerulonephritis C. hemo!ytic. u,..,mic . yndmme (HUS) O. thmmbotic thmmbocytic purpura (TTP) These pIItienUl may present with headache, seizures, mental status change.s and f.,. cal neurologic deficit. Intracerebral hemorrhage (le U) may occur. Tre a tm e n t Disordered autoregulation mandates tight control of blood pressure to avoid hyper· tension to reduce the risk ofICH. 2.11 . I. 1. l. •• S. 6. 1. S. References en.u...... Cool... """, o.ff.~.'i.1 di,,,,,,,i, of ...• "'<0'; .... di,.,.,. •. JAMA 1": 30111.6. 1917 FI.ml.. I(C. A"' ... AC.i'd<TS<. R C:O' ..... '..: 0." """,0<16 ...1,,,",,,. M 01. c~. Proe lO: IO')l·III7.199J. l"J>O"I>ki Z J. 0."' ...... (""'''' <..... II<1II .. SUI ..) JAMA nl. 1719·92.1987. 1'0'"1>0' p.r...."' •• M. R_,'M ,1. . . . .1, Orl.ri · • '" .. hOopi .. II'~Qkk1 po"""", O.1«>m<J >nil pl<' diclOr>. J "'" Cm."Soe .2: I!O')·I~ . 1994. 1'<,...... RC: Ae.,""QllfII""".I .... " Donl mi_ iI I","'mo.,io. r..\V811 M.d92: 141 ·1 . 1m. Hu le".C M.I'.MI N L. C,.m B J. E.aI.".,. oJ,*" «MI1bopoin ((II" ""' di""",;, c l4< ....... ' ... ,!.«h N,.,0149· 28·ll. 19111. SP.T ....... IO RJ.O'''I'"'''''OC1icldoftnln tMq>sY '" ... """"',....,..., •• d _ ". N..... ...... '1'41 ·123·)(1.1'191. Fan,.h P ... . _ I 8 . ... >Wo<I><. ,. ~i<:"''''i'h bt... I."""",, A >loo:Iy of III po,loN>. No",oIo&) 4): 1611.8) . 1m. 1o."".. 9. W.l<hI(M A.U.i ... SR:M ...... ,,'N<I. t«l .....h "' ,be " . " .., .... ''''' "'",",11.",,1 hell<l","" 1O<ie!y d ... i(,o,,,;'" 01 h<ad poi . . ... rth Stu to141' 451.62. 10. ~J II . '''' W, T.... ""' .. otmi'.-l ... LMn1 JJ9: IlOJ·9.lm . ~ m"'lk I P.(;_,,< DS .5<)'lxIkI M E:a.".. 1.0<" .0000000io .born •• Mell h<Mk1lo: N _ '2: _ Il. ll. I'. " •. 1915. q..,". L..opIti.M L.GoI<IrnG S: l\a$'I" .... 'Ym' ...... , ... ... iewo()Oco>c> . 1ImJ Db Chlld Ill: 111-!1. 197' 0;(;;.,... ••• , A I. Du.bot 8 S· E~.ttJ inje<li"'" of ' "101"1"" bloc<! leo- pooU"""*.po",,"te _ . "''''' . ......... _ ......1,.9; 16a.71. 1970. Stol>o<h .. J. R;bej", .... Lc (;.,11ou I L. .. "'" Epi. "",,,I blood PIlCh i.,he , .... .,."'o(po>, ""'tl p!I"'" ..... """'''''' A ""ubi< "...!y. Htad.oo:hO 19: 6)11-1. 1m. 1..>II«JW.B,.ndlC8,,... lumb" PO"""" . (.0",," 301): ",. '!9.\ lle<' ... I. \>I,,.., i,,,,,h<Mk""""', n. ". .." • .. n. ». ". ". poo.I"')'tIQl"'" Ioe>d",,""- lu"<b "" •• 0115: lOIS· 170.'971 . Se<h ... , H. Aboll: 1'0<"'100, 1.....".. .. he""· KIlo " ..,«, wOlt <.ff....: h . I... .". ... MII 4<"""'" "",,""". P... I. C ... Tloor R.. :z,o, )(17·11. 19JI. ". 'I. M.m>s ~ • R. i".oc...;'1 bypOltn>_ ...... ,Ii, "<."""In. J N",,01 S"' . ... .." ,,"y<loi.,., 06: , '49.51 . 19SJ. n. 19. Mil<hell S L.K ..I,O ~. ~i< 1 DP .... QI, The~· mioloU. ,,,.0;.1 <llara«<ri"" •• It-.! 011.",1 hillOr)' 0101"" .......... _ t<ti<le ... ",;'h . diq:_io .... Porli"'o,,.. ~i ...... J Am C.,blt So< 004: )9<·9. ClwtUc I(olk, II.! C.SOI"", 0 E. u"b."" ...... .... . llorit~ foe.1>< m. ",,,,,,,, .. oIhrlil,,*,', di<at< .•~ ....... ",,004(S"1'P410):S}·n19').O. NEUROLOGY .Y.,"".... ..,.·.d....... m ,. F'oo<. C M. ""'1 0 W. Sch<ittbot. L.., ai, N,"' d~ lOt "",Itlp!< "10",, .. : (;!>kiel;"", • ...... i< .. Hoe ... I", <e$<lll<h ptOID<O/o."". Ntutol 'J' Ill·) I. 19n S... "'",. I W: Mg" iplc .<I,ro,l" Upd'" if> di....,. .;, """ ""itw .... !"'>I._ok r",lOn. ~ l.yo CI;. 17 ,- UnJ"""J w. Ball.,., P. TttNdJ W•..,11.: ClIrQoi< porki.IOIIb m ,. hom.",,,,", '0 ' """'''''' Qf ""pori, di,..4IIIl"l ScI<e« 219, 979-10. 1911). 1..>111,1. E.I...<>wIOA"' : """i • Fi ... 'o( ,..., pano. N Ell" J Mtod JJ9: 11)004.'1. l'11ll. K" ...... o M ():~ ..... _katp.ol.,·IO ).. ... Iote,. Ae .. Nmtol S<an<I 71: 11).19. 1915. C,idel\bcrJ: Pl: _ .., ."""".." ..... _ j c '"'l<'1" S.........,,,.., lO: 91).7. 1m . 1..oJ~1i. f O. ~ .~ S C: Orr-lIlol ,be <linko! """"" of mglllp', ..I<l00;': II;..~I" of on i/Mcm • • liontl ...... , . Ne~ -46: \107·11 .1996. lI;"'i' ~ R A. Coh<. I ... . Wei."",,\;.(;o"""" B•., QI •. "'.....""' .. 01 mgl'ipk ..:lolO<il. N ~"&l J "'«I ll: 16001'11. 19117 . R""I .... L 1'. (06.) Mo.riIl ·. 4..4 _ 01 ...... _ ty. I,006 .• Lc.> o.nd Feb\.&<,. """ .... Iplli•• '9fl9. k .... T S. R.......... P.Il<.u·N;'r..~ E: .... ""'j. ..... o(lrico"'mal .... ttJp .... ilh m,ltipl... Ic<oois. ....... N..nII 6l, 182-9. 1912. "iI,ppi M. Honr.. 1d 101 A. M""'-y S P. " Ill, Qool1';,"i"" lni. "'ltl laion _ !'""lie.. ,he «>Un< oIeilrucaJly 1"'111'" ","""i~of "",I'ipk ><1<"", • . NeOll"OKlC ..: 6J5-4I. 1994. "',OanaJd W I.Co>m~ A. Ed .. (; •.. <>I.: R"""",· ..._~i""""i.<';'m."" ","~;pk «ielOl'S: (;,tdel .... I"""'fIe i.""''' ..... po .. lonthedi ... -.I ..... "",j'ipl< .. Ie"";'. A •• Nmtol SO: 111·1. .yndtome. Cu. H.GoidI,.i.'" S.R.,k,.It, """ 10 "<'"'.''''' IQ79. 16 .,.,,..Il>0l,,, Spoo,._ y,.,., 1(, 1JpJ... on """""",·s <Ii ...... Am .'.", PhpitiM59:1!S5.6J.I999. 1(""","'lk. D.l\onotoIi E .... ,-"nsf."... L O· P.IIi· <Io«Imy I", P......-·. ~lsu;c. C ... _p Ntu .... """" (6~ H.I996. D•• i,CC . W,UIan» ... C. MMItoy S P .~",' , CIwft· ic pr.rI;_~m 10 i"", •• _ . i.jocrion or""'p<ridi". .... """... "yell,.I., II .. I: 2A9·SO • Proe6ol. S77.J16. 19f19. aorklloff. f;lippi M.Millot OH ... n1" Compa" "", 01 MR Cfilttlt .. n", "",,""IO. IO!'""licl .... •• ,.;". '0 <1 .....11, ""nlli.. mukipl. ",,;""";'. a,... 1» 1059-69. 1991. T .. """ ..... R...i,. .... M ........\1 .... "I" boIOIt<1 Ge· myol ... ,'''' '1ool""""" c.,.,.,...;_ <>f dlfl...... MR ;""S'"' rnl<ti, 10 prtdic' """.. nlooo <o.HIIi· !mo.i., c.,ly 4<fi";« ",.hlpk ..Ie ....... AJSR 21: 702.6. ~. ". s.... an I M .II<>II..,Ow, B.... ' H L • .,al" M'a' .. lie 0"DQIIIf><0 i ""Sinc afI!I clinical .. loIi"",hipo ,. ",oUipl< ",,"""i,. M.Y<' Pr .. 6l: 17.·... . • cu. 1917 """"'[i. A I. 0.«", ... S. "..Ips C E." aI. ThO 2.11. Rderentea 00- " ".,V.,. aIIlI<) 01 mlsn<'"' ~ " '" ... " ., .........a 1/1 "",icnl' .,,,11 ''''f'O<!O<I ",.111fI/< ",,10_ .. J.v.tA ll.9. JI'O·'s I. I"J KoJdC. Thcorp< I W. ~A I• .,., s,....1 corti i/uV •.• Io1Rl ",I'r ...kI.am) Cl)ill_ r." III"' II, F, .....,.. '" "",h.p", >tJm>oj .. /'1 •• ,oIocrH. 16:32·1, I"1 ........ D L. u..... E 8 ' M ",~Ie ........-., ",,",in. ofthtbnin ..... IfII... A""I ...... M«lIOll 001- «"" l4.I~. ",_i, _ ... ,'''11«_" ..... "' ... ""............ L>w~I.M.I"...-DE,CNS;S~mI_ M• 'I\"....... i< ~ 1""'1'" of i.. ""my.II ... '"I k<ooo ~<1I""""'1oIogjI 001111); 9S6-9. :!OO"l. D"" F A, M, ... !oJ ~ ft. D'JVurd," J 1.« .... AICi.· r"1 .... ns< 0/ ....1, mlln poI;, ......iII> clh>leoll) 1... 10<001 , ) _.... Then*oftola-'- OfI MJU ,J Nt .... "c.""",.. P,~cII .. lr ~ 70: J9I).J . lIlOl . Ftu>J .... MS.n.o.,.p_[ J,O', .. ~O . ., Ill.: R""""""ookoI ..1t>dM<I ",...-pIt>o1 nuol .....y.;, ", "" d, . ~. 01 .-..IIlp1o Itlcroo,,_ ~ _ ....." ............. A«h /'Iou",I.:!', S6.l-10. ""yy G 101 , 11<n01 A C . 11u1... N r ."".. N<uJOp1_ dI_ _A"ponof""o ...... /'I ... roIocI'H: 1()(\oI'. 19'12, e.",hno,o C. Lao:onolll ... L, M...",,'" V.•, . 1· A ... ~Iod lrial of .. I"";~ ,. "")'OU<II>Inc I.II<rai H [nc1 J M«I 1>I: ~". 1990 . Rl"' ..... rOf lnIJIlIInIjIi'Ii< bocnl \Cl ..... ,. 111«1 Lt\ . "" '7' I 1)-'1. 1m Loo:oomb:" L. &:.0.; ..... G. G"lile, ~ .... ,_ ~ i "'· <0100 A """...·lIIiolil .. ~..., pi..,."""",, • • ,""'Ied_..... <I""ym >m)<lfl<>p/Ii< IlI<nl ><1«o",(",l.$). EI .. ' . ...... pb Clloo r>iou,opb,oioII 97; S6I.I9'lS(.botno<I), A~AK,"""'''' D GW.1(1tI>1I R• .,..I" c..fvo;di>I""''' ofCu;llol • •e."" .j ....".,.., MA N..... 01 J. ~"'.I97 I. M.o&11 1 R. 0.-0.1< ..110........., ""m)'<li ....,., poIyollClr;;"',,,,o",,,,"'~" AM" II .. ""' .... lll~. 1991_ ~>I1 .... "",,"1 W .C ......."'" O. IJ"m.1 W•• ,,,/, T.......... '" <Jo .... k ,.n ... __ .,.<l<m,.I_i"l poIY"'"'",""",Y ",i'h c"Jo>por ... A, J "'.uo .. 1'1 ..... ....,.. "'~1.1'l'6O' It..I.;, 199Ii Gotwo K C. Ropp« A H, CI'''' e O• .,.I.: T... ,_ mo.' or c~,.",;. ;,,11 . ...... ''''' <10",\,<1 ..",., pol,. ~ VII'" ion.ff• ......" 21, 1'1 ... ",,011' loO: JO_ 1. 19'/1.. G'II'!I ..... Ilar7tS~ .......... _ Tn,l Oro.p, Doo · or _ .... er"""... """"'" 1<"''''''' >. " " lIIHp!i..:l IrtII "' iIo!,...-., .....Il}''''''''''''''''-,. Gu,tloi... 6ar.t.,ncIrDm&. IAJouI II I. lU.-?O. I'I'1J . " ". ~ ~ " M, .. ". k'",,'" I c. OJ'''' M L! M1<lIrio...,J '":f<'~. I. CIlnDl ..... n>IogJ. 6>1:" ..01. 8 _ I~", ~J. (ed,.). Hupo, <h<l Rm• • II"..."'.... . 19\1" PI' l.Jl _101 P II, Acw ~"""'"'" "'IoiopotIo,. o\.r<lI NrtonI9 , 111·9. ,9&J [p'" H· n .......... "),<1"" <\e<I;Iy •••. R.I""" '" ....'" J "" ... So<tJ: 63" , IlU·9.19ll t.lp<Do lit. " _ol lll 0: ~""I<''''.'''''''ml''"lopII1II, !"oJul", A IolloW-"P " LId, . Ar. h N... rt>I 11' !H·1.'973 Rop,)c. A II . ro...~ .. '''' 0<;, Th< ~,,6f.., tnd ",100""" 'ra","'", ",),<.h) boWll on uriy A"" N",,,,I.· 11·9. 1971 a."", ... M. Ftldrro,. S . AlI"~. ...,.. .. peI_;', I ",,~ one! <II.",,;., ..... to<.. 01....... N... rof"ll' " , 966-71 . 1981. _ O, W.... II . KIo .... AJ, . r<LCT"'I' ..... " O. W OkuMoV' ""'_D~C1o"I<WPI'"_ ~_ ...... JOPI'''''' .. ..... ""' ..... Sca ... 7J .... ,,1M. ""'_'...... 2.11. RafBNmce5 oloTri_,/'I. ~E:I"" ........ I .~" """"""'IOII&k>rnpllo<"",., .,._1""""<0"'" S."/'irtonI 9-I~7 ' . I'I1 • • RIItittIJotIIM S. D<lI<"... I: A' I'IIIn1orouy _ ... &hIl .. """"'''''''"~'''''''''''''' '~)''''' lI1.yo C ~" I"ro< 11. 601~ . 19~1 , 01......., V 1'1<.. ~piNI n..w ......"""',.-.Iock.ol """ ..."n>IaoJ"'kl&I<ll .....1".,..... in 11>0 ,,;.""" ....... "'U....... "'''''~....10 SIu-. <Old ..... , IOS<IO. I9I1, 5 ..", D 1 .~1iI5 A,SewdIC,,/QI ""'.. or _ _ , .,~" c)'<l<>opormo. Acch r< .... 01 .9· 106J-12. 19S11. !'on 1 O. 6toud>omp H I, R.y.",.,... '",'"'_., ~ ""'<04' p.olllDl<>J.it-• ..,.,ln ","",>I<Il by'....'.. .." ........ ""Y~).IIIn<l"," . Rodlot:r>phI<1 II . HH'), 1991 . Sd\o<! .. »w.e...,...,.,., F S.Cool.ll.. MG. .. ttl, Dltroaioo_ ... I&IIL.... irnotit, dil<'liml ..... t>o<_ <)IIo>IO>ic 0lId «_ 11\. ",,1<10< "",., . ... 1<mp\i. ,S......... n : IOaz·~ . IWI Oucb c.,..,p"md ..,..<10".,....,...... ",,.,_..,._ 1.«10,.,,,,. ~ by M..... _ ••ObsIeI C ~_ 60: l29-l 1. "!IlI''''' ". . ' " " " " n , n. ~ " r..I"""",,,._. J""', """ ... """"go.... s.rc._ " lll-'Xl.1 9l16 " " ,.ri. " ,«...,c.., ..... " ..... plool"",)'<ljoi.1 A .. oM!) of I I 1><,...... Ann N< ...... U( I). IJ..n. 19IIJ ,.". ". 1f<lw>IoI... ". ". M. )(0: .... J J ~. I()<"OI '"III<)<"i" .s.r.ydj""'I Io. ''''''' oftht Inlo' 1........ "''' . .... ~pIo r>f1111 ow MRI . f..,UI< tnnO, .... 10)'<11'," J C ..... p'" A..... T....... I' 6O'i.t.lonl . 0.-. .... " C, B_~ V V. Coole S 0: 1'01,,01< be.· .r""01 off... Dr"'. . . . . I v ......... 1honoP)' i. "'."<I<m"'".. 'I ... "'.......... 'n"' ...... m~ejktl N<u ....."" JO, »-6. 1<teO S..... B I , ItturoW>ol. 10..1010., 01. _ ................1 .... Am.f\I ...... 4l; \I09-I7.I'I!:'i. n " " ". _'II. [E, "'UIOIIIOCf;I"', '9Sl. ~ .... F. C. Gol< ... S t.D_ ~ M.".I. 0.""" potor-""'" ""'.!<>polhy, C..ur.1 ""1.0"",,, . ...... iltd. A,," N. u,oI JJ . ~n~. 1m Moon: " M, It. Ntun>lol'" '''...pll",,!1on< of,"",.~'I .. An. 1'I<~ ... 1. jS~7.19n . Sol.""", C. COOl'" F. So,.d' L. .. ,,/, PoI1I"YlI' ".,h<~ -o:c!l_riW. N to.&1J M«l :J.07· l61·11. 'XK1z' SaI_iC,G"'-IS " .O'f. ILon W 101 , •• 0/ Tho "",\dtru 1!~ i< ill 01",._ M..... _ : A~n""l ........ i.,."Y<I.. />OI ..... A". In ..... Mod Ill . 19J· •• 19II) . 1.1.. _ Ii: D, Mi<IR<C I, SoIlord 01 •.,0/.. T",,,,,, 1. 1",,1cImc<_ OIiIoI.. ll'fO'C"II'iullof"_lor, IOn'" ,. 0tntw>0J 19loO·19t1. A.. hl1lb: II"'.," JI : 7' S~. I 9U o\lloft r< D. S,,,,,,,,,aJ S iI. P<>l~",).I, ...........1Ii<o 0lI<l ....,.,.. >rI<riIlt, M<4 C1ko N 0\ ..... 111. )69. /10. 19". 11.001<.0 G GlM' «II (.. "'1'0'*1) ........... Rbno .. Ob 0;" N II .... 110: 199-4D9. 1.9'10. HoIIS.llo<>d<oOG: h ,... "",01 IMO)'biaply ....... _ 7 ~I .y. ClI........ W 7'lJ·O. IWoO . c...lu RJ . Plnulotl R.IIJlId<l GG"'o-iJ ,.",... "",I ."""PI'"" .)0lIl ....... 1• • "'" "II \lfmI'II"Il) ""....... r.: ....oIoQ ]i, W).9. 1981 SIll ....' C.tt_O C: G...... II on ...liI"';u, lowtt)"AootJ" ..... i_ioo.-..,f_) 01 """""""" "'. "",,"1M""'."""" ""'" A"~rlilo 1t"""",C1; IOIM.JOOI 0 ......1 D.E ..... , L S' O'-iooool ' ru<m<,. 01 _o<Jo<;n' .... ldorly Mrd CIloNA_,lS. i!61 . 11. 1"' Kor-oco. ... o . 1..>:00 N. NW!I.,.;n 1': C"T Ii~'" '" .. tnpoo>l ....... U' A .. portor'''''' .... 1'1"""", rod 11: J7l. 1'116. Mco...n.tl P I . _ . G ... . "" i l~:O It. .. uI c..pp," .......... <>f.,..., .. "'""'Y. """'y. "'"",.""'. T.,""...I....,.,,"'A<I;"~_, . 0PI>- ' hlll""""'c:7 9], ~IJ..)O . 1"&, A<I>h. A A. Lie I tl G.It 0/" Iittw 0100, pt< . .... , -,i<.,.,~ If."""",.ff<d u...1>IDpo) 't."""',, NEUROwm· •.". lol'" II l.F....... 101. Co-rd>r " y""",~,.. . »o<_ a....cT,.. H_OO IbnpDM.,,~'.· ' ''' ". 1<01 . .""", ~ ...."'.. ......,.. A_ L....... rotod \11' 6U-1II. 1~11 . Sol........ C. 00iIrC1S E. O'F,IIoo W rot. II 1>/ ' fit...".,.., '" pOIJ~""p:o _ 1 0 0hn<IMd - , .. 101'-"". 1910- '991 ",••kio_""", )I' »9-1J. I " , M;:~IoITI.M_flA ""..-' ............ ". r-.,.;" 11'-«11 ("~)""""d A... 110- U. " U U W " ..... _ ,lIJ.. WI~I . 1 . c...;,,;F.WoarM C, OLIrieoi l.tltoI·. IitJ""""rl< ~ ..... ooodC·_~ .. _ " , .. "" .. _ _ af_ ..,,,"' ...........,I. roI,· ",",," rtorolUlico; A pr(IIpO<I ... i",_.• , .. "", _ Att~ IIo_JO: L'J." , JOOO. ..,'o!t:a._ A Io.,",~"" _. ~" 22D-JI . 1'lIJ No .. _",.~ M«I ........ .It. 1S-6. ,,,, ~TlU,_'j.l .fecJ AS 1_"111" " ' ' ' ' " _ ......... .,. ............ pocoi ... dI.opDI. ""_~ N6UROW OY .. _ _ A.. JMooI 1. 97· IM, 1981. 1100-6. 1m H_ A N. IIWC l .ZnI« DL.,oI. F,,,,,,,,,,,,· "'~~''Ill»l.<I ".. ......... <vOUd......" .....,. • ..1III.....,......_ . J .v.Ll lj~ _,_".0", "'I~'''1' AJ R 1:16.9»-60. ,. , ..., l.L:rlc:oooo 1( . rc......,..,.""'I.. d,>pL.oI. ..,11<>1'..... ..... "'" 1Jnioo· ~ .......... 00 d! .. • ai, ..... 1I<.. ,it..~ra<I<n., 1<o 51 ...... IJ ' 6-.31. M"oI,1'" II L. n_.... L"u) ;p.......... ,"" koo ... III C..... '" '_1'101 II.. oIiou .., 5" . 1<0 HI SH, Im . ~ " _loJf_.".,.. d,.plUl. O'I>oroAO ......... '- ~ i!::A"fJOI'''''''''' '''''' ''''''' "'Ofm... ....s .. S'~"" ·' L7·~.1977 CI\oMI, H, Yoloodi 1( . lbo-Z" ... M T" ."" Cion,· dl"""""""or._II· A"""'''' ..... 1.....1i.., ........ 1<16: 9~9 , tw,o " 3.1. Surface anatomy 3.1.1 . Cortical surface anatomy Figun 3·/ shows som" importanl""rti~1I1 surface landmaTlta. This may be h~lpful in corre1atinr with MRI to detennine the location orl~()n!lL. The MFG ;" usually more .nnuou.s CENTRAL SULCUS (Rolandic fissure) than the IYO Or SFG, oonnec~ to p~...,entraJ gyrus lind (t oA.en the viII a thin i!lthmua. The celltrsl ,uJcu~joins the Sylvian fiuure in only 2% orcases (i.e. in 98% of OilS"" there i , II -aubcentno!" i:'Y1'UJI) , The ;nte'l»'rieLaJ ~ulcus (ips ) I"parates the s uperior lind inferior parieUli lobules. The IPL is composed primllrily of the AG lind S MG. The SylviaD fissure lennina te.'! in tfle SMG (8rodmann'. area 40), The .uperior temporal sylow; tenniollt.es in the AG . Figura 3·1 C",ebral collical ",lIace lIrlaLomy' BI .~ Btodmann'l" ..... (~~ s... fllblll".,.rod f IllW3·ZlOIlbbr. ¥lotions, Brodmann's "r"ali Figun 3· / also identines the tiiniClllly significant al'" ml/.p of th" cytoa reb; tectonic field~ of the human brain. FUnct,ionw aignificance ofthese areus "all ofBrodOlann's (8r.) ill /1$ (OUOWI; Table 3-1 Cerebl1ll sulci pr«>tntral SlJeus poSI<&rlIIaI sulcvs ,a, if, SUperior,lr!IlIrior lron- ,.. ,~ ,,-- Sr. areas 3,1,2: prima ry tOmato8<!1l8ory corteK Br. Hreas 41 & 42: primal)' audil.ory area/l (tra"""enle ~~"" gyri of He.!Chl) $ 1.8, ,La superior, iolerior li!fTI' Br, area 4: precentral gyrus, prim8/')' motor cort.!" (AKA ~motor ~ tr ;p·). lA;"e conc~nt.rntiOlI of giant py. lnwrpI!rietal sulcus ips ramidal cells of Betz pre«Qpital notdl Br. area 6: premotor area or supplemental motor area. Immediately anterior to motor strip, ;t playll a role;o CI,)lltraJateral motor pTOgl'amming Br. area 4<1 : (dominant hemLllphere) Br oca'" a re .. (motor speecht- "'" " 3, Neuroa natomy and pbysiolocy N1!UROSURGERY Sr. area 17: primary vi .ual C<)rtel< We",;" ke'. ar .... (lan,guager": ,nlhe dominant hemisphere, most of Br. area 40 a nd II portion orBr. are~ 59 (may .. 190 include _ tJOSl.erior third or Table 3·2 cerebral STG) Br. arell 8: the strilWd portion in FIf;. ey~ tield ) irtitiatc3 vol· untary eye movements I.(l tha oppOllite direction "re3·1 (frontal 3.1.2. Surface anatomy of the cranium CRANIOMETRIC POINTS Craniometrie poin!!! in Fillure 3·2. Pterion: ~gion wherf). the following bonOIS a~ ilP' prollimaU!!i: I'rontal, pari. etlli. l.eroporaland sphenoid (g>'1!IIter wing). Estim ated as 2 finger-breadtlulab(.v" the ~ygomatic arch. and a thumb'. breadth bmind tbe frontal p~ofthe ~y§l:l_ matic bon • . Asterio n :jllndion of ilImbdoid, occipitomastllid and parietomllstoid . "t"us. Overlie. thejllnoli(lll of trnns"erae and lrigmoid .inu,;es . Vene.., the \.Opmosl point Ills skull. LlIlIlbda : junction of tll .. 1ambdoid and sllgltttli sutu .... s. S t e pbanio n: junction oftbe coronal ,UIUreand the 9up('rior tlllnporal line. Fll1 ure 3-2 Cranlome.rIc pOOnl5' CfBlllailltll.vtes G h.bclho: thB """" for- AtJtiIt!VJi!IQm; OWS ,. UIOtitCI w'ilg '" ~~ IIOoJe. Q\ " ..... 01l1li r;uward prtlject.ing painlof tbe Iol!. is " lambdoid SlJIuIe, sU ",supetiot II!IIpOI8i line, ZVO. z:ygomali:. forehead lit the level of ch~ N;Jmed boneS awe~r irI.~ vppeI elise I!1t:e1~ supraorbital ridge in the midline. Opiathioll: th e p61terior ma rgin of tile foramen magn um II' the midUn e. 8 l"fl gm 1O: tbe junction of the eoronnillud ugittaJ BU1Ul'@a. are ~ho\lln or A. l~.~ r~octioo ... "" .... ~ <elitbJy I.... U.. d 00 . "",tuol< """,,,,,, d~n.. l<tdlv!du.1 Y''''oblll..,. In I", euOI 1(I<IIlion; in Mltr lOpeno"" ",...;"",1 brain "'Mction.... ith ",i . imol n.k.,c oph..i. , 1«1>. niqu .. "o<h u inl,....,I"',..liy.. bl'llin ",. ppm" Dr 10'l1unc I'or ph _ _ ....,1 on lo'nop."n;y•• 0.... ii •• 1 SSE'" ohould bo .... pl.)'d NEUROSURGERY 3 Neuroanatomy and phY8loiogy .. RELATION OF SKULL MARKINGS TO CERE8RAL ANATOMY Taylor-Haughton IiDea Taylor-Haughton (T_H) line s ca.o bf! constructed on an angiogram, CT scout film, or uulllt-ray, and can IMn be reo coll8lructed on the patient in the O.R. bned on vi.ible external Isndmsrk$'. T-H li""l1 are shown 1108 dashed lines in Figure 3-3. 1. F't-ankfurt plan e, AKA baseline: line from inferior margin of orbit through the lIll.Iltt ma rgin of the exte rnal au dio tory meatus (EAM) (as distinguished from Reid's bn&e line: from infe_ rior orbital margin through thec~lIj~rofth e EAM)' lo llll 2. the rustll1l<:e from the nasion to the inion is mea'-- ~"",., tine su red 8"rt>55 t .... top of the CIIIlvsria and is divided into qusrters (Clln be done aimply with a piece Figure 3--3 TayIor·Haught"" liMs of tape which is then and Other localizing methOds folded in half twice) 3. posterior ear line: perpendicular to the bsseline through the mastoid process 4. oondylar line: perpendiculsr to the b8.$eline through the mandibular OI)ndyle 5. 'I'·H lines can then be used to app,oximste the sylvisn fissure (su />flow) snd the motor OI)rtex (alao su ~low) Sylyi an fissure AKA lale ral fi ss ure Approximated by a line connecting the latera) canthuB to the point 314 of the way pDl;tenor along the SrC running over convexity from nasion to inion (T·H lines). Angula r gyrus Locatedjust above the pinna, important on the dominant hemisphere aa part of Wernicke's ares. Note: there is significant individual vanability in the location'. Angular arte.-y Located 6 cm sbove the EAM . Motor cortex Numerous method. utilize externallandmarb tol"""te the mowr strip(p~n tral gyrus) or the ~ail.ull:l.m (Rolsndic fissure) which separates motor strip anteriorly from primary sensory cortex poIIterior ly. These arejust approximations ain<:e individual variability causes the motor ~trip to lie anywhere froro 4 to 5.4 cm behind the coronsl 8utUre', The centralaulcus cannot even be relisbly identified visually at 6urgery1. llIethod 1, the superior aspect of the motor cortex is slm08tstrsighL up from the EAM nea r the rnidlioe method 2' : the <:entralsulcus is approximated by connecting: A. the point2 cm posterior to the midpoaition of the ArC extending from nasion to inioo (illustrated in Figu.re 3-3), to B. the point 5 Clll straight up from the EAM method 3: uBing T-H lil1f:s, the central ulcus is approximated by connecting: A the point where tbe ' posterior eaT line" in tersects the ci",umference of the skull (Ut Fi6W""1! 3·3) (usually about I em behirnl the vertex, and 3-4 em behind thO! COTOnal ~uture), to B, the point where the 'condyla r line" intersects the line representing the aylvian fissure " 3. Neuroanatomy and physiolOiJ NEUROSURGERY me.Ulod 4: a line drawn 4S' to Re id's ba(.e liJ:,e starling III tha f le.non points in the dJ.tKl~ Gf tbe. motor $tOp' .. ••... ) R ELATIONSHIP OF VENTRICLES TO SKULL f?iIf,un 3-4 ~bDW~ the. rei,,· tionsbip of non -hydrocepbalic v!!ntricJl!!I to t b!! $kull in t be lullral view . Sollie dimensions of Internl are 8110wn in T{Jbl~ 3_3'°. In UH! nOIl-h~drocephaHc adul t. t hE' latera] ventric~. lje 45 ~m below th outer ~ k ull !urf!ct!. The center an be bodyaftbe lateral ventricle "UI in tile mid pupillary line, and the fronta l hom i. intersected by lit line passing pe.rpendicu la.r to the colvaria 1\10118 this IIneu _ The anterior bomsextend 1-2 CIIl IItnteriorto the C/lTOlIlIl Bnllln,\'. Averagl'llength of t hird ventricle _ 2.8 CIO. The mid poin t af'J'wining'.line ( . in Fic''''' 3-4) should lie wiUlin the 4th ven t riet • . FIgura J-4 Retalioosl'>lp oj venll.c:le5lo $lWll lanclfTWksAI:It>«Iv~liont : jF E ~ OOlall»'n. B E t)II<I) ... . al~""' , 0 .. oceipotal nom. r hOm) 01 "1~aI venlricloo. FM E lenmen 01 Morno, ,o,q .. lyI..l." ~u.dutl. V3 _ 1IWcl "",,1_ . ,,4 ,.!OUIIh Y8I1IrIcI.. ct; .. """",,,I lUlu", ~!IIeIlSimII 0 ' -<1 SiMT_3-3 -'' ' '1'0' ' T"ble 3.3 Olmensions from FlgufII 3-4 """""'" , (S!~ Description lowerUmlt I~I F'PgIJfI1.NJ DO ,. OJ 3.1 .3. Avrr. ,~, &'tglll at IIOIltBI 110m atlieriDr LO FM dis(&nCe!ram clivUs LO fOol at41h vl!lllriele I I ievei oIllStiqium' Iengm 01 411'1 ventricle at le-;eI oIlast¢Im' '"10,0 dis18/1O&!rom lasb!lium' 10 opisthion 30.0 "".1 14.6 '" Up$It1' lI mlt (mm) 40.0 19.0 " .0 Surface landmarks of cervical levels E.timalel gr""rvicallev~J. for "nterior cervl~"l BpinelUfgery may be made using the lan<lmaru shuwn in Tabl~3_4_ l ntro_0pe.rative C_spinex_ rnya artte ....... nli ol to verify lhel!e e9tilnatu. NEUROSURGERY T" ble 3-4 ClWliClillevel. " 3_ Neuroanotomy and phyo;iology " 3 .2. Cranial foramina & their contents Tllble 3·5 Cranial lO'811'1 1n8 and their eontent s' , III I I *_. "lItn..alioN. a *~. U • ~ ~e(..... v, W s .M'., n _ ........... M '" ~ . • .,. ...... _,I"," • Iorlrt'ol'n, doll . If;vl,,,,,,, n~"'H.br . _ Ill""",,, Ct. Porus 8c u s ti c u s !~ Fillur<': 8·5) Th'l lilll lrulnts of th ... aCQuuj" pon;on orVIIl ""netTate th e tiny open- inp arthe lamina crlhrosa of the t'tIChlea. "rea" . T ... ns"t'r'IIecrest~ sra les auperior ves tibulHr laool ca~1 (edt VI!) wni::alaesl ,,<></ , area /lll\d fadal canal (above) from the inferiCl' vestib ular IIl"1'a lind cochl~ /Ir .. rea (below'" Verr.ical Cn!!'It: ""pllo ra tes superior v", tibular a!l!1I from meatus to canal. " Ito ulncIe &. 5!!perior &. literal semiciroJlar dt.c\$) supelPDT ~ ilIe!I 1IaMW!/$& tresl (CIlSIa lalQ/orlms) lI1IeTIOf vestibu~ area. (10 $OICCule) ~~rnef\ sitIgtia.e (10 posterior semio::ireul~r IliXIJ tlllCllJ$ 5jliraiis 1000miflOSU5 (oochlel r ~rea) (ae(N.Islic: pcttiJn 01Cr N Villi r~ci~l 3. NeUroatliltomy a nd p hysiology NEUROSURGERY 3.3. Spinal cord anatomy 3.3.1. Spinal cord tracts ~ .. MOTOA (descending Pllths) bi..jlrectional ", S = sacral T = thoracic C = cervical SENSORY (ascending paths) 11 13 "-_.1. anlooOf spinal ,"'" 15 anteriOr motor nerve roo A gure 3-6 Schemalic crClSS-sec1lOI1 0/ oervicaJ 'pinal !lOrd Figun.3·6 depio~ a cl"OiSs-s« tion ora typi ..... l spinal cord Bl'gmenl. combinlng some elemenU! from dirre~nt levela (e.g. the Int.ennediol~t.erlll grey nucleull is only present from 'l' l "' _ L l or L2 where th"I"I! art! synlpllthetic lthoracolumbarou tOow ) nudei). It is schematically divided into p;;<;ending lind descending halves, however, in actuality, as· cending and desoending paths <x>e.ust on bolh aides. Fisure 3·6 abo depicts sOme of the laminae according to theschemeofRexed. Lamina II j, equivalent to the l ubstantill gelalinosa. L.e.n.;nac III and TV are the nudeus propriu l. Laming V1 is locat.ed in the baJf.' IIflhe pOf!terior hom. Table 3·6 NEUROSURGERY tracts ( I 3. Neuroanatomy and physiology Path hllle 3-8 functlcln Flgure3~ SeNSATION PAIN & TEMPERATURE: BOOY ReeeptO\'1l: tree nerve end ingJ Cproblib!e). 161 order neuron: amaU . nnely mye'inll~ aff,,",nta; ..,ma in d"",,1 "",l","glion (no l)'1UJpae). Ent.croord aldor1!Olptllrallrllct (zone OrUOIU\ler). $)on_pH: lubltoanti' .... (ati nooa CRaxed 11). 2nd order neuron ll.I.on CI"OQ obliquely in the pnterior white WllImlalmllll,c:endlnll ~ 1-3 Ilegme ne8 while CtoMing 1.0 e nter LM Illma' spinothallmic lracL Syn>l~' VPL thalamus. 3Td order neurons pas. through Ie 10 poIItcentcaJ gyru& (BrodDl8nn"...-u.s 3, 1,2)_ FINE TOUCH, DEEP PRESSURE & PROPRIOCEPTION: 8(XIY F ine touch AKA di!lCl"iminative 101><'11. Rettptors: Me.i$ll.ol"\'"" &. parini8n a..-pu"..r ..., Merkel'. d',b. frl!e nerveendlngs. lit ord~ neuron : helvi'" myelinated 8tfe~nta; 1IOm8 in dQf"llll..ll'OOt pngJioa tno IIYnBpse). Short branchnlynapte in nud eu. propnus (Rued 11\ &.1V)orpGliu rior grq. long f,ben enter the ipsil at6-al poaterior CX)lumn. with(IUt lynapsit18 (below T6, fucic:-uIUlgratil ••; above 'l'6: rudeul u. uonutu.). Synapse· nudeu. f'"3ei1is!cuneatul \ ... pec:li~,.). j ...t above pr.amid,1 dKUlHlion. 2nd order neuron axon. i;)nu iolemalan:uate fibers,decu!ISBte in \ower medu lla a~ m e dia lle ....... l..,,, •. SynaJ)H: VPL thalamua. 3Td order neurona pHI throullh Ie primarily to P'II'tcentfal gynq. L.1GHT (CRUDE) TOUCH: 800Y RKeplOl$: ILl fuw tooch t- "bout). a110 peritridUa.i . rboriutiooa. lit order neuron: larp, bovll,y myeli,..~ .I'fueIlU (Type IU; 50lIl. in do,...1 TOOl pnelio" (no '1fUIpH). Sortlfl IlC:eod unc.--l in pIIIt.CDlumn. (with fine touth). lJIast qnapu ,n Re.ed VI .. VII . 2nd order n-e .... on lUCon. trOM in anterior whiteC(IIDltuMmt fa few don't crou): enloer anUorior .p;nOlh.lllDi~ 1r'~L Syn'PH' VPI.. thlll.,O .... 3rd order ne .... on. PllIIlhrough Ie prim.ril,y 1.0 poIt<:en1r. 1CYflII. 3.3.2. Dermatomes and sensory nerves Fi8un 3·7 . hOWl anlerior.nd pCllUonor view. uch ICheQUltically Hpar.lltltd into pi!riphera\ H n-..ry nerYll di.tnbuUon. li!n~d«rm.tome. (M'fPDt!IIUoi) .nd 3. Neuroan .... tomy .nd ph,.iolOfDl !-lEUROSURGERY ANTERIOR RMAT OMES POSTERIOR CUTANEOUS NERVES Flgure:1-7 o.,rmalomal and sensory nerve dislrl:>U1ion (Red.awn lrom -Inlroduelion 10 BaoiC Neurology'". by Ha.ry O. PallOn. JoM W. Sun<lSlen. We1'" E". Crdland Phlftlp O. Swanaon. C 1976. PI> 173. w. e , S.unclef. Co .. ""~_ lphiI. P.... ..;j~po<mi """ ) 3.3.3. Spinal cord vasculature Although a radiculAr artery from the aorta acwmpanies the nerve root at many lev_ els, most of these C()ntrihute little flow t() the "pinal C()ro itself. The major blood supply t() the IllIterior spinal C()ro is from 6-8 radicular arteries at the following levels (" Tlldicu· lomedullary arteries·, the level.lUited are fairly C()osistent, but the 5ide vann" " " ""): C3 - arises from vertebral artery C6 . U$UBUy ari&es from deep cervical artery} _ 10% ofpOpulalion lack In anlcriQr C8 . uyually from cost()cervical trunk m ic:ulu ilIluy in lower cervical . pine'· T4 orTS Adamkiewici (rUM/OW ) The paired posterior apinalarteries are leu well defined than the anterior apinal artery, a nd are fed by 1(1·23 radicular branchl'$. The mid thoracic I'<!gion hu a tenuou s vascular aupply ("watershed wne"), possessing only the above noted artery at T4 or T5. It is thus more susceptible t() v89Cular in · ,ult.!!. NEUROSURGERY 3. NeutOOnat()my and physiology "gu,e 3-8 Sdlomillc ($11\Qf1l/T1 01 ~I COld a_1aI su~ty (Modi!ie<l~om Oiognosllc Neu,o'.~IoIogY . 2f11l"'~ VOl""" II. PII. II B1 . Tav." ... J M. WOO<IS E H. edilCn. • 1918. IN ~ !_ .fIIl WiIkIrIa 00 • B.lllimQr • • ..,l/l ''1 p.''''...... .Artery of Adamkiewicz AKA arteria radi cwaris antl'riQr magna the main .rtvnal tupply for the ,pi lUll cord from ~ T6 to the ronu. located on tb. I"R in 80% O<:c:ura ootwHn 1'9 &. 1.2 in 851l. (between '['9" TI2 in 75%); in remaining 15% ootwoon T5 &. T8 (in t.... eaa latter cases. lhe~ may be a ~uppl 'mental radicular artery further down) usually fairly large, givtl8Qffrepila.lk IUId CAudal branch (J atur i. u3u811y larger) giving II eheractcristie hair·pin appearance nil IIngiogruphy 3.4. Cerebrovascular anatomy 3.4.1. Cerebral vascular territories FitJun 3-9 depicta apprnUmn!~ VlIOitulardi,tribut,oBR nf the major cerebral anories . 3. Neuroanatomy and phJlliology NEUROSURGERY ThenJ i . conaiderable "ariabili~y ohbe major o.wr il'll'. " willi ... the cen lrB l d i!Lr ibuti('>1I {tJte.lentiadostrintH. recUrntlt artery of Hlllbner (ftH) (AKA media l uri.1.e artery). d c. ha"e v,u:yin;: di$tributiaml'nod may have oligin!l ()/T' ofdill'l"'!cne Hgmentl oflhe middle or an...nor cerebrw Itt.ery) 4XIAI. ... ,EW CORON.I. ... ,IEW 3.4.2. Cerebral arterial anatomy The aymbol "-" i. used to denaw a region supplied by the indiCllted .~. SeeAn . liography (NnbrafJ on pIIte 130 for anrlographic diagram .. of :.he folla...inC .....tomy. CIRCLE OF W ilUS A baJIIJlOOd eonfigurlluon o{ th e Ci.rcle of Willi. ,~p..-nt If! only Is.. of the populi' !.loo. Hypoplasia of I nr both p-comms IIC:curl in 22-3K, llbam~ nf hypoplastic AI ,.g. mentll oa:\.ll'll in 26". AnatomicalllegmeDta of iotrllcranllll cere.br . l arteriell carotid artery; the traditional numbering (~un\.er t.~'~'~"~3~'~'~~~~~'~';Ih~'~'C~'~ to th ... dIrection offiow. nnd theda! nwnbering ly,;teUl" WlU &(,>IJI rostra l totocau ""bl!!nt "fth.. laher IIJ'Wri~). A number (,>f ayl\.e1llS have been deacribed to addresses thli in<:OlUj'tency and qlflO 10 IdeDtH'y I1l1n· lomic:a lly impDrtant IMIgmenl:l oflhe leA th.t wen! n .... oI'iginaUy delif'lf!al.l!d ('-1. "" Thblft 3·9'°). AlIo."" ~Iow for mOrl d.t~iI an terio r cerebral It; • AI: ACA f,,:n'U onain to ACoA • A2: ACA rrom ACoA to branch-poinl or wlOllOmargiDal • A.3: from brandl· poi IlL orcaUOIoOtnirain· al to , upenor aurface of ~rpul calloosun' NEUROSURGERY " 3 ~r;n posterior to the. genu A4: pl!ri~al1ol8l • A5: t..nninal branch middle cerebrnl'": • 11011: MeA from origin to blfurwtion (horizo ntal segment On AP angiogram) • 11012: MeA from bifun:.!Ition to emergence from Sylvian fill>lure • M3·4 : distal braoch .... • 11015: t..nn;nal branch post..rior cerebral (PC,I t ) (several nomenclature schem .... ""i8:"''' ~ • PI : PCA from thllQrigin l.O post..rior CQmmuni~ating artery (AKA melM!n · cephalic, precommlUlicating. circular, peduncular, ba,,;lar ... ). 1'be long lind .. hon circumflex and tbalamoperforating atteri .... arise. frem PI • P2; PCA from origin of p-comm to the origin of inferior toomporal arterieol (AKA ambient, potitoommWlieating, perime!lencephaUcJ, P2 traverses the nmbient ciBt..rn. Hippocampal, antoorior t..mporal, peduJlcular perforating and medial po.tenor choroidal arterie!'rise from P2 • P3; PCA frem the origin of the inferior temporal branches to the origin of the t..nninal brlU'che" (AKA quadrigeminal ~gmentl. P3 travenlu the quadrigeminal d stem • P4: ~egment BitU the origin oflhe parieto-oecipital and ca lcarine Qrteries. indude~ the cortical branch"" of the PCA • • oplicn. (er N. II) . I FIgure '·10 C"tlf-ol WiUis viewed Irom In lronl of nne below 11>8 briM Key po in t: the anterioroe~ral anenes PI'~9 over the supe.rior ," urface of the optic chi asm. " 3. NeuroanatQmy "lid phy~jololO' NEUROSURGERY ANTERIOR CIRCULATION INTERNAL CAR OTID (ICA) Acutely occluding one carotid arr.ecry will eause a stroke in 15·'20'ltofpeople. Segm e n ts of th e lCA and its branc hes "Caroti d sipho n": begiO!l at the posterior oond of the CaVemoUli ICA. and enda at the ICA bifurcation (thus incorporating the cavernous. ophthalmic and communicating segmentsl" . C I (ce rvic aJ): begins Dt carotid bifurcation. Travels in oarotid sheath with IN and vagus nerve. encircled with postganglionicaympathetic nerves (PGSN). Lies posterior & medial to the external carotid. Ends wheTe it enters carotid canal of ~trou8 bone. No branch~s C2 (petroua): still surrounded by PGSNa. Ends at the posterior edge of the fon· men laoerum (f.Lac) (inferomedial to lheedgeofthe Oso.serian ganglion io Meck. el's cave ). Three legments: A. verticalaegment: ICA ascends then bends as the .. B, posterio;>r loop: anterior tocochlea, bends antem.medially becoming th e ... C. horizontal segment: deep and medial \0 greater and lesser superficial ~tros.ol nerv'ea, anterior \0 tympanic membr/lne (TM ) ClI (Iace rum) : the ICA passes over (but not t hrough) the f·Lac fonning the lateralloop. Ascends in the canalicular portion of the f·Lac tojuxtaBeliar position, piercing the dW'8 as it pasae8 the petrolingualligament \0 become the eavemo\UI segment. Branc h.... (usually not visible angiogrnphicallyl: A carotiwtyropanic (inconsistentl - tympanic cavit y B. pterygoid (vidian) branch: passes through foramen laceTUm, pruent in 30%, may wotinue a~ artery of pte rygoid canal C4 (cavernou s); covaNd by vascular memb.-ane linin, sinus, s!illsurrounded by PGSNs . Passu anteriorly th~n supe~mediaJly, bell<.b J>OI!leriorly (mediall{){)p ofiCAJ. travelshori:tOlltally, and bends antenorly(part of an len o r I{){)p oflCA) to anterior clinoid process. Ends at the pro~mol dural ring (incomplete encircles ICA). Many branchea, main ones indude: A, meningohypophyseal trunk (1argeat & most proximal) 1. A. "ftentorium (AKA arte ry of Bernasconi & Cas6lnari) 2. dOnll!.l meningeal a. 3. inferior hypophyseal s. (- poIItenor lobe of pituitary): occlusion causes pit uitary infarcts in post-partum Sheehan's necrosis, however , OJ is rare because the stalk is spared . B. anterior meningeal a. C. a, to inferior portion of cavernous sinus (present in ~) D. cap$ular aa . of'McConnell (in 30%): supply the capsule of the pituitary" C6 (clinoid ): eods at the distal dural ring (wmpletel)' encirdes ICA) where the ICA becomes intradural C6 (ophtha lmic): begins at distal dural ring, endsjuat proximal to p.comm A. ophthalmic a.: the origin from the ICA is distal to me cavernous sinus in 89%(intracavemous in 8%, absent in 3%"). Pssses through the optic canal into the orbiL Has s characteristic bayonet-like ~nk· 00 lateral angi~ iTam. B. superior hypophyseal a. branches _ anlerior lobe of pi t uitary & stalk (1st branoh ofsupraoiiooid ICA) C. posterior commWlicating a. (p-comm ) I. few anterior thaJaOloperlorat(! .... (- opt ic tfllet, chiasm & po!Iwrior bypothalamus): see Plnttrior t ireulation below D. a.n te rlor c ho roldal a r tery": takeoff2-4 mm distal top-wmm - (variable) portion of optic t r&ct, medial globus pallidus, g~nu of internal capsule a C) (in 50%1, inferior half ofJ>Ol!lerior limb of IC, uncus, retrolenticular fibers (optic rad iation), lateral geniculate i»dy (seepage 778 for occlusion syndromes) I , plexal segment: enters supracomual reteU oflemporal horn, - only this portion of choroid plexus 2, cisternal segment: passe! through CTUtal ciltern C 7 (eommun;ea t ing): begi... just prox.iJnal to p-tomm or igin, tTavels bet"""",n Cr. N, II & Ill. wnninstesjust below anterior perforated l ubstance where it bi. furcates into the ACA & MCA NEUROSURGERY 3. Neuroonatomy and physiology " ANTER IOR CEREBRAL (ACA) r"un between Cr. N II . nd ante rior perfol'llurd 5ubostMce. Su 1'16",..5·2. pap 132 for angiornm lind bran~bBlo. MIDDLE CEREBRAL (MC A) $eU"lIurt 6 ·3, pag~ 132 fllr a"llogram and branch"'. PO STER IOR CIRCULATION VeRTEBRAL ARTERY (VAl 'The VA i8 t he first and usually the l.rGut brllncil ortlle.ubel.'·;"n a rt.l!1")'. V.rianl: the len VA Bri., oJT the B()I'tje arch in . ... Oi.mft-olr. 3 101)'1. M"e blood flow _ ISO mllm,n. Thlliell VA i, dominant in 6<H&. The right VA will be hypoplUtic in 1"•• nd the left will be hypopillstic in S". The VA illltret;c and doe. Dot enmmUniClI1II with the BA on the left in 3%. lind on the riGht in 2" . PtCA~I' a'fI _..urior II'IeII1oIi:Ir "9111'" 1m _lateral - . . . ~ !aud.llloop) 1m"~$Ij1m1.'t11 M _ ~ (wpra:onsIIol H9TII!" (~.loop) ts _ COIticiI ~ FllI"'rw 3-1' lI~aI<Ngt ... 1Ihowing In~""'. VA anD PICA RgmII<ItI "'0<10/'1no<I}'-..., . \oltIL 1"'''''' ..... """" t.c... .. Sa ,ClLao,OI, _ o.o..LoItfln.", Do, AL- o.o.! _ . _ _ I.. ...... ..r_r... ___ ...,....",. I_.lOO1.91•• ) 1S6-6111 Four Mlmen ..., fil"lt legmen!! COUrHt a Upf:riorly and poatenorly and en ...... L'-w fora ruen tron ... venariulll , "lual1y oftheGth vert.l!bl'lLl body a«ond IIII(I'ITIen!! a_ndl vertically with in the tnl nlJVUW fortuninaoftheoervial vetteh,.. . accompanied by a nelwork ofaympat.heu.: fibel"l """m the lteUale gan . . NEUROSURGERY glion) lind II " .. Mug pi"""". It til"", JawraUy will,," the {rB'llI~ proc: "~ oftl,1!' ~" ~gm~nt: exi t.\. the fOnllnen oftha IU<i~ and curves postl!'n orly and medinlly third in II JlToove on u-.e UPI""T ,urf9<1f! ofthll atlaa and en.... n th e foramen magnum fourth segmen t: pie",a. the dura and imwedint.ely en16. eubarschnoid apate. Joina t'On tT1lIIl .... ~al VA at tha verte bral co nn",,"a loe!Ited at tha k1wer pontine border to form lba blUlilar II r!.llry (BA) BrAnehea: I . ""terior meningeal: arisea at body o(~ (axi s). may fe~d ~hort\omu or foramen magnum rneningiomlLf, may also II<: t u collaterAl in "a.o;eular oo:elU!lion 2. pone.rior meningn l 3. medullary lbulbar) aa. 4. po~terior spinal 5, PICA (large&t b,am:h l: \ue Fill"" 3·J I) arise.(! _10 mm disUlI to point wh.re VA !lacom" intradu ral , _ 15 lI:un proxima] to the vl!I"!ebrobasilar junction (in 5·8'10 the PICA Ila~ ar. extndurtd erigin j A. "!egmenL&"(acuneaysteml80me deseribeon]y 4). During surgery, the lint til," mWit De preserved. but lh. lut 2 may usually be I18crillCf!d with min· imal deficit"; 1. auw.rior meduilo.ry: from PICA origin to inferior olivary prominence. I Or 2 ll bort medullary short circumflex branches _ yeolnl medulla 2. lalen.! medullary; worigin oCnerv"" [X, X& Xl , Up 14 5- \:u-anchut.bat supply braillllt.em 3. tonllil]omedull"ry: to tonsillar mid portion (tonUlins caudalloolLon nngiol 4. lelov~lot.on6il18r (IU pratOl15iJ\ar): aJ;amdll in toQ.l!iUomedu ll ary liu ure a 6. (contain. rot.niPJJ\!:D.lI. on anglo) 5. cortical e~ents 3 branche! I . o boroidul a. (BRANCH I) ~ri S\lli from crenialloop (cboroid!! l PQiruj, _ cboroid !,lexus of 4th ventricle 2. tfrminal branche" B. t onaUlobem.J.pberic (BRANCH 2 ) h. inferior vermian (BRANC H 3) inferior jnfle<:tion ~ ~ JI.!ilill, on Bngio Mteriorapinal BASILAR ARTERV (B A) Formed by th aj unctiou of~lle 2 yert.ebral ~riea. Bran~h l!ll: I . AlCA: from Lower part ufBA. runS post.erol~Lerally anteriurU) VI, VII & VI II . 0(. ten give! oITo loop !hal runB loto tile lAC and give$ ofT the labyrinthine 1I.l:tery lIod then emerge!! to a,,!,ply tll~ anietoLatera.l i"ferior co.:teb~Hum and then ""811tamoses with [lICA 2. intemal auditory {labyrinthinel 3. IJOOtine branch", 4. .uperior Cf!rebellar a. (SCA) A. J Up. v~rmian 1'> . pru&t.eriDr " ....... " .... 1: joined by J>-<'O'T'm~ major origin of the PCA in 15% end ;. _ 1 ern f...... m o rigin \.I!rrD~ \ th~ tH-""nTT>m i£ lh~ · feLa]" ~it<:ulatiou, hilateral ill 2%1, 3 ~e,,'-' (named (or sUlTOuoding ciatem.l lind tbeir brnn~be!' A. pedulltultlJ" .egment,(P l) I. meseneepbalic )It' rforatmg Ga . (- teetum, ~erebral pedWlcles. and thl'S~ n"deli: Edinge ... Wes;tphal , oculomotor and tl"l)Chl~a rl 2. int.erpeduncular t bnlamoperforatol'fl (l al of 2 groups e( poIIterior Ihalamoperfor&ting aa.) 3. roedia! post. choroidal ( tn<l6t from Pl or P2) B. Dn,bient ugme.ot{P2) 1. lat.e"'! poIlt. chorcidaL (mlllll from P2) 2. thal&mogeo iculate thalamopcrf"oratora (2nd of2 groupo! of po&w.rior thal .. mOj.>l'.rWrating A~.)_ g@niculatebodiea+ pulvinar 3. antoorior t.empor"l (anastanwiell with anletior tempo",l br. ofMCA) 4. poot.erior !.IImpornl " . pari~eo·ot'ci pital NEUROSURGERY 3. Neurosnatomy and pby!iology " 6. .,.learine C, q\,ladrigeminal Sl!(l'ttM!nt (P3) 1, q ... lldrigeminal & genicula~ bnnchu _quadri,cminal plate II post. pariulJoaal('plenia1) (1UlIl8tIlU:lOIu with periclIllOilftl of ACA) E XTERNAL CAROTIO 1. aupermr thyroid' III anterior braneh 2. Alloeooine: pharynruJ liogual ... r..,;a1: bran.ch.. ana,"'~ with ophthalm ;~ Ikwy in rol1ataralllnw l 5. oocipiUll 6. posterior lIuric:lliar 7 . aupcrficia! telJlporal A. rmnlal branch 8. pAJielal hranch 8. maxillary - initially within parotid ,I.nd A. "';ddle meni'IjIar.l 8. IIHIninp.1 C. inferiwal .. toI)lar D. inf'r...".bital E. Dthen: dial.al branch" ofwhich me)' an.. lO_ with brarKh... orDph. thalmlc artery in tlla orbit a. _.0.,. 3.4.3. Cerebral venous anatomy S UPRATENTORIAL VENOUS SYSTE M SM FiB"" 5·4, page 133 r",. lltIp:.gr.m .nd braneh ea. The len. end richt intema l JuguJar ... ina (IN.) are the l7Ia,ior -.un:e or outllow 01 blDod from tht: inlr&Crllo;al companment. 111, ri&hl. IJV i. u.uaUyd~minlUlt. Other iOIJrce! or our.f]nw include orbi1.al veill.! lind the vertebral W!nDUS plul!!.. Diploic and &Calp veina Illay act .. collate... 1 pathwayll, 01.1 . with ,uperior ~tu l t iDUM ohatructioo". Th" followlne oUllloe uaces t.I'. e v"noW! drainage back from the UV • . A.. inferior petroaa! Jin ... B. aivrnoid . inuB I. I " perior petrosallin u! 2. traru;ve~ sinw; (R,. L in 65'1» A.. v. ofl,.a bbo. {inferior an astDmDtie v.1 B. ,xmfiuefl5 ef8illllSe~ (IOrcuiar benlphili) 1. 0«!pltaI61 ........ 2. , u perior .agitUll 6 inus g. w. of'Trnlard tsuperior 8na.llwnlIItk ... ): the p ... m'j nen~,uparl'icial vein lID the Illm·dominant!hie l .... bbtll it...",.. prominent on the d(>minlll)t aide) 3. alrllight sinus a. inrerl~r ugittallinu B b. grWot cerebral v. (orOalen) i. p re·cen t. a! cv.,.bel1l1J' ... Ii . bsaal .. ein of Rc8t!nthal iii. intemal cerebral ...: jolnl!<lat the fMalDen orMonro Ivenous aIlel.) by: I. /lnt.eriQr kptal v 2.. th,lama.lri.t.e Y, CAVERNOUS SINUS Althoulb ch'IMicaJ tel:lcb inl depitU: thl! caveruou , ~in"""" allr,e venoua,pfou witb multip ~ trabo:!culatioll8, ll\il!Coou It"dlu" and ,urgical experi~ I IIPPOrl.ll thl ...{ t he caVlmoU' Binu, pll :\uMofvelll8. I. contrib ... tinl! "elnl : concap~ " u. 3. Nll'Umana1.om), ind phyRI(>logy NEUROSURGERY A. , upol'rior & torerior ophthD.lmic "em.i B. l upemcia.l middle cerebral vBinS C. sphenoparietal ' i- "0' D. superior &: inf"'; OT petroSD.1 ainul 2. contents:» OculoUiotu n. (lll) Trochlen r n. (IV) Ophthllimic divi_ s ion o(trigeminal (VI) Muil illrydiviaion of trigeminal (V2): the only ne ..... e of tbe CS"erDOUa ai- 'I nu.th/l.t~.n'l exilthe skull through the iUpe_ rior orbitallissure (it Hits through Figura 3-12. Righi ca.emous sinus (ooronal sectloo) (Modilie<lbom IM J OVmli OI ...... F. ~...., f1. r"r"ln"n rotun_ N..lIIar!. VoI.~. pp. Z28-3oI, 1982 • ....., I)etmlo.oiOn) dum) C ",.ot id Abducens n. (VI): thq only ne ....... NOT alUlehNi t.o IlIter!il dUTllI ... ttU 3. triAngul ll r 8J'Iacel"r PDrkin~"n ) : s uperior bord~r fonned by Cr. N. 11 1 &: IV, lind the lower m8 r(in formed by VI & VI {II landmBTk ror BlJrgicD.I entrance to tbe ell ..... emou s SinUI»'·" '. ;wn ,_rv-r, 3 .5. Internal capsule Vasclilar ,"pply or the internal cap, "le (I e) I. anterior choroidal: - all of ~trolenl.iCtllar part{indudes opti<: radial;on ) and ventral part of poat~rior limb oflC 2. latera l stri ate branebes (AKA capsular branch",) of middle cerebral artery: mMt of anterior AND posterior limbo of lC 3. genu uaually r«eivl!!! some direct branc b"" of the intemel. carotid artery Most Ie lesions are eIIused by vascular e(~identa (thrombol!is or bemorrhage). Table 3-10 Four Tl'Ialamic: "Iubradlallona" (AKA Ihalaml c: peclunc:les) (!abeleo A.0 In F">gUIB3 /3) -- ...,"'" ..."" ...... ...... RadllUon I~ oentrallh/Jlanie IIIJ- gere,al ~ Ir!lelS I'om boItt ,olandic:a'eEl$ '" DCcipMl & posIerlor ))lin. 1'1 .~ posIerior i1leoo, 101 "'"""'"' ConMCIIon medial & ~le<lOIltIiIamic IllInlMlrstl temponli 1If' rusol Hesctll NEUROSURGERY 3. - '" & head 10 tefn*lale In posICen- MOB (smaU) Ir1c\uOeIl ;JU(jitory radWil - !IaI~s(OIJeu3,I .2l CII\II8I )I'Ialamus N~url)an8tomy "" and physiology "' 3.6. Miscellaneous OBERSTEINER·REOI.ICH ZONE ( O R Z) AKA root entry toue. Tr&-'' liition f!'(lm eNS myelin to po!riphera! lI\)'clin of cranial '" area whe~ root ~ntry zone p",ssure fmm inllll~rnniB] sW"ucrurea CIIn caUSftCrtl· I\I!rv~ nial nerve 3ymptOmt (trigeminal ne"ralgi~. hemifl.dol apa3m, disabling pOllitional ver- tigu, e!.l: ,)p. Also, zone where neopla.m5 U:'nd to occur, l!!lpecililly aal!l.tic neuroma . On Cr. N. VIlI , the ORZ is 8-12 tum dilla! t.o exit point from brai1ll tem, Bad is dose to porot 8custicus (e&peci ally common on ve.tibular division Y" ....I. DENTATE L~MENT The spinal IICtellS(lry nerve is dOrMl to theden t.ate tigument. 1be denLllt.c! ligamenl fi.ep8ratf's do""aJ from ,·.. ntral nerve fQOl.S in !.he spinal ""'rvel. 3.7. Neurophysiology 3.7.1. Blood-brain barrier '!"he paaaage ofwater-lQlubJe substanCl'll from the blood to Ihe CNS is limlted by tight jW1 t1.ionll (um ul" .. ocdud"D~ ) which lire found between cerebral ca pillary eodo1.belia! ""IL., limiti"!! penetration "r the "",,,bra! paraucbyma (b!<>Od·brain barrier, (BBB»), lit well as between choroid pluuB epithelial celL. (blood·CSF' barrier)". A "urn· berofspecialired mediated Lraru;port sysloelOSal]ow trIInlmisshm of, amc ngothcr tbinlJ$, glucose and certain amino acide. (especially preeursOl"li to neurotranamitteTII ). The "ffi""cy of the BBB i. eompr"",ised in ""rta'n p~tbological ~tates (e.g. tumor. infection, lrauma. stroke, hep;atic elll.'I!phaiopathy. .. I, and can al!lO be manipulated pharmacologically (e.g. hypertonic monnllUl increases t he ~rmeahmty ...... her~s sloeroidl! 1'<1duce the penetration oramall hydrophilie molecules). The BBB i~ ab&ent in the roUowinll areas: dlOroid plexus, hyp(lpl\)"IIi" tuber ci. ne reum, srem paatrems, pinn l and preopl ie n!'CeSB. 3. N~uroonatomy ~nd phl'llioiOO NEUROSURGERY CEREBRAL EDEMA Three balic types (dif!"u.ion·w.. ight.ed MRJ may be able to dif!"ert>nti.te, Ht JXl6t 136); I. "ytotOld ,,: BBB is closed. the ... f,,", no protein utrav ..... tilln. then!fure nG en· cr hanoement on or MRI . Cell ••well then .brink. Seer. e .•. in h u d i.,jury 2. v" lIOg .. ni,,: BBB disrupted . Prol.ein (serum) INk. out of v..cular IYttern. end the ... fon may .. nhllJ\Ceoo imagin,. Extra"",llular'paee fECS) upand •• Ce ll •• re stable. Responds to cortioosl.e...,id. (..... dex.met ........ nel. Seen ' " .lUrTOund inll metastatic brain tUmGr 3. i,..,bemic : . combination of the.~ BBB c\oted initia lly, but th.n may open. ECS shrinkll then upandl. Fluid .x tra vallal.ellate. May aUN d.. l.yed del.e'ioration following inlra"", ... bral hernorrh"'. (_ ~ 8.S$) 3.7.2. Regional brain syndromes This section IoervU to brieRy describe typiaol.ynd .... me .nociated with Ieoion. in variou8 areu of the braIn. Unlu. otherwiMl not.ed, Inionl conlidered Ire dtJ!oli:m:... I, r.on t allobo!! A, unilaterlll il\iury: l , may produ"", few clinic.1 findi .... ,x"'pt with very I.rge Inioou 2. bilaur.1 or I..ge unilal.e.,1 lesionl: apathy, abulia 3. the frontal.ye field (fGr contral8l.er.1 gazel dlocated in the poIIl.erio. frontal lobe (8 • • a. ea 8, , hown I I th u triped area in Fitu", 3·J. page 68). Deetructive le,ions impair gaze to thecont •• lal.eral aide (patient lookl .llU!Llllh the .lde of the lu iGn), whereas irritative lesions (i.e. lei · lurn) caule the center to activate, producing contralateral gau (pa. tient looltll ~ )'!'lll. from the side Gfthe luion) . Also IIU pagt 584 B. bi lateral injury: may produce apat hy, abul ia C. Glfactory fioova rtgiGn : may produce Foster· Kennedy syndrome (see bf,low) 0 , ~fronta lobet control "exec utive runction": planning, prioriti:;ng. orga· niling tholl4lhta, suppressing impul8el, understanding the OOflsequencet of dedsionl 2, parietal lobe: major featuretl Cst. pog# 87 for deta il9} A , either ,Ide : conical aenlo,y ' yndrome, sensory extinction, contralate.ral homonymous hemianopia . contralateral neglect B. donei,,"n! parietal lobe luion (len in rn<>St): language disorders (aphasilll), eerttmann', sy ndrome (_ M t 87). bilateral astereognosis C. """.domin,"" parietal lobe lei''''''' topographie raemory Iosa, anosogTlOliia and dressing apra~i. 3. occipiullobc: homonymGul hemianopsia 4, ""'rebellum A. leaiGni of the cerebellar Mmi.pM", cause atuie In the jpsilateuJ l'robs B. letion. o{ the cerebellar vennis cau"" truncal aluia 5. brainstem: usually produces a mixture o{cranial nerve deficilll and long tract findings (1ft Mu.w fo.- some specific brainsl.em syndromes) 8. pineal region A. p.rinaud'. ,yndl"OV'le; 8ft pap 86 FOSTER-KENNEOY SYtJQROME Ul ually from olfactory groove CIt media l third aphenGid wif\i: tumo , (ulua)ly menin_ gioma). Now nlre due to earlier detection by CT KaD. ClaAic triad : 1. ipsil.teral anosmia 2. ~ centra l scotoma {wi th optic I.1aUili:t: due pressure on optic nerve} 3. contralatergl papilledema (from elevated lCP) O«lIIiooally ipsilateru l proptosis will also OCCur due too.bi",l invuion of tumor. 3.7.2.1 . Brain stem and related syndromes W EBER'S SYNDROME Cr. N. III pally with contra later.l Mmipa reti. (a lso 1M LDcu ..o. "fOott" PIIp 716). Third nerve palsin frGm parenchymal leaionl may be ..l.tively pupil .pa rin • . NEUROSURGERY " BENEDIKT'S SYNDROME Similar to WebB'a, plus red nucleullellioll. Cr. N. 111 pals)'wilb rontrnl8~TlII hemi· Uceplllml which hn hYP" rk.ine8ia , atu.io, and a CO'n<! ;nto;nlion tAmo •. Le· s ion; m>dbrlin Io!ymentum i"Y01 ~; nl! ~ !lucie"., brllthium col'\lu llttl.V1,m , /llIIf fllaeitlel oflU. panstS M II.I..ARD-GU8LER SYNDROME Facial (VI I) " abducenl ]VJ) pal.y . contralat.er~ IM!miplegia ((:(Jr tlcoapinsl lTatt) from Leaio<1 in hue. of po ... (1.IIIIall), iKhmic in faf1:t, oo:euionally tum or). PAR/HAVD's SYNDROME Con~rrence • • a:ommod.tilKl fInd IUpr'lllicla. r upwnd gaze pIIllIy \I .• . U ppl~ pill · a)' wilb nO"",11 .tllponsa to yO!l1.lc.l dol1'l e)'u' wittl lid retmetion (" Pia .. pilla), + lid reo trlKlion .. ".euill' a UD . i.,.o). M-.y ha~e fuctd pupils, dinoo:iated liJht.-ne8r responae, convtrgeme apelm and n),IIUIJIIlUI re lrac.toriu • . Skaw ~.tion mil' be a unil/1teraJ ~arianl. When combined wi !.h downga .. pall)', I'arinllud'aI)'JIdfOUll (P S ) i.lLnllWn 11.' !.he I),od ""..." ollila Syl";lIn Iqued u c:l . E ti o logi el l. 1IUi.u1 pAHingdirec:tly on quad ripm;nl l plate (1I.g. pineal region tumOrl) 2. eJ~.ted ICP: MICOIIdary to c:ompl'ftSion of~phalic teclum by di\ated~u· prapinul noI'' ', "" . In hyd.rol:tphllllli Diffe rential diaguo. i. Condition • • rrectine oo:utar mati lit)' thai could fOlmic the u pglal! prills)'of f'S: l. Cuilla.in· Bam 2, m)'ll5th.nia pv15 3. bot'uLism 4. hypothyroidism 5. !.hen ma), t.. gradual benign 1_ OruPi'lI18 with sene_ nee .,nd.o:ne 3.7.3. Jugular foramen syndromes Ccmuntf orjugular ro. al:'lea (JY): Cr. N. IX. x, Xl , pelTO$ll K\nus, $IgmoId .l nlll , lOma m~i ngeal branch .. tram the __ ndin l ph8ryngeal and oo:cipiLal aneri~. Nearby: Cr. N. Xl i p.iI$~ Ihroulh hypoKi08la\ t'III'Ial in the OttIpital ""nd),lll. Theca. oUd IIrt@l}'wi!.hthl!aym· pathelic.pluu. enlerl the carotid canal. See Tobk 3· // for II I UDUna1)' and Fig",. 3 ·14 for a ochemalic diai"UD of denc;\a in various JF synd romes. ~ha Vernet'a "yn<irome: AKA ,),ndlOnle of th ejugl.llar roramen . Damage or lll! .... es ;n J F it.llelf, mo. e Liktlydue to ;Ot rlC'rIDI. 1!11"10n. Co lJe t.-SiC8rd syndrome: Mo re liJr;ely with J"ion Qlm.iIlll.UwU. Ifcaused by an inLnlc' llDialluion, ilwould hive to "" or IIUW a la rge .iu l h. t it wou ld uluaHy produce brain stem comproll:.on - lonl tract finding •• VlIlaret', .,.ndrome: Postarior 1'1111'11' phl!ryng~a l "yn d rome. Agu.. 3·'. ~kllIne Sc.he1Tllllil; a.~'.mol ~ lor.. mM .... ndromta tnrough • nerve indIcIIlet a dIfId\) IdW>ed line IncIical.,. ~ . "WEUROSUROERY Table 3-11 3.7.4. P{lRIETAL L08EANAT04fY The parietal lobt: II loelli.ed behlnd tha amU'a l .ulcu., abo¥e the Sylvian fiuure, mel"flnll' posteriorly into tha ~pit.ol lobe (the border on the rDl!dial.urfB("e of brain i. dllfi ned by II line connect ing \lMIl'ariet.o-o«ipitallulcu. ta lhe p...orcipit.ol nOld>l, PARIETAL LOSE' Nf!UF/()PHYS/OI..OOY elth~ r , id.: . ntenor parlet.ol CONK organi,," tactila pre.:ept.s (probably conUlllatera l) and inwt;ra~1!I with vUIII.I.nd IIliditar)' -.nsaOon to bu ild awareness IIf body ond its IlPltial relaLioli' domiNlnt $id. {on l"ttln 97-' of ad u lu }: unds",unding 18ngu11lf, iIIcludl!fl "cros.s. mod.l mntchlnl'" (a uditory· vieu",], vlsual.u.rtik-, ete,). DysphMi.a pres<mt wit h domina.nt lobe lulan. olU:n impedellWlln$men t non.do minant .id~. (r i,hl in m()lll ): inleiTl'~ vi,ual and proprioceptive $\Inliation to allow manipuillion of body and objl!"Ui, and ror e~r\.lli n toOSlroc:UonalllCtiVi- tiwi CLINICAL SYNOROMES OF PARIETAL LOBE DISEASE l. unilotel'lll pruil'tallobt di!M.'aat (domman l OT non -docoill8llt): A. eorllcal HI'ISO r)' lyndrome /~ w lmu) aod HMOry eJ<ti.n~tian Cneglectilli l of2 .imultanl!9us]y pre6f)llted GLllnuli ). Large lesion - hem i8nl!lt huil B. congenital Injury - mild hemip~resil & conlrll iatetal nill.de atropllY C. homonymous hemianopls or visual mattenli venM5 D. aa:a,i(lIIaJly: anOllCllnOO!lia E. neglect. of eont.:ralaural balfof body .nd vi~u 91 (moli! COOlmon with right . ide le$loruJ P. .bolition of ontokjn,yc O\'atarmull ta OIle side 2. additiona l effect.! ofOOm;"''''1 parielS] lobe l!!Iioo (left i..., mOllt): A. la ngual" d~rde~ (a phuias) B . • p<!«h· related Or verball,. mll!distfd [email protected]·lIIodalm.u:hing (e.g_pati~t unde.-.lJmda lpol",,,, word. lind eM .read , but o;/InnQt under· nan(! Mnteneell with eleDlf.nlll of.elationmipa) C. Geutm.nn ', .,...dr<>m~. clal!liQl.lI,.: 1. agraphia without alex.ia (pw.tienu Ull f1l&d but cannot wriU ) 2. left..rigfu confusion 3, digit agnosia: inabUlly to idt= ntify tin&f-r br .... m. 4. aetlk .. li. D. tacti le qnOllia (bilalAl.. I .. Ie!1!Ogr>uSi.) E. bilateral ideomotor .p.....,u. [ioabllity to;.:any out vuba l tonunandl for lie· dvi lles th a~ c:an oth_1M! be ~rformed apontanl!9U1ly wIth NN) S. addiliOflaJ effecu of """,-d.omillOlll parietal lobe te.iollll C.... uaU,. nihtl: A. topOgr:llphil: memory 10lIl B. anOlOgnOllla and drealil\r.pn>t.. 'p_ NEUROSURGeRY 87 CORTIC AL SENSORV SYNDROME Letlion ",fpostamtrnl gyT11S, £specially 81"118 that mUJlII 10 hand. llensory defitit ~ A. loss of position ,""nN and of pa!l8lVe mOVemCnl sanae B. inability 10 Io<:ul.i ~ l1Iotile, therm&!, Ilnd noxious stimuli C. ps~reogn06is (I nability to judge object Sil~, shape. and iden t ity by feel) D. agnphesthesi. (carutot interpRt nu mbers ",riLUn on band) E. 10llll o(1:WQ poio.l dilOi!rimination preserYed un9alionl: pain. lOudl, pre!l!lure, vibrst ion, temperatu re other feature!! A. easy fatigsbility of.aen801"y pe=ptiOl:\I B. difficulty distincuiahiog ,imull1lnOl(lu8 atimulanOlls C. prolongstion ofauperfieial pain WiLh hyperpathia D. toueh h 9Uueinaliool A SOMATAGNOSIAS A NTON· BABINSKI SYNDRQt.fE Un ilaUiral a!lOlDIIltIgIlosia. May &I!~m more common with non-uomina nt (r ight) pa. rietal luion, ~lIUU it maybe obscured by Ihe 8ph!llli~ that Ottu". ....ith dominant(len) sided l"ioM. 1. 1ltI000000oaia (indiffereoce Or UnaWllTeneSli ofdefioit.s, patient may deny thal paraJyud exlremity il r.l1eiral 2, a p'llhy (indiffe rent" 10 failure ) 3. olloc:heiria (one ... ided 'limuli percl!ived contrelaterally) 4. dre5Oiinl: apl"!ll<in: negl~tof one aide of body in dreslllnl: \llId grooming 5. utinttion' eontTnlaterall,y 1.0 double· sided SlInultaneo ua ~timu lation 6. inattention 10 nn en tiN visuallield (wilh or without homonymous hemianopia), WIth dl!viation ofhud, eyea, and IOn;on of bod)' to unalf~d eide APHASIAS All related to parie13l lobe lesioll!!: 1. Wernicke's . ph .... ;,,; lea;on of \ludita-ry 8I1!111ciaLion 8""111 nr tbeir ,epa rati on from anguJar gyrus am! primary auditory rorte". A.D.llllll aphasia (normal ten· ten~1! length &. Intonatioo, devoid ofmean ing1- May indud .. paraph.a.silll. Lealon in region of Wernicke·, area (Brodmann are~1 40 &. 39. l ee FiC"'" 3· 1, Pl'1:1! 68) 2. Broca'a (motor) aph_i.: in reality, "8praxla" of motor "",uenc;ng for speeoh (Ipeech and phonation muKieR aren"l parll]y~ed, and fundlon for other nd-lVi· t inl. prod ucing faltering, dyeaJ"\h.rit Jpeech . Lesion;n region ofBroea'a ar~ (Brodmann area 44 , ' '''' Fig"N! 3· 1, page 68) 3. globll illpha ,,;n; us\U. lly due to lulon that dellrOYI large port,on oflangual:a tenUlr; aU IiBpects of speech and lanb'Uage affected A. unab!" to apenk "xeept for lIO!tIe tlicho!s. habiu.al phrases. or expletives B. anomia Unnbilit)' to name obje<,:ts Or POI'\.S or otl,iecta) C. verbal and motor peTSeVenl t;on D. unAble to und~'.tlltld an Ut .. pt fo r a r..... wo.d& E. inability to read Or write 4. coaduction \lphasia: tua to disniptiOll o(connections l>etwee.:l fronl1ll and temporal apl!etb areas, usually involving supramarginal gyrus. Si milar to W~mjcke·a U1uen~ spontane0U8 spe~ sod psrsphui,..l. b"'l patielltl! undel"lLllnd spoken or wtitt.m words, and are aware.of the;r deficit. Repetition i9 severely s lTected S. pu.re word bUndnf!S5: AKA Ilh~a ill without ag"I'lIph;1I (rare) due to lesion in pa. rieto-oc:<:ipitallobe thu intf!rrupl.ll conn&etionl bIItween left angula r SY"U and bot h oc:<:ipitallobes. Pntienta Mn write, bUlllJ"ll unable to read what th.ey've written, and freq ueotly uem Wlconco::moo nboUI thii. Often ncwmpanilld by low of ability to name .:(lIon. Reading and naming number. usuall.Y preserYed 3.7.5. . AltllQugh Babinski sign ~b'lltdlld as the mO!lt f8mou ~ slgn in neurology, there it still di ugTHmI!nl 3. Neuroanatomy and phy!liology NEURQSURGER1· over what constlu.lles a notmal rupon"- and ... hcn .bnormlll r1!.!p<InSE1l !hould 'The following rep~"nu OC(U~'. onc inl<lrpretation. pl .. ntar ren ex (PR) (AKA BabiDski aign) i.!I" primitive rene)!., present in inr"ne)" conailting of extenslun of the GTeat lOt! m IUpOll!!<'! to" nCIlI:ioWi ! bl1lulUfll,lpplied to th e foot , The~malll.oell may fan, but W . r. nott'l)ntii~knt no r cHlllully rmpO~nL The PR diaappeanl u8ual1y aL - 10 lDont .... age (rang~ : 6 !liD!! to 12 Y1'S), pres umably UIlder inhibitory control u myelination oftha eNS OOC\1r$, and the IIDI'1'DII] .espanae then eOn verU to plantarl\""ion of the greet toe. An upper motor neuron ruMN) Jellion anywbenl along the pyramidal (eorl ioospinal) Irlltl ITom the mowr strip Wlwn to _lA will ruult in a 108& orinhibition, arK! the PR will be "unmasked" producing u le/ltWJn ofLh .. great toe. With auch IUl U/To(l'Ilealoo, there may also be eX3Jgeration arn.xor ,,),nerK)' n!l!ulting in rlon;ifle..Uon ofth a ankle. and flexlon ofth~ iule8 and hip (AKA tripl e nOlIor ""lIpo ll fe). Th~ Ne uroa n a tom y Th~ affennt limb ofth~ reOex originale! in cu· lAneous rl!Cepto~ restritted to th e first !;acraL dermalome (S1) and travel~ prQx.imal1 y via th~ tibial nl!I'Ve. '!'he ~pin81 cord Hgruenta Invol..oo in the renex-an: lie within Li:li2. 'The efTe:rent limbto the t£Ie exten50111 tnovela via tho !l!!roneal DCal!. Eti o lo gi ea Table 3-12 DI!ferentlal d iagno,ls of the PR spinalooro~ies' cervicll SPinal !l'l)'elopall"t' 6on'l in <I'UOr SIIIp or tt:emal C8~ I\I~ lell.... 1Umor, conwskln .. ) Les;OIlS producing '- PR Deed not be ,\ruc!u... l. but may be runctionalllnd rllWl!reible. etiologi~s an! Ij,lA.ld fn Tobi~ 3-12. wtQ,'aIO! epodulll! t-1«M Ilydllmeraphaly loldo;.melabok COII'IiI Eli ci ting the PR, and vari a ti o n s $8Ilures lrau!!llo Theoptimal stimu h,s consists ohHmulnlion flf the lalera] plalllAr I Urf""", and l,anaverK areh in II henIJp. mIg,;une I llIgle movement IMtlng 5·6 1!IConM". Other means moIOI neurm disuse (ALS) ror applying noxio", atimuli may also elicit the plan... spinIIl CtlId Jr.tu--. 1M FR .... y tar refln (even oUl.8ide L'>e 51 diormatoMe, although ~ I~· t>e _OIl d-.gl/le PlflClCloI these do not produce toe nexion in lIorm.I~I. DI!. $pfI\01"1I\Odo.°I_page ~ scribtld m.neU'·era inclu:le; C ha ddock (&er atch Ih\'laleral fOOl; pGIIitiveln 3'\to wb ..", plantar stimulat ion was negative), Schaeffer (pinch the Aehllles tandon ). Oppenheim (Ilide knuckles down shinJ, COrdOll (momentarily 8Queeu.lower g~stroene.millil). mng (light pinpriciu on darsolateral ~I ), GondaorStr QlUlky (pull thl! 4th or 5th toe down /lnd out a nd allow it to snap back!. "'" Hoffmllnn', .iltD MIlY signify a almilar UMN InlnTuplion to the upper extremitl<>&. Eli(;lted by Jna", pillJl thedis!al phalanx cf the Iniddle finge-r; a p8thologicresPOIISllroll5is ~orthumb nexion (may be weskly presenl in nonna ls). Can $Omelimes be see" AS normal in YOWiG individual wilh dilfu'l<!!) bri~ k renexes &. poiIitive jaw jerk, usually I yrometric. When present pathologically, N!preunts disinhibition ofa CB re n8lt, .". ind ieale!llNion ~bcNf, ca. 3.7.6. Bladder neurophysiology CENTRAL PATHWAYS The primary coordjn~ting eenl.O't ror bladder fundion re- sides within the nudeu8locu~ coerule u8 of the pons. Thi BOOnIA.lr 8ynchroniu!'I bladde r eontraction with relaxation orthe urethral sph,lIcle, during voidin, .. VOIW\t8ry cortieal rontrol primarily "wolvei inhibition of the ponline ren~, "lid Otigin81.O'8 in the anternmedial por. FlgrJr. 3-15 LocaliOfl 01 lion "rthe frontal lobes .lId in the genu of the rorpu~ callospinal cord bladoer eN.. • 8Um. In an uninhibitt!d bladder (e.g. infanQyl the pontine voidingcelll.O'T rUllclions wilhuut ""rtiCIII il,lhibi tion !lIld lite detrosor IIl"aderontr.ctswhen lite bladder ru.ch ua critia,,] capaci ty. Voluntary .uppre"i~n from theeol'tel< via the pyl1llOidal tract may r:ontratL tha e~ternal aptlinclerllnd t:lay alIIo inhibit detruwr rontraction . (."orticalle.e.iofUI in this 10eaU"n - urgency ineontinence willt inability to luppr,," th~ micturition renex"".'''IJ. Elfen!llt.i; to Lhe bladd .... trllyel in IhedoNl~1 portian ofth .. !al<!ral ""Iullln. of the spi_ NEUROSURGf:RY 3. !'leuroanlllolny gnd phYlliology " nal cord (ahaded areas in Figan 3·/5). MOTOF! There are two aphinctera that pre,·ent the flow of urine from the bladder: internal (a utonomic, involuntllry control), end external (striatOO mu""le, v"luntllry control). Paruymp athe Hca (PS N): the detrusor mo""leofthe b!addercontracts and the in· ternal sphincter relaxes under PSN stimolation. PSN preganglionic cell bodies reside in the intennediolater al grey orspinal cord segmenta ~_ Fibe,... exit e8 ventral nel"l/e root.s and travel via pelvic splanchnic nerves (n ervi e ri&"<!Dtea) to terminate On ganglia within th e wall of the detrusor mu""le i.n the body and dome of the bladdCl'. Som etl c ne rve ..: somatic voluntary oo nltol descends in the pyramidal trM! to syn· apae On motor nerves in S2.4, and then t ravels via the pudendal ne rve to the e><temal sphincter. Tbis sphincter may be voluntarily contracted, but relaxes reflu.ly with open· ing of the internal sphi ncter at the ini tiation of micturition. Primarily mainl.pin8 <:<lnti · nence duriog I vesical pressure (e.g. val88lva), Sympa the ti c.: sympathetic cell bodies lie within the intermediolateral gray column of lumba r api nal cord from segments T12· L2. Pregangl io nic uon. pass through the sympathetic chain (witho'J t synapsing) to the inferior mesenteric ganglion. Postgan· glionic fibers pass through the inferior hypogastric plexus to the bladder waU and inter· nalilphincter. Sympathetics heavily innervate lhe bladder neck and trig!."'e. Sympa thetics have little effect on bladder wowr activity, bu t alpha adrenergic stimula· tion results in bladder neck dosu re which is neceQa ry for bladde r follinII'. Pelv ic nerve stimulation - increased sympathetic tone - detrusor relaxation & in· creased bladder neck tone (a llowing larger volume to be accommodated). SENSORY t...,.S!; well UJlderstood than motor innervation. Bladder wall stretch receptortl sense bladder lilliI'll' lind send afferent signa19 via pelvic, pudendal and hypogastric nerves to spi nal cord llegmentsT10·L2 '" S2·4. Fibers 85C8nd primarily in the spinothalamic traot. UAJNAAY 8LADOEA DY SFUNCTION The tenn ne uroge nic bladder describes blAdde r d}'$Function due to leBion~ within thecentrai or peripheral nervous systems. Some use the tenn synonymously with detru· sor arene1<.ia. D0r881 (sensory) root.lll~ions interrupt the afferent limb, producing a n atonic blad· der that fills unti\ dribbling and overflow incontinenC<l """",r. No sensation of bladder fullness is appN!Ciated. Volun.tary voiding is still possible, but i~ usually incomplete. D.:!trullOr hype .... eflcI la: Can result fron. inten-uption ofefTerents anywher e from cor· tex to sacral cord. When a cri t ical volume is attained, renex bladde r emptying occurs. Clinically associated with frequent, uncontrollable, precipitous VOiding. Cerebral lesions indude: CVA, head injury, brain tumors. hydrocepbali.18, Parkinson'a disease, various de· mentias, and MS. Cord lesions include anything that causes myelopRtby hee Myelopa · thy, page 902). Detrusor llJ'eflcxia: Clinica lly correlates with difficulty initiating micturition, inter· rupted now, and significant residual urine .lnro ntinence may re5ult from ovel'-rlilltention of the bladder (o ve rflo w Incontin en ce), Or may be assodale(l with absence ofspblncter tone. EtiologiC!:: indude: ch ro.:l.ic infection, l<'lng.tenn bladde r csU,eteriution, certain droi:ll (es~;aUy phenothiazines), injury or lumor or!he cauda equina or conus med· uUaris, myelomeningocele, aod diabetes mellitus (autonomic neuropathy). In general . rega rding discrete neurologic lesion! affecting the blsdde ....: I. IIuprlUlp;nel (lesions above the brain stem )' loss of centrally :nediated inhibition of th e pontine voiding renex. Usually produces involuntllry bladder contrllction8 with smooth and striated ephioc\.Cl' ")'!Jergy, often with p~rved 8ensation and volunUlry striated sphincter function . Symptoms: urinal)' frequency Or ucgency, urgency incontinence, and nocturia". If sensory p!lthwa}'$ are interrupted, un· consc1OUII incontinente oa:ur1I (incontinente of the unawares type). Since muscles are coordinated, normal bladder pressures are main tained and there is low risk of high· pressure related renal dysfunction. Voluntary bladder emptying i, usual · Iy maintained, lind ~imed voiding together with anlitholinertic medicationll ara used in management. Areflex.ia may sometimes occur 2. complete (or nea r complete) "Pinel cord I~ioo" " 3. Neuroanatomyand physiology NEUROSURGERY iI.bmr.e. the 52 ,pinal ~ level. which is ~ T I 2/l..1 ver' tehral body level in an adult): the sacral voiding center is located in the co· nus medullari$. Etiologies: spinal cord injuries (after spinal shock bas 5ub~idedAJ . tumon;. transverse myelitis _Usually develop de!,Cu80chyperre. Jll:xi.lI- involuntary bladder contractions without sensation (autom at ic bla dder). smooth sphincter synergy. but stri ated dyssynergy (involuntary contraction of the extema l sphincter during voiding which produce. a fi.IJ1c· tional outlet ohstruction with poor emptying and h.igh vesical pressures). Bladder fills and emptiea .ponlaneously (or in respoOBe to lower extremity cutaneous s timulation). Bladder compliance is ofu!n reduced. Managed by intenl)ittent catheteri1ations + antichohnergia B. intT8IIIIcraliH io n s (lesion below the S2 spinal cord level): includes injury to conus tneduLlaris, cauda equina or periphe ral nerves (fo rmerly referred to as lower motor neu ron lesions). Etiologies: large HLD. tnuma with com · promiseofapinal caDal. Usually develop detrusor sreflexia. and do not have: involuntary bladdercontractioo8_ Red uced urinal'l flow rateorretentioll re-8ulta. and voluntary voiding may be lost. Over flow incontiDeDce develop6. There may he reduced comphaoce during Iilling. a nd pa ralysis of the smooth sphincte r. Usually associated with lou ofbulbocavemosusand anal wink rene:.: (preserved in 8uprasacral lesions) and perineal sensory l088 inte lTUpti on o£the peripheral .... ne:o arc : may produce disturb.ilnces similar to low spinal coni injury wit h detrusor arefle><ia, low compliance and inability to relfUI the striated sphincter herniated lumba r disc: (su fJOIlt 302) most consist initia lly of difficulty voiding, .training. or urinary retention . Later . initative symptoms may develop spinal8tenosi. (l umbar or cervical): W'Ologic symptoms vary. aod depend on the spinal level(s) involved and the type of involvement cauda equina syndrome: usually produces urinary reteotion. although sometimes incontinence may OCCU r (some eases are overflow inton~inence) (sec fJOIlt 305) peripheral oeuropathies: such !Ill wi t h dialxltes. usually produce impaired detru. SOr activity neurospina 1dysra phism: most myelodysplastic patients have an a reflexic bladder with an open bladder neck. T he bladder usually fills until the resting residual fIxed e~ temal spbincter pressure is exceeded and the leakage OCCUT$ multiple scleros is: ftO·9O%0fpatienl.8 develop voiding symptom$ at lOme time. The demyelination primarily involves t he posterio r and lateral columns of the cervical spinal cord . Detrusor hyperreflexia is t he moat OOmmOD urodynamic abo normality (in &()..99'I>0fcnes), with bladder arefluia being le&l common (5-21)%) A. IIuprasacr a l (lesion 3. 4. ft. 6. 1. 8. 9. URINARY RETENTION Etiologies of urinary reten t ion: 1. bladder outlet obstruction (a briefdiffereDtiaJ diagnosis list is presented here) A. urethral stridu re: reteotion tends to be progressive over time B. prostatic enhu-gement in males: 1. benign prostatic hypertrophy (BPH) & prostate CIInCer: retention tends to be progreSllive ove r time 2. acute prostatitis : onset of retention may be IIlId!I.m 3. rare: extruded prol!ta t ic stone C. women may develop a cystocele whkh cao produce a urethral kink D. rare: uret hral callter 2. detrusor arenexia (u, poe, 90) or hypotonia A. s pinal cord injury B, cauda eqUlJla syndrome (s« page 305) C. chronic infection D. long.tenn bladder c8 theteri~ation E . certain dn.lgs (narcotics. pherlOthia~ioeal F. injury of tbe cauda equina or COIIUS meduLlaris, o. of the spinal cord at or below the sacrom I. tmuma 2. tum<>r 3. myelomeningocele A. durin&: , pin.1 'hook <- pop 698). <h. bl .d~, i •• ttmtr. ",iI" . phin ... , IO<le ...u. lly ~" .... ood urin. 1')' d_ Ml O«\I r e. .. pt wi'" ov.rdi.lenhun) NEUROSURGERY ~ te nli o n ""d ... Ihmc [~truso, . ~n.,.;. ~ i. Lhe ",10 (urin.ry in<oon.i .... """ re • • "lIy 3, Neuroanatomy and phyaiology " G. di"betH mellitus (eutoll<lm,c neurop.thy) H. hup" '<lISter at the lev.! flf Ih" u~r.1 do .... 1root langh . .. '..•.. I. ;nCllmplete openi ngofthe bladder neck; OCCUJ"I .Iroost exclusively in young males with lonptandinl flbslructive and irri tative Iymptoml·. ··"'" J . following severa blooder over disteo~lon froo, M)' flfthe abQ ... e 3. postoperative re~nlion: weU·rtc:...gruted but pOOrly und.,..,IP!ld. Mureeummoo Ir· ~r lower urinary tretl , perineal. pneoc:olnlk and f.l)flr~t.l1 o!'l •• tion•• Melilh",· ,ia and enal~.ia may colltribute to. nurn'M r offacto...... '. ... 4 psydl"lenic EVALUATION OF QUDOER FUNCTlON URODvN"M/CS Urou.Uy tOmbined wIth :..."" (o;y6to .... lrnIfr.m (CfttG)1 or nUll"" (v id*"u.odynam. ICil. MeMllrel inl ...... aieuJar pruaure. durin, ,..trognd~ blBdd~r mUn, through" urethral catheter. usullLy comhlMd with Iphlnct.l!r electrolD)'OllJ""phy. ~Hnce or ablente td~lru""," .~n.l<.i. ,.u k/.,...)oI"detru"". ,..flu il detected. Ifp.uent. plVtedur. is repeeled. askin, plltient to .u~reSl thl! UTi" to void. Inability to I UPPI"dI i, CIJled "n un · mhibittd detrulO. re.nu IAKA detrulor hyperrenexil • .Ift oboo<! >. SPHINCtER ELECtROMI'OGIIAPH'f (EMG) Eillw.".. needle electr0Ge6, Or .... ith externaJly lD(>u n~ w rflrotl e:lectrodes. VoIu,,uny .phincter CUnlra~I>Ofl ...... IlIl.aM:tnea ol l uprlUlpinal innervllti(ln. When CClmhin!l<l w,th CMG, det«ts eIHlrical.divity;n Iphinden during Usocillled "hue!" ordelruaof contr1lrtion. VOIDING CYSTOURETHROGI«'" "NO INTRAVENOUS PYELOGRAPHY (IVP) Void"" c)'ltou.e~luvcrn m (VCVG ) del.e1:t\I u",wlIl paili(ltogy (di vertkula, stric· tUtes ... )' abnonm.li til!l oIbla4der (diverticula, detroSOl' ~tabecul.lio.'1li" Usocillted with ionpu..ding contracl iom apin.t high rN ilt.llnce ... ), Ind vesical-ureteral re!lulI: , T REATMENT Goa.Ia II'f to prt&erve renal funttion (wh'~h lUI ually iovolvilS p,..,veotion ofUTb,"'" filii clIlculi, and ureu.ral renu>; due III high int,..,yesiculu preslUres) and opti millition or utinllry rontinem:e. Palient$ "',minad~uate emptying or incre.sed bladder preuure I,.., often II\3nlged by intermittent c.th.~riutiGIII I nd I1Iticholinergica. Anlicholinerti""'lInd beiulvio ... 1 the..py an used fur patients with mIIintained voluntary blldder emp~y'ng w,th Utlnl!"), frequef1cy or urgency incontinen~. 3.B. , , References _1<~ TI';",a ''''''' afn. .." ... -.-,.. _..........., ])tSowI~~.~, 0 , . - G. 0,-- J.ldlKlo E. n ... ~..;n' ' - ' '..... Il1<01 .............. _ ............. "'ft","""ltlot _ .. _"'"""'""-....:.~ , . In 1'"'''''''' ) ''''~.I," Sorut.I"'."',..IN 1..."""',.,... """', ..... _ ........ j,....,,""*""' " ...."" ........ ..,-"",-...,._,.,.. " ....... In ... _, . ..... • , •. .. • ("_~ J_-. 76: 101-"10 . 199:WI" .. WD.Gt_.RG ,...""""_ ........ ~ I.MeoIic>oIMMI"CIIIioIoslr ("V_.lI 1....~.),d .d . ' 91j pp'91,'. W.. U;~ R. w ~Iw... ~ L,I" . ~ Grv-o_,. }S"'..t. WII . S..........,IoIIoIjoIoI. '97) Ki40D,LlMo1 M. LI.",_" .,• . C~ .... """..... lorolb.oo_oltht _ _ l)"IrO • ••• '"""",,1.J) 11'-T,IUO M.MI,....Go.n...S.\I,_F .....~ I_""" . ""'''''' .... """", r.OM)oo.oIIo<"'''_ C.... " w._ ........ . ..l1>li_.'''I. ~ 1I' _ 1»M. I"'-1. I [ C,-·..u.. af~ "'<11, T. 101"...... 11 " •• _"""'S S.(.... ,): ....... -..., ~·IIiI.Nt .. Y.. ~ , t~ . ..--.,w. lMMLI. K... rL"_"' ... _ _ JooI ............... Mc<Ijnj_... .... 0Ii<. ., 197l. eo.o,.l.C.... I"l<Io .... ......,..".aI_,pI_ _ , . . , . . , . . _ )1'<......... " fIH. '9IS W.. I.J"'IIG' ......... <____ .... _101,..,.... __............. I. . . . " ...v .."" f'Icw 't'-" ''ill' ' -6 roo.. . _ _ l>t'1Ioo " " " ~ lIP ~"L, .. . ,...~-.Io- poo.o.< ... .... _~ ~ 1'I.. -.,..,4 10s..JIIII~S'.I).' 1'I , n_JM . Woocle" , ~ ___ ItJ 2flCl0II w _ _ W.l... aoll_. 't'7t. T _ I ~t Stria .... H..... O' ' _MlII"Yoi NEUROSURGERY ,..."um"... " '''"«f''O<lI . ..... A",,~ph. l<uob,.,,,1od) I N.",,,.. ,~ 1~ ~1 1 · 6S , 196ol . " . do, Z ..... 11. . Hill.,. 8, TW. ~." CAl'. to oJ .. v.",,,;mr ,.m'OI'ie>o/ 'IIe ...)OI' """'b .... ... .." ... J """....... '1 IWl g(,,,,, '1, ,:r...o. doI._ • E. "'lI'ab....!chunS'" "c F;I<"" ~lm ~"""Id. Z<.lnlbl "".I'fI<""'l'JOI). » " " " C Die " " " U "n . ,"C tII~ l1. 1911. Sot.,l\illiof II ..... I,.c""... H M. Kd" J1' kII· ...... 01 ,II< in.."", , orOl..! ~fJ" A ...... <I . .. ,n · .~,.'). I'M K"1,.1>Uh1 H. y..,..,,, MG, R"",,~"' _,,~,",j. tU~M"W/O'" I. 7......, ...... onKler.' "'pblt!lo. ~I;nit. ."d p",". Hobo, r .led.) TIl, .... Y.,IIS.S,""'"'" 1m : ".,*:016 """"" "".,,,,,,,,:,,,l1: E<~ .. ...'...,,_d Clout, A. il.. _no<,iIorI " I\; '"A.~phlc Io<.oU .. t~ofiat ..........w ......... ,ClI .."' C. n · """ •• s""",r.. kJ.III ,,,,,, •• ' 9" "".)l , K"I~.t.Ii,., H ,. . y ... ",,11ot G. In C...... "'I •• • "",""~~r O"'" .... """..LDnd<>o. <n<l 00. 1%Ii ' pp It<M W H. R"'"" II l.: M.crooIIr£lrnl_r"f ,...... It..-"',;,., J /'<'C\I ....... ~l· lU·". 191) R""""'"L.II. Tb<_ .... Nt-u ..... ••• ,... , " (' S-rplI: SlJ.l20. '.!CIOl. ll<t<,) R.R_ "L.~"', ... oI>I ... T "DI~ M """ .... JI<~ ."'''''''1 or .... "",:<<i<!1 ;01'...... """boll .. ...." ",...--.-..,.,. 10 . 11'\).99. 191:1. C; ...... CC.O':i"*'''' ....) 0 91(,<1<11., s.u.,<01 """'"l"meni of ,_o&! _01)'''''' :.. ". " ". N. '_flf'l II NEUROSURGERY _""'I. J N........"" 7~: 1IJ7. y .... "') 1t.(N 1 "' ......... &1<..........,.,. ltt<l,,,j . "'. 8 s..oden.Fh;~~; • . 198Z. 1....... rl, MoIlaM 8 .MoIkrA R-~r"'...,. >11-.1 "¢IIi,o, /I t:nal J Mf<I )10' t100-).19SoI _ ,n.._ Ncu"",~ EII.O"",. P .... MtCormo<k C ~ "DI< O' ..."' _ _ 'Ht.om.. M...,. .,.,.,.,""i_-".• lb~""",.uMl _ _ "'IkU•• " U. .. « _,"not IloMl.,a !>n". N"reAI'II<'" 11 .,9·11. "IllS. $ ..... H). lIoI;" H I.. ~ : .... lot H' I.!.,. "" ...... .)'00""". ...., ". 11._ " ... ... ,.... 0<IIc:.., """...... fo,,,,,', _ ,;.,.. •• ,r"9n . u.. (toIU .."" " vol.,., .... (><»..- ..fu.,,«I'Ob:II .. ....,.,.c..... U. f'h<, ''''''''.n<1\n ""'P 1'''''''"'''11 26 (9)1 ,·7.:I00I S<ltrnidU II II ,,,,,,, l M. ;'; ... p l P ' T"'~ ""_, ')'SkIIl,Nor", ....,"'.,. 11 64.1.78.. 192~ TlpIa ) N' no: _.I""_~ " ~ k '" oftl><_",,,,",,,,,, k. ,.,p(i<OI ... , r",,,..,......,. ' ...... I01 ... 712·1.11>11. l>ioI:""'''''''' ,..... .... 1119' . ~ , . Gil>o H ,t..."~yC.~"L.. Mo<_~".'",",· "'"r or,1I< .opn< IONHd ~"on of",. ,...mol ...... ........ , ' J N"_"' J"· ~l'.l98l. ...."., Soklla> I.N· ot>m>"~_"', ,0' ~0>1.3 '''' __ ..... , 1.. ",. 10 To"..,,,. of .h •• r. aial_, I>O •• ,.s........ I./'I ..., S<~_ Y L.I..:I>.I. fIio"," P\d)~""", . M""", Jtn ",~, 1911. ppst~I~ . u..-.~ , F. """"," H' Tht "'''''oj . . 011 or,,,",,,,.· • .,.,." ....... "'iU 'l>"<t.1 ,..r....-1"1II< Moon ,.· 101.. ,,, • . J N."~" . , 16 22&.1'. 1~1 "01.40 .... II~. ,...11 .. JT.E'·KalIOI)' M. ,,~. .U'''' ' r _ N....o!ou :""..,. Mo;(in.".n,tl. "'~ yert\.. l'ltl MaItu. I C Flo.", ~t.o .......""""'" I. ct..~1r<" .. io~ """". _ """"'" Ic:< ...... olr<b " ...1'01 4'1 1, 9!t .• • lm. OontnwInCJ. _0<1; W) , Th< trn. "'" O!>Ii ... l""""""of<I i< ~_I ......, \ J39.4 ' . I9'7J. ~ -n. 1\J!C>' t>J" "'."".,'" bia'.l<l<r 1oI"•• .......,..,,_ . C"""""p H.I999. .(>10'" • "'OI:Di_ '" ~. (J, 191.!109.llio6l. Mom' It D. Y'n. M: Pri"'lpI .. oe ........ ,"I1. "'_0.,11(.,· w, "' ... J N'"'_<></rIQ'dpf'<M'''''' ."""'"".<, ,.,.,.,,, ~_'. ln "'ii < "'_, C_pboO', . _ "11'. w.l>~ P C.~,riIr II B. "'_""" t o . .,oII.• fOll'.I. WO ~.I'b;"",,,lpioio. 1O/1«1 .• IWIi. Y'" !. Cbopl<'" I'l' 9ll·loot;, 3. NIllJroanDt<nOlJl end phY8'(lingy .'''' ) ..... • 4.1 . Arachnoid cysts 4.1.1 . Arachnoid cysts, intracranial AKA le pto me ninge al cy~te . di stinct frompMllro",.."IU: J~pt.Gmeningeal cyst:! (AKA growing sku ll frfIctW'ft, _pa£~ 668), and "nnlatt:d to i"f<!Cl ion. Arachnoid cy.1.a (AC) am eongenlUillel!ion. tbat arise du ring d .... elopm(!.nt from splitting IIfsrac:hnoid me.obrane (thu y they nre tecl1nica lly jntrfH.rochrwid eyst.s). "Tem poral lobe agenes;, syndrome" ix II label that had been used to de/lcnbe the findings wIth middlecranilll J"ossa ACs. This leon iii now obsolelesi..cebl"aln volumes on uch side are actu ally the l ame'. bone expalUJon and shlfl of brai n malLe' accoun t fGr the pa.renchymll that a ppellrll to be rl!plsced by the AC. In cidence i5 5 per 1000 in ftUl.Op~y series. Tw o type. of histological find.inga·, L "!limpl\! IIncbnoid t yau": " .lIchnoid lining with ceUs that apP'!lI r to be tllpllule of active CSF s.ecrelioJl. Middl ... fo;lSSl cyst.<! seem to be exclusively of IhiB tYJloi! 2. cysts with tnore:complex lining which may slaoOllntain neuroglia, ependyma, and O lh~r l i,o;su., type~ PRESENTATION MoslAe" thaLbecome symptomatic do so in enrly childhood'. The presentation varies with location of th e ~Ylt. and of'l.entiruu appear mild con sideri ng the large 'Ii ze; of some. Typical prllsent.a- tions are sMwn in Tllblf "_1" and i ndud .., Tabla 4-1 Typical presenlaUona 0 1 araehnold cysta - --Mldd ll los· .. ,yt l. SuprastUar cy5l1 wllh hycl,ocep!lalul -, ~ant.l1 headache h)1le1lftnSior1 hemiparesis developmental CIeIir~ 'iWa11oss D,l1uaa I Up"'" or Inlra!flllOf1. I I cyJts with hyc!racephalus inUlICIa"lia! hype<1ensroo ganiotr~ ~mernaI 08Ia~ I. ~~"'!1<111'~ symptom$ o(;n· t rBerani,,1 hypertension (ehwaLed l e p): H/A, NN,lethargy 2. eei~urea 3, ludden ddt.(!rioration: A. due to heloorrhage.(into cyst or au bdllul cum Pllrtment): middle fO&" cyst>; are notoriou . for hemorrbagedu!! III t.ear1ng of bridging vejlUl . Solue sparta organj~tion~ do notaUow participation in OIIntact$port5 for thue pat ienUr B, dlletoruptureoflhecyat at a focal protr"u~;o n aflh., s kull wilh focal BignliaymptOn-.. ofa space occupying le~ion incidental finding di scovered during evaluation for unrelated condition 7, su prasellar cysts mlly additionally prellent with': A. Jl,)'drocephaJIUI (probably dne to compfl'alIion oflhl' third ventricle) B. endocrine sympwma; QCCUN in up 1Il6O%.lncludea precociou./l puberty C. head bobbing (th e t a.ca lled "bobble-bud doH ayndrolue"): con. idered lug. gt!'St.iVl'-o{ , uprll'l4!!i IlT cYlib!. bu t O«UTS ,n aa few at 10'J> 4. o. 6. 4. DevelopmenltlJ anom~Jres NEUnOSUnGERY D. vi.ual lmp&ir!llen~ OISTRIElUTION Almon all OC:CU r in ,ela lion to a n arachnoid cisU!rn {ncept;\ln: iotrasellu, the cmly one that;, (!>i tradural, • • TobI~ 4.2). RetrOCt<Tf!belbr arachn oid .:ya18 may mimic DandyWa lker malform9tion {Hlgf! 110), Table 4-2 O!stribullon 01 arachnoid cvst.· <1ft! EVALUATION Routine evaluation WIth CT Or MRI Is u5ually l at15fao:tory_ Further eval uation with CS F c"ntra~t Olr now 6tudie, <ciste.rnograms, ventricuIOlgralll s ... ) aN! only occasio na lly "" _ ry for u,ediogn<>llis "fmldline suprOl!lIltar IlIld politerill' fosSIl !esioll/l' (ror DilTe~ntia l diagnOl;Ls,.", llllr<U:f'Qllj. III C)'51~, page 928). See Fig~~ 4·1 for da..sification rOl, middle fOSSll cysUl. CTSCAN Smo<>th bord ered non-caltilied ext.aparenchymal cyatic Clan wilh densi ty .imilar t.o CSF and no enh.ancemeDt with IV cont,ost Expansion otollllrby bon~ by remodelling is usually ""eD, con finoiog their chron ic ORtUN!_ OlWn lISlIOCiated with V\!otriculoClegaly (in 64% of 6U pl1lU!D t.o ri a llllld 110% ofinfrat.en!.Oria! cyata). Convellity or middle fossa cysl.9 exert mns5 effect on Blljaoonl brain and may com;J Te sslps HaU!rallate ral v"ntride and [)ll u9O! midline shill. Supnuellor. Q:uadrigeminal pl a te. IlIld midline posterior-fossil eyst.s may compra.a thathird li nd founh ventride aod c8 us~ hydrocepha lus by "bstnJcting the foramiDB or MonrOl or lhe Sylvill.n aque- Typtt l: ~ bioorrve~ kx:;ol ed in anIIlrior letnpo!ll\ ~. No mass etfeet. Communic::aIIlS "'~h subilrac:ll1Oid Sf*:e on water~DII! conlra>! CT cis· ten\Og'iIII1 (WS<TC) TI'JlII !t i'1'foflof!$pr~at'Id jrtemmte segrnenls 01 SyMa~ flSSlJ rct. Comptelely opeI'l Jnrdl giVes r~r 5hape.. P,ni,1l COOYIlIJRicaIIOO on WS-CTC dueL MR/ Br.tler than CT '" different iatinll the CS F contained In 8,..dlnoid ey.;11 from !.h.. tI"'d or ne<lpillstie cysts. May aJli<) show cy5t wal ls. CISTERNOGRAMS ANDl'JR IIENTR/CULOGRAMS Us ing "'i ther iDdinated cont.rast or radion uclide ttacer1 Variable rate of Opaeilic8\.ion W .... ~ulted in diflkulty correltltin g r p3u!ta with operntive findings_ Sollie cy~t3 are I>(:tuo]ly d ive rti.:. u!p. aoo may fiUw lth rad.ia tracer Type IP~ rr.ot.l!S entire S)1v~ an IissuID. Mallled mdile shin. Borty e~panslot1 01 mod· die lossa (elevalion o! lesser wing o! spheooId. O'J1WartJ ell' pansion of ~s terlIPGral bone). Minimal communblion on WS{:T C. $Ufglcl.llreatmem usuall'f does not resu~ in IoIaI rtol'~ pension ot brain (may 3:1prOilch type Il te$iOll) Qrcont,.,.s ~ NEUROSURGERY " TREATMENT Mlllty t but n04 a ll ) a .. thon rf\COmmend not trealitll/ aracltnoid Cfst.& thai dOl not tIOUN mlln elTect or symptom" ""lIrdll!M ofthei. ,iu and 10000tion. Sur';..,.) tMalmeRl optiona are iummariU<! in 7"blfl4.:J. Table . ·3 S u.glc..llr •• lmfill opl lonl lOf . rachnold eylls CYST SHUNTING Probe.bly Ihe ben O~1'1I1I treatment. For . hunting into peritoneum, """' a ~ I(u......, II ronm....,..t ~.nlrkulomeIt8Ly. on. may 8imult&n~u!ly place" ventocu.l •• Ihuntle.lI'_ I.htoUJb a -r conneccorl. Ultratound. ventricul<I8tQpe, or 1m. guidaDCOlmay u.is till lcatlngsuprll.\lllllarqets. Shunlinrofmiddle f0Sll8 AC. mil) o[so be a«OQ'lpiahed through tht Jaleralvenlride , thUil shunting bot-h almpartmvlI,s', nIlS ... I..... 5uPAASElLAR CYSTS TI'1I!8tmenlll propDlled intlude; 1 In!inS(:llIiI)$lJI tyt;~Wrmy " I"'n:utaneous vlrolricukM;:yuostomy' procedure of eh oiA orPielT8- Kahn et "I.', Puforroed via. paramedian roroaal bUIT hole through U\e IIIUlr.1 ventricle lind fo.amf!n of M ooro (may be r.dlluted by u&ing a venlricul~~) 3. lubf'rontal.pprQoaCh ffor fenennl;on OT R!mo¥/ll~ dongerO<>Ii and indf~I !¥'" 4, • ¥entnculllr d .... in .. I~: inefT«tjv" (aclu;)lI), promoleS C)'lI I en.Iat'Jemen t) 2. OUTCOME E'I1!n follow.ng IU«esslu! tl'\'/Ilment . portion ofthec)'S( ma)' remain due to the rft. modelinr of the bone Ind chronK ..hilt 01 brain tQIltenu . Hydl"OCl!ph al u8 rna" develop fo4· Iowiug t ...... I~I. Enclocri.nopalhia tomd to pt!BlAllI>'en al\er IlIC"a!Q flll ,."lItm.. II' of '"pn.sellBt C)'116. 4.1.2. Arachnoid cysts. Intraspinal 4.2. Intracranial lipomas I nlTl~nl. lllnd .Mrupol!.allipom" /lR rel~ 1.0 be fir maldevelo;Jfl"lenltil orisin" ,. .... ud mil" anN! from failunt otin¥otlluan oflha pnmilJve mMin".. 'l. Epidemiology ot i.ntra~l"'llJ)!a l lipo m/ls Inddo!nc.t: 81n 10,000 outopei"". U'''11I" round In or near lh.e llliduCl t tllJ pl.~, pIIrticuiorl)' over the corpu'Qlllo.um (I'pomas UI ,hi, ",~n a re frequently • _ _ ted " 4. De .. ~opmen\llI.llOmll;es NEUROSURGERY with »genesis ofthe eorpu.. (lIU""um,~, /Xl&" 114). 1'h('. tuber ti nereullllln.d quad rigem· inal phl teare frequl'ntly affected". Rarely , u.eCP angt,",orc~rehellar ...emlie may bf: involved. May oc:cur in isolation , bu~ also has been dfSCribed in anociatiOIl with anum· bu ofoongenital anomalillS. Includin,: tri$omy 21. Pai's syndrome. frontal encephala· cele. fecial anomalies. ,.. Other midlineabnormolitielS may . lso be found: ogene8is of!.he. tOrpu~ CIIllolJllm, myelomeningocele, and spina bifida" . I", E valu a tion May be diagnosed by CT, MRI (study ofchoieel. and by ultrawUJ1d in Infanl8. C'J': Low dene' Iy, rtl6Y hay,", peripheral caJcifie>llion (difficult Lo apprec'iate on M RI J'~_ Oi rrerentisl diagrOllia on CT' primarily between dermo~ cyst, teratoma" and ge rminoma " . MR I: characteristic finding l& a midline lesion with signal ch... raCterlslU:~ orfot (higb int.enaily on Tl.Wl. low inten5ity OIl '1'2\\'1/. P r p.s e n ta tio n Often discovered incidentally , u lr'ge Lipomas may be assoc:ial.ed with sei~un!8, hy. pothalamic dyarunction, or hydrocephDlu8 (pos6lbly from oomp r1'Ssion of the eq ue<!uet). ..... sociated findinp that mayor tIlay not be directly related : .oeotal reUirdalion , behav. iora! dillOTders ond headHche. 1'reatm ent Direct eorgical approach is Hldom nE'Cll&Sll1')' for il)tlllcr~niallipom.81'·. Shuuting OlDy be required ror caSO!'! where hydrocephalu8 n!sulta fron, obstruction ofCSP circu lation" 4.3. Hypothalamic hamartomas Hypothalamic hamartomas 8m rnrll n(Hl-neop!a.tic oong.mitAl DUllfonnDliona <'lll1' .ilit ing ofnuu;ses Ofec:lopic neuronal tissue thot arise rrOOl t he ioferiorhypoUllllamul or luber cinen!uttL Cliniea l rnanl festationfi include: I. spedfic types of&fltures: A. gelll.Stic (laughing) ""zurea: the mOt'll characteril;tic type , Res;$lant \0 med· luI maml,ament and can lead to COf'titive and b~l!.avio.. 1defidl.ll B. 19l.er development of complex pHrtial &f!izures, d rop aIUlckB-, tonic seizures. tonic",lonlc I"'lures. and Sf:<:Ondarily generall.ed liei,un!a 2. behayioral disturbance3 : aggreniYe bfhavior, Toge allacu .. . 3. prec:ociou. puberty 4. menuol teurdation 5. visua! il1'lpairmfO: 'I'wa subtYJIU ofhypol ha18mic hamartom88". 1. pedunculp\.el:l 01' pIlrahypothaJamie: MrT'Ower base al taet.e-d to the floor of the hy· pothalem\l.ll (not Bri8ing wilrun hypothalamu s), Tend to produce precociOO8 po · berty more t han they produCIi'-gelaslk sehure. 2. s-esaileor intrathalaml<:: broad atUldllnent to hypOthalar.:ou li. More often associ· alA!d with gelsstie seilUre9 Treatment Treatment .ltern&t'v8ll: 1. medic.] tTeat.men ~ for precocious puberty 2. .Iereotact.ic ..di .... uf'£')1')' 3. ~u tgieol resec:tion Indieolion" fllr surgery: I. precodOUI puberty tIl"t faiia \0 respond 10 meo:!icallhera?y 2. );I!lllfllc .eizo res: no effectiVil med~ll therapy'· 3. neuroll1(ic deflcit from maSlleffect or the tumor SUrgicaloption8: I. ptt>nonal approach 2. tran_lIosal anten or interfomiceal" 3. neuTOt!ndO>lCOpicapproach: difficull because vel1tritl" aM ra rely dilated NEUROSURGER Y 4. [)"v.. lllpml!flUlI anlllllDHe~ 4.4. Neurenteric cysts No uniformly ao;cepl.ed nomendature. Working detinitOo n: . CNSc)'It lined byendo. thelium primarily rtllembl..ina thatoftheGi tract, or le$&ol\en, the rapil1ltory tl'toct. Not true neop{umll. The mostcolDnlon .ltenatt term ill e n ter oge no ul c y a t , with 1,.. oom· mon U,>rm:i including: tel1ll.olllatol.1f; cr-t. intntinoma, ar(:hentenc C)'It". enttl"Ofene cyst, and endodenllal c)'It. Uwally affect UM upper thoracic and cervical ,pine, a nd other associated developmental vertebral.nomalin .r. commoo", &'-0 oc<:u r Intrac... n;. ally, including 6 reported en" in thi! «rebellopontine angle (CPA)" . S pinal neurenteric cysts (NEe) may h.~ a fistulous or fibrou. connection 1.0 the GI l!'IId and lOOle c.1I t hese e ndod erm a l .inu . eyat t. ' " - are thol1lhl tooccur al. rnu lt ofincompJett developmental separation of the noe.od!ord from the primitive guL 'MI lt is di, tinct from ;"'" !.led intracrani.1 entero&eoou1 q at&.. fool.,. C lin ical MOII( commonly prueol d",rin, the r\l"5tdecade of Ii,. ... Pain or lQ~lopathy from the intraspinalma.. are the mo&t common presentation. in older children and adulta. Ne'mal.cl and)'Ol.l"l children may preMnt with cudiorupi ratory oompromi.e from an iMrathoracic mas. or cervical Iplna! cord compreMion'". Meningitit may Ottur from the fistulous tTact. upec:iaUy io newbornl and infanta. Hi stology MOit are sim ple c)'t'" lined by cuboidal_ lumnar epithelium and mucin secreting goblet celli. Leu common typet of epithelium described include: stratified sqUll11l0UA and psludostratified columnar, and ciliated epi thelial cells. Mesodennal componenu may be presen~ including I mooth mu.-:le And Adipose tiuue, and some have called these Ulr· stomatou. cy."'''·'' which it not to be confUHd .... ith teratomaa which are tn>e germinal cell neoplum • . Trea tme n t Complete removal of.pina. NECI usually reverses the symptolll8. An aoiherenteap, ule msy prevent completo ~jon of intracnmial lesion&. which p..,wSp0se8 todelayed reaJlT~mce and mandal.cllong.!.e nn follo...··up. 4.5. Craniofacial development 4.5.1. Normal development F O NTANEL LES 6.u.tJtri~_ntJ!Mlli:: the largest fontanelle . Diamond shaped , ~ em CAP) _ 'Hi em (transve ... e) at birth. Nor mally d ose. by age 2.5".., ~~Q[ footwel!e; triangular. Nonnally doses by age 2·3 mos. and mutoid fontandl«: arnall, ilTegular. Normally, forrnercl_. by a~ 2-3 mos. latUlr by age I yr. ~ CRANIAL VAULT Growth: largely determined by growth orbrain: 9~ oradult head size J. achieved by age 1 yr; 95'lo by age 6 yn. Growth esse ntially ceaaes at age 7 y .... By end of 2nd yr. bonn have interlocked at l utu"" and Further (I"Owth Ottu ... by accretion and absorption . Skull i. unU.minar at birth. DiplOe appear by 4th yr and reach a ,oa.xJmum by age 35 yn (when diploic veilll fonn). Mastoid pl'1Xftl: fonnationcommencu by age 2"... air cell formation ox;cUIli during 6th yr. . 4. Developmental anomaliu NEUROSURGERY 4.5.2. Craniosynostosis Ori(ina\ly caUed cr.n;Oiteno.i~. InCldf'llce: ~ 0.611000 liO(f: birth •. Pn"lIl1ily' pT. natal derarlOit)', po. Lnatal cranio.ynOlltoaia (CSO) occu"' III><'OJl}monly (postnatal "ause. cone;~t pri n •• rUy orpoilitioD~I . lt. •• lIon. which roay not repre" "l trull l ynClltotitj. CSO ie ,...,,,Iy nlOci,t.d wilh bydl'l'lClphalui {II CP)". n.e I&sftrtion that eso may foUow CSF Ihuntinl for HCP II unpNtVen Iior(' ~ J99). Other calll~ (or f, ilure ornonnalaku U gTowth inc1ud a llickofbr.in growlh dl.le lo AAY orlhe "~III"" orarrelted d8Yelopmf/ltol'the eerebnll ria, ~e (.II~ea ofhyd'LlItnrtphaly... ). hltllli , phe~1 Uiu enoa pha ly. micropalm- 'I"r'fatment;. WlUQUy furgiCIIJ. In roost LllllIIncE'll, the mdiar.tion ror 'U rJl!ry .. for (0;1111"11 and ttl p",venl the H~re l"'y1: holoric;alefflct.! orh.""". didipnna d,l'orrni· I)'. HOWl!vtlr, with mult.lple eso, brain Vrowth IN)' ~ im~~ hy th e unyielding .kuU. Abo. fCP may be pIItholoBically eleYlited, lind a lthoulh th1& 1& morealmmonln multiple CSO". el<!vjlt.!d lC P oc:~u,..ln_ 11 ~ or ca~uwllh, s iDI1e,t.enotiel utute. Coronal.,-na.· w.i. ean ta use ~mblyoprll. MOiI\ of'inel. IUlunllnvolvemenl un be trea~ with linear neiaion of the l utu re . Inv olvement Dfmuh.iple I Uluru or th s kull bue ulllla lly tit." r elluj"" theoomblned effort. of. neU(OiIurgtoOn and eraD.iof.cillllurgeon. and /NO)' nead In till ~t8Hed in lOrD" ca_. Ri.u of I Uritry ,"elud.: blood 10M, te\1,,-,,",. I tnlU. DIAG NOSIS Many caJeiI of -'yoOllw.ia" .... ",Ilty dua to p(NI;tionlll noUe nil\f (e. r . "I.Ey l.tmb· doid". au IH:lowJ. U thit i. '1Upeete\t. inslJ'uet parenU to kttlp need olfo(n"IWied are. and tllcbl!Ck palie al in 6·8 wttlu: ifilwu poiIit.ional, it lhould tA impl1M!d. if II was CSO then il ul uully dk l" ..... ILllelr. The di .......it a f CSO may be . i~ed by . 1. PIIlJaoti<>n of .. bony pl'OminellC1e DYer the IUspected 5ynoatotie autura\UOIption. lambdoidall)'1l(lltDllil,.t b./ow) 2. I':~ntlfl finn pr~u~ ... IUl tha thumb. Wl.t to I'\!1JU;Y8 moye~nt of the bones on either lide of the luture 3 plaia sku\! x·ray.: A. laek ofnBI'"/I'UIJ Juoen l;)' In centet"ohut"l"e. Someee_ with oonna l x· ....y"". pearance of the ""tu", (even 00 CTt "'B)' be due \(J fOUl ! bon)' .picule ronn .. tion"" B. boos ten coppt!r calvaria 1_ ~~ 101), sutural d'liSllIlht snd .."",iOll ofth", Hils maybe seen in cases ofinc",8IIed ICE-t CT_n: 1<" hel .. demanal.raLe c:t'onlal rootour B. ros)' .haw ~hickening andlor rid~ng st the aiLe of,.,..,_i. C. ....11 demo .. alret.e hydrooephJ ... if preseIU D. nuoy . h_ expuaion of lh. rl'Onl.ai l ubaraclmoid sp __ E. ~hree-dim~Ii~ CT may help be~ter vi .... liu aboormalities 6. ;n queationsbJe ......... a technetium bon .. Ile8n tIlIl be p:-rformed"': the", it liWe ilolOpe uptllke byan)' ofthec:t'l ni el autu,," in the til'llt we;!Q ot"Jife • in prematurely clo-.nrsutures, intruHd aetiYJt1 almpam to the oth~ (normal) . uturel ...ilI be demonll:tnt.ed in compl ..tely cI~ IU~U""" , no uptaka will be de",orun.T~ted 6. MRI: ul ua Uy ...........ed ftI, ~ "'Ilh auoria ted inU'kl'\lni.J e bnllnnllolit;eli.. <men ell,,'" 7. not " I helpful .. CT measlltementa, ! ucb aaocc:,pilO-fnlnUo I-ci",umCe",1lOI! mII)'.wlJ, be sbnol'mlleve n In the fa«. of .. deformed I kuU . hape locrep,aed l e p Evidenot ofi~aaed Ie? in the n....·born with cranio.ynOlUllis includ<!: 1. radlographic'lpa (00 pl iin 'kull x·rll.y or CT. $H 4boue1 2 f.ilure of calva nal rrowth (unlika the non-. ynolll.ol,iclkuU wh ..... ;no;-relled lep cause. roacror:rania in the newbom. he", It ;' the lyn08toail thatrouRd the in· treued Ie? a nc tAllk orakull rrowlh \ 3 Pfoplliedemi -t o 1I..... lopment.al delay NEUROSURGeRY -to Oevelopment.al s nomahe. . T YPES OF C RANIOSYNOSTOSIS SAGITT,u, SYNOSTOSIS The mo.t common CSO affeeting a " nl/le luture; 80% male. Heaulu in dollchoce pb a ly or lICa phoce ph a ly (boat l haped I kull) with fron .... 1 bnuinll' prominent 0cciput, p'1p'bI. keel-lib IJIlgi Ual ridlla . OPC remains close 1.0 norma l, but the bip'rie\.al diaroeter Ui markedly ..dUM. Surgicall r ea tm e nt Skin inei.ion rolY b. longi tudinal or tralllverM. A linu r "ltri p" craniectomy i. per· formed. excisi ng the .agittal J uLure from the coronal to the l&IUbdoid l uture. preferably within the fiMlt 3·6 montlu of li fe. 'l'he wid th of th e "rip should bea t l.attS em, no proOf exi'l$ that interpo.i ng artificial aublltaneu (e.lI. silauic sheeting (IV' r the exposed edg.. of the p'rietal bone) retarda the recurrenceor .yno.~i •. Great care i. \.aken toavoid durallaceration with potenti al itijury to the underlying , upenor ••Kitt..l . in ..... The chi ld i. follo,,·ed and reoperated if fusion ree "MI before 6 montlu lIe. After . I YT 'ge, more extensive crenial remode llinll i. ulually required . CORONAL SYNOSTOSIS Accounts for 189lt ofCSO, roore common in feroal ... In Crou U)n'. I yndrom e th;. is accompanied by abnormalitie-$ of , phel\(lid, orbi\.aland facit l bona (llypopJu;' tlimid. face ), and in Apert'•• yndrome i. accompanied by .yrw:iactyty-. Unil ateral coronal eso - pla gioceph81y with forehead on affeeted .ide nattened Or concave above ~e(narmal side fa lsely appesMl to bulge abnormally), luprao(l.bital margin higher than norma l .ide ((III skull x-ray - h8rl equin eye l ilt'l). The orbit rotates out On the abnormal l ide, ond can produce omblyopia. Wi thou t treatmeot, flattened cheeks develop and \.he no. devi_ ates to the normal side ( mot of nOM tend . to rotate t.oward s deformity). Bilateral coroaal eso (usually io craniofacial d)'lmorphi l m with mul t iple lut ure CSO, e.g. Apert's) - brachycephal y with broad , nattened forehe"d (acrocepbaly). When combiooo wilh p~malUre d08L1A offrootosphenoidlland front.oethmoidal l utLlrel, resu lts in foreshortened anterior f0618 with maxillary hypoplatill , . hallow orbits, progN$Si,-e proptosis. Surgiealtreatment Simple strip craniect.oml oflhe involved sutUA has been used, often with excellent cosmetic """It. HoweYer, some argument that this may nol be adequlte hili been presented. Therefore, a moreculTf!nt recommendation is todofrontal <raniotorny (uni· Or bi· lateral) with lateral canthal adva ncement by taJUog off orbital har. METOPIC SYNOSTOSIS At birth , the frontal bone consistaoftwo halvH sepa rated by the froo\.al or metopic lu t" re. Abnormal dosure result.a in II pointed forehead .... ith a midline ridge (trigonocephaly). Many of these have" 19p chromosome abnonn.ality and are retarded. LAMBOOIO SYNOSTOSIS Epid e miol ogy Lons con.ider«la clinical rarity wilh " reported incidence of 1·9'/lo ofCSO'". re<:ent reportll IUllgest. hisher ineiderw::a of IO.~ wbich may be due to an actual increased incidence, or . imply \.0 increased aWareness orchangi"ll diagnostic t riteria. More common in males (male,fema le. 4 ;1), and the riaht'ide" involved in 7~ofcasn. Usually present.s between S· 18 monlhl of age, but .... y b. HIIIal early .. 1-2 mooths of .ge. Controve,..y emu realtdiRJ the criteria for Ih;' Qlndit ion, and !tOme autMMI differeu u . te bet ween those C88n whid> appe.r to have a primary abnormality of the lambdoid lUtu re from !hOM which rna, be due to .,..itional flattenin«, the ....called "lazy 18mbdoid". Othe.. do lIot make thi. distinction. and tometime. refer to the condition as occipital pl"gioctcphaly to avoid the need to implicete abnonnalilies of lhllambdoid l uture. Po.i tional na ttening (0. molding) may be produoed by; I . deereated mobility; patients wMconltanUy Ii. lupine with the head 1.0 Ihe lame lide, cemral pally, men\.al retarda tion. prematurity, chronic illn.... 2. abnormal postures: ~~I, Qln,enital dillOrde .. Of l he c:ervi~a l , pine 3. int.cntional poIitioni,.: trend , ince 1992 to place newborn, in a lupine sleeping position to ~u<:e the rill. orsudden infant death Iyndrome (SIOS )", IOmelimes e.,. ". 4. Developmental anomalies NEUROSURGERY 4. with II fwom wedge toG tilt Lhe child to ,,"" .id.. to red",,", Ihe risk offUlpirati"n mtraul .. rine etillbglu": intrllutennllcrowding (e.g. {rom multiparous birth. or ll1rge futalsizel. uterine !IJlomaJiell Clinical fiudiDglI Flattening of the oo:ipu~ May be unilateral or bil!lter~J . If llnilllteral, It Is !lOmetilll'" termed laro bdold ph.gi ocephflly which when severillailo produces bulgingoft.h ij>l:lillll.eraJ fo~he"d rtIIIuh.ing;n II "rhomboid" .kll il with !.he ipSlli.to'rai .,u located anterior and inferior toG the contralateral ear. TheoontTalateral orbi~ and forehud may also be flattened. Th;, may be confll$M with hemifatial mitrosomia or with plagiocephaly ""en in unilatolul oorona1 craniosYt\06toois. Bilate ra,llambdoid synostosi. produces brllchycepha ly with bilth eur.disploced antt'riorly 8IId inferiorly"'. Unlike \he palpable rid,gt of ugittal Or oonm91 Kyn""wsis. on W4~ may be palpated along Ole synos' totic lll.mbdoid l ulure (although II peri,u tural ridge may ~ round in alllIle). DLagnos tic evalu a ti o D The phy8ieal exllm illile mOBl impDrtlln~aB~Lofdiagn09i~ . SkIlUx'·rIlY mAy help diff~rlntiate (8<>. below). Ifth e IkuU x.ray ill equivocal. preven t the infant from layin;g on the .ffetted $ide rOT nvua] wl'ekll. ~ bons &tan Bhould be oblained. ifno improvement OCCUT'll (8« below). In definil.t ca5e$ ofsyn(lftt<>sis, and for SOme taSlU of refradory posi· tioll.ai flattening \ ... hi~h usually (OlTt'cr. with time. bu t may l.ake up to 2 yea..,,! 5llrgi~ol lr'~Htment /WIy ~ indicated . Skull ,.·ray : ShOWIl 8 ""lerotic luarg;n along one edge orth .. la..rubdoid 8",t"'"' in 71)~ of ealle&, Local "beaten copper cranium" (BCC) occuion8Uy may be 6e'en due \0 indenta· u.;.nll in llIe bone from underlying gyri .... hich may be due to locally increased ICP. Bce producell a characteristic mottled appearance oftbe bone with lucendea orurying depth having ro",nd a nd poorly mllrginated ed8"l!! . BCC correlole:lwitb generalized, ICP only when it ia seen wllh sellar erosioll and sutural diastasis.. , c r .can, Bone windo ws may show eroded or thllllled Inner table In the occipital region in li)·2~ ofcollell"', > 95~ a", DO the side of the Involvement. The lIuture moy appear closed . Brain w;lIdow" 5how parenchymal bnti.n abnormalilies in" 2%: hel.erotopiaa, hy· droci!phalus. ag~nuiB oflhe corpus c.alIosum ; but _ 70~ will ha~.. significant ex pfUl~ion oflh., frontal " ubarochnoid l pace (mllY beaeen in syno.slOllis of other sutllres.~u above). Bon.. scan : loot.ope uptake in the IllJ'IIbdoid 8uture itu!relUlell d uring the Ii",t year, wilh a peak IIt3 month" of ~ (follow;"1: the u.~u31 ioact;vi~y of the. fin;l w",kli uf life). TIuI finding. with "YTI06tosil.Rre those typ;ta] for CSO (_ fJ'J#1~ 99). 1TeRtmeot Ea rly sur gical t,.atment iI indicated 10 cases with 5evere.,:ranio!""cial d;sfill" rementor those WIth ~videllce ofi.ncreased ICP. Otherwise, cltildre,n may be matUlged nOn· ~u rgl~llUy for 3·6 month •. Tbe mll,jority of CalleS wiU .... maln stotie or will improve with time aDd limpl e nonsurgical ;nte .... ~Dlio". App roximately 15')& will oontinue wdevelop 8 significo.nt C<i!lmlltic defonnity. NDnaurgieaL mana.""mentM: Although ;n.ptovemenl ean usua)!y be attained, some degree of permanent didig. urement ii frequent. Rl!pllllilioning ""ill be effective to - 85% orciI.5I!i. Patienu; are plaeed OR theunaff~t­ ed sideD. on the abdom~n. Infanta wi t h occipita l fi;<lttening from torticollis ehould haye .ggr..... jv~ phy .i~" I1h e ... PT and rr ..lulion ~ou ld be ob._ed .. ithin!l-G mOlltM. More severe invo]y ... ment nlDybe veated with 0 trial ofmoldingh ... I01e~(however, no controlled study hOI proveD the effiCACy!. Surgitlll tr'1!8tm ... nt Req,ojred (n only_ 20% o f calleS. Tile ideal age for lurgery is between 6 and 1& mOrlthB. The pIIlien t i~ positioned pr one on e well·""dded cerebellar lIe~drest (the faoo should be lined and gtntly massaged ,,"ery _ 30 minutes by tbl PtleathuiologisL to prevooL pTllssu re injuries). Surgi~ol Option. u nge trom .imp]e u nilateral cronieetorny orthe suture til. elll.bo",U! recunnruction hy a cranlofoc;al teom. Linear c:raru~ctomy extends from tha ugiu.alsuLure 1.0 t he asterion il ofuln ade. quate for palients $ 12 weeks ofoge withouLleveredi:ilig\lreme"l. Great care;i takell to avoid durll)latt!rltion ou r the astorion whim Is in th e region nfthe traru;verH !in,,~ . The exdsed suture derocn$lratel an inli..'mlIl ridge. B~tter re&ulta ar&obtainoo with earlier su rgery. more rlKiie.l] surgary ma.y ha nl!CeBoary nful r the age orB month • . Averag... blood loas for unt'OlllpliCAted ca&el is 100·200 ml and therefore tronsfusion NEUROSURGERY 4. Developm~Dtal anomaliee '" >II often ""fIuirnd. M UL T/PLE SYNOSTOSES Fu~ion of man)' Dr all cr8 ni81.IltuR~ - oEyu pb • •)' {to w..- stui.! wilh ainusI!II8Dd lh.lJ.".. (lrbibl).1'hese patienUi haye ~1e'<8ted ICP. u"d~e'oped CRANIOFACW. DYSMORPHIC SYNDROMES Over 00 ayndromell have been de!oCl"ibed, 1'obk 4-4, snows a few ~Iec!.ood Dlle!!. A number of ~r8niD6ynmt03il syud roIllBS are due to mutation. in the FGFR (fibro· bJ~8t growth faclor receptor) B"l!lIeII. FGFR gane .related cranio~yno~t.oIIis syndrom"'! in. elude l ome duaic synrlrOmell (Apert. CroUlon, Pfei ffer .•. ) lit" well as severn! newer enti t ies {Be3N>-Ste¥!MOn, Muenke, Jaclu!on·Wei!lS ayndromell}. All exhibit autoBOm31 do.uinlllll inheritance. Tablu 4-4 Selecte-d cranlolaelltl dysmorphlc: syndrome. (modifiedf! '.'.....~ , , , ., abb,..,..,,!OnS: AO ., 1N1OSaTIaI~: FG/'~ ... bIobII~ grOWIi> 1at:lGf' r~ cso .. ~lOOIs: ~ ~ rlyl!f'OCOIl/UI"" ; UE "' ~PJ>OI a.<l(8mililt 4.5.3. ~ed : Encepha locele Crsnium hifidum 18' defect i.o the ru~ion of the c:ranin! bone, j~ OttW"'ll in the mid· line, IUld ilmOll! (om man in th e occipital region . Ifmeuingelloo CSf' hern iate tllrough the defect, it i$ called I mening~le. Umenmgt'sand cer ebMlI tissue protrude. it (seni le!! an encephalllOllle. E ncephalocele AKA c:e pbahx,ele ;s an extenS;(lfL ofintracran' alatrllClUNII DI.ltllide of the normal coufiue! of the sltu ll. One C8/i1! wlU seen for eyery fi ve C/l\le.t ofspinal r:oy...[omen'Iij!oceles". A Ilasal polypoid mru;s in .. ~bolm should be C(lnaidered an en· e.!phaklcele until proven otherwise. See al&9 Differentio/ diag'lCfis. J>9ge 936 CLASSIFICATION Systt!m baaed on Su .... n"'el. and Suwanwela1'O: 1. occipital: often involvu v8lleular structu res 2. c ranial vault: compri!!!!~ _ 80% of ene.!phalocelea in Western hemi sphe re A. int.erfrontaJ n. .nterior fontanelle C. interparietal: often involves vasculllJ" ~Iruetures D. tempo rn! E. po5t.erior fontap!!.lle 3. fronto-etbmoidll J, AKA $lncipital ; IS'N of encepbalOCftles, exterolll opening inlo face in one oftha following 3 region •• A. na,ofrontal: ex t;!ma.l def~ i.n the nll",on B. nQllO-ethmoidal: defect between lIasal bone lind nanl cartilage C. naB<Hlrbillll , defect in the aote ro-inferior portion of madill I whital wall 4. oosal: J.5~ of encephlocele~; (8ft billow) A. transethiDoidal: protrudes into lIasn! cUlit)' th rough d~ect in cribrifonn plate B. s pheno-ethmoida[! protrudes into posterio r na!lal C'1lvitr C. tranloliphenoidal; protrudes into . pl!;,noid alnus or nuophJlrynJI through patent cranioph.ryngeal tansl (foNlmen teewn) o froD tI)-sphenoidal or .ph~n<Hl rbit81: protrode.. into orbit through superior I02 4. Oevelopm!'t\tal a non,ali.,. NEUROSURGERY orbital fissure 5. po,terior fossa : WluBlly oontllins cerebellar tissue and ventricular component BASAL ENCEPHALOCELE i'heonly group thatdoes not produ~ a visiblesof\ tissue ma8.ll. May present as CSF leak or recurrent meningitis. May be aS$OCiated with other erB niofadal deformities, in· duding: den lip, bifid nose, optic-narve dysplasia, coloboma and micropllthalmia, bypothalamic·pituitary dysfunction. In iencepbaly is cllaracterizW by defe<:ts around tile foramen magnum, rachiscllis is and retrocollis. Mo.st are stillborn , $Orne survi ve up to age 17. ETIOLOGY Two main theories: 1. arrested clo.sure of normal confi ning tissue sJlow, ll emiation tllrougll per.iatent defeo:t 2. early outgrowth of neural tissue prevents normal c")!Iure of cranial covering!! TREATM Etrr Occipital e ncepbaloce le Surgical excision of the 88e and its contents ""ith water-tight dur..! do.sure. It must be kept in mind thst vascular structures are often included in tile sac. Hydrocephalus is of\en presen t and may n<!f!d to be trea-ted l eparately . Basa l encepbalocele Caution: a- trsnsnasal approach to a basal encephalocele (even for biopsy alone) may be fraugllt witll intracrani81llernorrllage, meningitis, or pe",istent CSF leak . Us ually a combined intracranisl approach (", itll amputation of tile extratra nial maM) and !-ransnasal approach is used . OUTCOME Occipital ence pha locele The prognosis is better in occipital meningocele tllan in encepllalocele, The prognosis is worae if a significant amount cerebrel tissue is present in the sac, if the ventricle! extend into tile sac. or if tIlere is hydrocepllal us. Less tllan ~ 5%ofinfan~ with encephalooele develop normally. 4.6. Chiari malformation The term "Clliari malformation" (after pa. thologiBt, H.. ". ChiDn) i . preferred for tYP<! I malformations, with the term "Arnold·Clliari malforma· tion" re\lerved for typ<! 2 malformatic>n . The Cb.iari malfor· mations consista offou r type!t ofllindbrain abnor· malities, probably Uilrelate<! to each other. The majority of Chiari malformations are type5 1 or 2 (set" Tobie 4·5). a very lim_ ited number of cases com· prise tile remaining types. NEUROSURGERY Table 4-5 Comparisons 01 Chlarllype 1 and 2 a nomalies (,.. 1~J.''''''''' 4. DeV1':lopmentalenomalies '03 TypE. 1 CH1ARl MALFORMATION t K..y fealllrejl: • a het..rugeneou~ entity with th"l:Ummo" future of impaired CSF circulation through the fe".men magnulu a:rebeUar tunsillar w rniation: varieble, '" 5 rom below the f(>~men magnum is common. but i9 "at .. _ ntial nor d'agnOiltic ofth" co"dition t ....... tment, wh .. n ind icated , 19 ONrl(ical, bu~ aspeel8 or what tha t 8urgery IIhould e ntail areCQntroversial (enlB r~men t offonunen I1l.IIgIlum is Ul!ually In"oJved) • auociated with syrinsomyelia in 30-70% ",hieh almost 1I1",ay. improvell ",jth treatment of th a Chiari malformation AKA primarycen!bell~r ec t.Opia" , AKA odultChiari mnlfonnatlon (.ince-it tenda t.O be diagno&ed in the 2nd o r 3ni d''''''lde ofHfe j. A heterogenooWl grou;) ofrondiclons, with the u[\de.lyil\& eommoml]ily of disruption of normal CSF now throu!I"h the foramen mlllr· nurn (FM) . Sam.. ~.a."" Are ronB"olnital. but othef"8 are oClQuired. Clall.!!icII.llyd ... etibed a. a r8r .. . bnol"1l'l~lity restricted tu noudal dUiplacernent ofcerebeJlum with t.onsillar hemiation be low the foramen magnum (_ MRI belnw fur enl,,· na )and "~g-liJu, elnngation "F ton,it.". UnH.lr.r.Chlari type 2. the mooulla i~ Il.IIl. caudaUy di . plllUd (some lIu1ho., dillllgTe"'!)n thlS paillto/) , the brainltem is lI!)t invDlved. lower crll.Oial n erves.re II"t elollpted. lind uppe~ ceroiClitI li e""'" d!) not (ouI"Hcephlila d, Sy· ringamyeliD" of the apin al cord il pnl.ent in 3O -7Q'K.... Hydrotephah,s Oc:eu rs in 7·9% (lI<tien15 with Chian type I mlllfllrmalion and syrinllomyelia". Certbel1ar ton9il descent below FM with ;mpaelion. while common, ;5 110 longer /I sine qua non Of dillgll DlJis. Etlo l"lO" may be fl..Sl!oc:ill ted with ), II . mlll poslerior fOIlBR A, underdevelQprnellt of lhe oa:i pi La I bQne B. low lyinil tenwnum (the roof nf the p-fOUil) C. thickened Or el'"vtlted occi pital bone (the floor ofll,e p-fos.u) O. space oc:eupyiOS" I~i"n in p.fosJl!l: tlrftchnoid, cyst, tumor (~.I. F'M m""ingi_ om~ or cerebell a r a&trocytOm a ), hypervallcular durn 2. tllli been d e~cribed withjll8t "bout a nything tbat tak~ u p intrNtrllnia) . Jl"ce A. cbronic 8ubduI"1I1 hemawmas B, hydroceph81us 3 f"lI"winl IUlnboperitoneal shunt <_ POll" 189) or multiplll (:rllumatic) LPs" , acq uired Chia n I malfc nn atioll (u, ually BsYmptomatic ) " . a rachnoid web Or 8car o r lib,osu around bndnstem and tonal1s near FM 6 a bnormalities of the up per cervical Bpin~ A. hypermobility oftlte c'll(I iove-ru::b rHljUllctinn B. Klippel-Feil.yndrome C_ OQCipitauZlItion of the aU lis 0 , anterinr indent.tion lit f"Mlmen "'lignum: e.g. basilll ' invaIPllatiO(1 or ret.-roversion ofth. pd"nwid p n>Ce911 6, Ehlerl!-Danlos sYDdrome 1. eTIIJli~ynOSt08ia: espedally ctlSe81,,~ol~ing 111 1suwrea 8. r1!taiCled mmnhoid roof: "H1J "r EP,DEMIOLOGY Ave, age agio: at prellenlatiM ie "1 yell"l I ..... oge: 12.1a yn). Slight female preponde .... anctl (female:mllie a 1.3:l t Average duration of.ympt.ows clearly rell'ltcd 1(1 Chlan malformalin" is :t t)'l"$ Irange: t mMth_20 )ITs); if non~pec:i fic eompJair,t/i, e.g. lilA , a re induded, this bec:nmes 7.3 ye/ml". Thi. lateCley is probably low~r i~ the MRI ef$.. CLINICAL Par.ient.6 with Chia ri type t malfonnatic)Il /lUI}· present due tu;my o r aU " f the fol- lowing: I. oompreasion " f brain stem "I the level of the ftooraroen mllgnum 2, hydrocephalus A. True hydnom.y. l", probabl,y a_n'l O<ruT. C8F n...... lut. _ _n docum..,ud in mon, ond lIlt ~ n· . ""Ity ""tp"nibl. III find ....,.,un;........ bctw .... tl,~ , """ .,riA. ond 4. Oevel"pmental ano'nalin 1h~ ""nl .. I<.l1.O l lnChl.ri I ""- NEUROSURGERY 3 4. 5. syri ngomyelia isolation ofthl! intracra nial PT1!5SUN! eompartmen! from the spina l CODlpartment causing transient elevations of intra crania 1 pressure 15-30% of patient.. with adultChiari mal. formation lIre asymptomstit"" SYMPTOMS The most common sym ptom is pain (69%), especially headache which is usuatiy felt in the suboxcipital regilm (ut' Tobie 4-6). HlA are often brought on by neck e ~ t.ension Or valsalva maneuver. Weakne$$ is also prominent, espe<.:ialJy unilat- Table 4-6 Presenting IXIIUllllIDl In CIII, nl mallolmllllOn ., (7 1 cases") ned! (wboceipilal. ctrvica~ ~" eral gt'lIsp. U'ermitt.e's sign may nlsoocC'U t . L<lwer ext""mity involvement usua liy consists ofbilateral spasticity. SiGNS See Ta.ble ;ng of signs": ".7.Three main patterns orc1ust.e r· 1. fqrllmen mamwn...CSlluPrtSsjoD "xndrpme (22%): ataxia, corticospinal lind sensory deficits, cerebellar signs. lower cranial nerve pals; .... 37% have severe HlA 2. ~~~ ( 65%): diftsocia!.ed !lens!)!), 105$ (lOllS of pain & t..>,mperature eentlltion with preserved touch &'JPS), 0<:caaionaleegmental weaknes9, a nd lOll!! tract signs (.yrilljl:Olllye lic sYlldrome"). 11% have lower cranial nerve pal.9ies 3. ~e(l!be!!ar 1Iv.ndt!wl£ (11%): trunCliI and limb al.a.ll.ia, nystagmus, dysarthria Downbeat lIystagmus is considered II charact4l ristic of this coooitioll. 10% will have a normal neurologic e~lIm wi l h occipital WA as their only complaint. Som e patients may pre.ent prillUlrily wi th spasticity, lalnting Iada! numbness ., Table 4-7 Preaentlng IilulI In Cillarl l ma lformallon NATURAL HISTORY The natural history ia not known with certainty (ollly 2 reports on "natunlJ history"). A patient may remain stable for years, witb intermitt.ent period s of deterioration. Rarely, spontaneous improvement may OCcur Cdebat.- od'. E VALUATION Plain x_rays Of10 skull x-ra}'ll, only 36% were a bnormal (26% s howed basilar impression, 7% platybasin, and 1 patient each with Paget's and concave clivus): in 60 C·Bpine x-rnya, 35% were abnormal (including assimilation of at.las, widened calla !. cervical fusions, agenesi s of posterior arch of aUMl. MRI d.~ -..beal ~1agmuIl oo...-..c:al _men~ and ftllalory nysIagm ... on horl· zenlal movemenI: no o.:ludes osellop$ia"" Diagnostic ",st of choice. Ea.sily shows many of the d al!9ic abnormalities described <1aflier. including tonsillar herniation, u well as hydrosyringomyelia which oceUrli ill 20-30% of Ca8U. AJ !IO demo!'lStrates venITal NEUROSURGERY 4. Developmental anomalies "s brain nem eompl'<!&!Iion when presen t. Tonsillar berniation : Cri~ri B for the d~BCent of thl! tonRi llar t ip" belDW Lhe fommM mal):num (FM) to dilltm06e Chillri ty~ I malform.1tioll ha"e co ne Lh rough II number of reeon8ide rati~. I.....'" 1:" ClIiIIrI m.lronzaalicm IIQd . • In itially." Ii DUll wIIs ddined 8lI dearly pathologic:"'lwith 3-6 mm heincbordt'rlina). Bark.ovieh" found t.<>n$illar positions 88 Bho .... n inTabl~ 4·8. and Tabl~ 4 ·9 ehow. th e ef. feet of utililing 2 Vt. 3 mm (Ii the lowe$t lIo rmal position . Table 4-9 Cri lerla lor Chlarll ~ Crileri.lor Iownt Sensitivity Speclllcity e~t 01 tanslls at> lor Cll\lrli IorC\'ltlrl I cepled II norlll!ll 21T)1'T1 below FM t OO'l\o ~.5" ~ 0<1 ""' ..... 'emo~lS In 2(0 !III"I1a1s i<I<I 25 C/Ii/Id I pallenlilaken In "'11100 !D .,... Iow<It pan O! tile torame~ 1IlOIlIOO'" The lnnsih. normally u<:end .... ith age" u s hown in Tabl~4· JO. P.tUml.s with syrj ngohydl'Qnlyelia without hindbrain h erniation that responded til p"fos~s decomprj>osion have been deKribed~ (aGoC!l ll ed · Chi"rl zero Il1l1lrormatlon"l. Conversely, 14% of patienl.s with tonsillllr hernilltion " Ii mID al'flllsyrnplomati c'" fa verage utent of l!C\.OpiR in this group .... as 11.4,. 4.86 mm). POlentially moruigoificanl than the absolute t onail· lar desce nt i~ Ihe aU1Ou,n.l. or<:oropreuion ot the brainSleJll 81 the PM, best appreciated en axial T2Wl MRllllough t.l1e FM. Cnmplete.obliteration or CS I' Hignal llnd com pre56ion oflhe brainSlem at th e I'M by impeeted tonsil, it e (ommQll .'gtU!icanl r,nding. Cine. MRl : May oerooOSt rllte blodr.age orCS I' flo .... at PM . .... Table 4-1D Tonaillar debelow FM related 10 s~nt ' s.o. • _,d """'a\lon. DIIsoonI:>2 S O. beyond <lO'mO.1", ""9OI'S1N" 8 t& I..... !of loelilJ. , e<:Io\liIl Myelogr8p hy Only6'Jb false nega tive. Muit 1'\111 dye all t ile way up 10 the foramen magnum . CT CT baS dimwl ty eVlllu a t ingthe fom men mQgIlum region dueto bony artrfad. When combined .... ith intnllheca l ,..a\Jlr·IQluble contras t (myelogt'tl m). rehahility improveB. Filldings: tonsiUard .... cellt ""d/or ve ntricular dilata t ion . T REATM£NT Ind iclil lions tor lIurgery Since patientll respond best wilen opl!I'Hted on within 2 yea~ of the on.q el or~)'l1'Ipo­ tornli (!lee Operoliw f«U/IS bela....}. early a urgery ie reeonlmended for symptomatk pa· tien (4. A!;ymptomatie pa t ,enlll may be followed and operat.ed UpOn iraod wll~ they be<:ooIe s)'II'ptom alie. P8tieals .... ho hsVII be@nsymptoma tieandst.t.hle for y<!8fS mlll'bAoon!ide red for observation ... it.l18urg«ry indicated for aigna ofdeterioratlon. Surgical techniq u ell The mllSL frequently pe:rformed operation is poaterior fOSlln decomp",,,,,ion (su bocd pitlll er..rue<:tomyJ, with or without other proced ures (uluaUy combined w i~h duul patch (l'aft inc aod ee rv icallaminect4my of Cl, soDletiml>fi to C2 or C3l. Some lIuthoT& advocate performing 8 tra"'30ra1 c1ivus·odon\.Oid r esection in eaSl'S wit b v@O lralbrain ·.temoompreBsioll.fiBtheyfeel thesepaLient . may pot.entia lly deleri . orutewith p<lllterior rosaadocompr OlSSion alon ..... Since this deterioration wm$ I'Ilve,."ible with odontoideetomy, it mny be rensonl1ble to perform t m. proeedure on patien ts who show signs ofdeterioration Or progression of basilu impression on ~mil MRI. alter p<III. '" NEUROSURGERY UlrOor fossa derompression . OPERA TIVE FINDINGS 5ff Table 4·// . Tonsillar herniation is present in all eases (by definition); the most commo;>o position being atCt ( 6~) . Fibrous adhes ions between dura, arachnoid s nd tonails with occlusion of forami _ na ofLUlIChka snd Magendie in 41%. The toMils sepa rated easily in 40%. Table 4-11 r In Chlarl I I I below loramen magnum " " SURGICAL COMPLICATIONS CO After suboccipital craniectomy plus Cl·Slaminectomy in 71 patients, with dursl patch grat\iog in 69, One death due to s leep apnea oceurTed 36 hra post-op. Respiratory depression was the most COmmon post..,p eomplicetion (in 10 pa· tients ), ..... u.al1y withi n 5 days. mostly at night. Clou respiratory monitoring is therefore rerommended". Other r isks of the procedure indude: CSF leak. hern iation of eerebellar hemisphe res. vascular illiuries (to PICA ... ). unspeciIied level ~" inverted foramen m8ll"1lm keel rJ bone Cl aret! alresia .tIn"'.... vncular abnOrmal ..... P ICA d~ate<I '" 1 """,.,. in B1'0"••>1, ",ICA ollen deSOllnel' 1 0 _ margin or ""'$IIs"I: lor"" 11 ..... 1","""U, Iolta in 3 OPERATIVE RESULTS See Table 4 ·12. PalLante with. pre·op romplain ts of paio geoarally respond well (Q s urge ry. Wea kness is less responsive 10 Sur· gery, elIpecially .... hen musde atrophy;s pre!lent". Sensation roay improve when th e posterior columns are unaffected and the defieit is due to s pi notha la Ulic involvement alone. Rhoton f""ls that the main benefIt DrOperation is to alTest progression. The moat favorable results OCCUlTed in patients with ureb<>llar syodrome (87% showing improvement. no la~ detf!rioration). Factors that colTelate ""jIb a worse outcom e are the presenc.e of atrophy, ataxia, scoliosis, .",rJ ¥Y"'I'wrn» 1~¥t;nJj IOll ger th"n 2 ye~,..,," . Table 4-12 Long-term follow-up aner surg ery lor CIIlarl 1 malformation (69 patients, 4 ~ea(S mean IQj!ow-uP") lI1ese parionl6 dflhtriolah'<l Ie ptfI..QIl , l atus (none dele.."..lod 10000hllr) witt*l2-3 yews or S<lrgery: relapS<l <>CC:\I<f8d in 30% will> lor ... 11>10 magnum c<lmj)ressioo IO)Indrome. _In 21 % ... In cenltal 00td IO)Indrotnfl TYPE 2 (ARNOLO}-CHIARI MALFORMATION Usually associated with myelomeningocele CMM"!. Or rarely spina bifi ds occulta. PATHOPHYSIOLOGY Probably does ~ result from tethering of t he cord by the acrompanying MM . Pri_ mary dysgenesis of the brainst.em with multiple other developm e ntal anomalies is mOre likely"". Major findin gs Caudally dislocated cervicornedullary j unction , poIll. 4th ....entricle and med ulla. Cerebellar tonsils located at Or below the foramen magnum. Replacement of normal cervicomedullary junction flexure with a "kink- like deformity". NEUROSURGERY 4. Developmental anomalies '" Other possible associated findings: 1. !.>eaking of tectum 2. absence of the septum peJlucidum with enlarged interthalamic adhesion' absen~ of the septum pellucidum it thought to be due to necro.is with resorption secondary to hydrocephalus, and not a congenital absence'''''' ,,', 3. poorly myelinated <:e"lbella r folia 4 . hydrocephalu s: present in most 5. heterotopia. 6. hY'popIDS~a offal" 7. mlCrogyrlO 8. degeneration of lower uanial nerve nudei 9. bony abnormalities: A. of ~rvicomedullary junction 8. assimilation of atlas C. platybasia O. basilar impression E. Klippel-Feil deConoity: su page 119 10. hydromyelia II . c.aniolacunia of the Iku ll (8ft ~Iow ) PRESENTATION Findings an d~ to brain stem and lower cranial nel"\'e dysfunction . Onset is rare in adulthood . The presentation ofneonataadiffs .. substantially from older childnn, and neonates ,,'eO! mON! likely to develop rapid neurologi~al deterioration with profOWld brain stem dysfunction over a period of several days than were older children in whom symptoms were more insidious and rarely as severe". Findings include>'·II: I . swallowing difficulties (neu rogenic dysphagia) (69%)". Manifests as poor feeding. cyan0!5is during feeding, nasal regurgitation, prolonged feeding time, or pooling of oral secretions. Oag rene~ often decreased . More severe in neonat.e~ 2. apneic spells (58%): due to impaired ventilatory drive. More common;n neonates 3. stridor (56%): more common in neonates. usually WOn;\! on inspiration (abductor and occasionally adductor ,'O<:al cord paralysis seen on laryngoscopy) d ~ to 10th nel"\'e pa res i.; usually transient. but may Progn'-SS to n'!!pi ratory arrest 4 . aspi ration (40'>\) 5. ann weakness (27%) that may progre~! to quadriparesi~" 6. opisthotonos (18%) 7. nystagmul: especially dl.lwnbeat nystagmus 8. weak or absent cry 9. facial weakness DIAGNOSTIC EVALUATION Skull films May demonstrate cephalofscial disproportion from congenital HCP. Cl'II.n iolacu. oi. (AKA liick.e nschiide l) ;n 85% (roWld defects in the skull with sharp bordel'$, &epaMlted by irregularly branching bands of bone). Low lying intemaloccipitol protuberance (foreshortened poIItenor fossa ). "; nla rged foran,en magoun' in 7()<.{,; elongation of upper cervical lamina". CT and/or MRI find ings (" ,l<! .... with.n •• ",n.k ... t...at.pprf<'i.Led On MRI) primary findings A. ·Z· I.>eod deformity of medulla~ B. cerebellar peg C. tectal fusion ("tectal beaking") O. enlarged massa interml?dia (int.erthab.mic adhesion )· E . elongatiolV'cavicall;zation of medulla F. low attachment of tentorium associated findings A. hydrocephalus n. syringomyelia in the area of the cervicomedullary junction (reported inci· dence in pre MRI era" ranges from 48·88%) C. trapped fourth wnlride O. agenuisldysgeneais or corpus callosun,· '"' 4. ee,·elopmenLalal'1Omo.lies NEUROSURGERY E. cerebe llomedullBI)' e<>mpr"''''on Lary ll gOSCOpy Performed in pa t i.nQ with lirido r to rule out croup or other upper ~"piratory tracl i"fection. TREATMENT inw,t CSF . hunt for hydro«pholua (or check funct.ion 0( ex ialing ahunt ) if neurogenic dy.phagia, Htndor . or apneic apell. occur, upeditious poiI~rior r.... l a d«omp~ .. lon i. recommended (_ Nlo",) (r.quired in 18.7<;\0 of MM pat ienll"); btfore recommending de«>mpression. alway. n,ake aurt tM pa~nt h .. a functioninB .h untl S u rgical d eco mp re.. io n NB : it hPi been arllled that part of the explon-'lon for t he poor operative r..ulUl in infants ia thot many of the ne urological fiedine' may be dut in part to intnnaie (u ncorrectable) abnorma litie. which l urgie. l decompreuion unroot improve"·", A diutnting view i. that the hi.tologic luion.s.1'1! du e to chronie bl'llin ltoem compreuion and conoomitant isehemia, aosd that upeditiou. brain I tem deoompreuion .hould bt:carned out when any of th e followingm t ical warning . ign. dev.lop: nlUr<l!rfnjc dy:apbagja . t ri· ~tiu.ndll". Surgical t.ech nique: Oeoompreuion of cerebellar ton l il., ulually with du",l rraft to dec<)mpreu dur • . Patienll i. pla""d prone, wi th the neck nexf<!. A . uboccipital Cl'1Iniectomy ia tombin@<! wit h a cervical laminectomy which must be cam@<! down to the bottom of the ton . lIlIr ti ..... A thick COn$tncting d ura l baed is ulually found between the CI arch .nd ro",men magnum . The duro is open@<! in a "Y" shaped Ind. ion . Caution when openi ng the dura above t he level of the forllOlen magnum in infant. as they have I well developed Ottipiu l sinus and may have lar!,'le dural Ink",". 00 NOT .!.tempt to dissect tonsils from underlying medulla. In c.ses with a . ignif..:.nt .yringomyelic cavity,.a .yrin&o. .... b.rachnoid sh unt is pla"fd". T ra cheostomy (usually temporary) i. ",oommftM!ed ifltrido r and .abductor laryn. geal palsy were present pre-op. CI06e po$t..op respi ratory mon itoring i. nc@(\ed for obstruction W reduced vmtilatory drive fmech.niul ventilation i. indicated ror hypoxia or hypercarbi.). OUTCOME 68<;\0 h.d complete (Q' ne.r oomplete resolution of.ymptoms, 12<;\0 h.d mild to mod· erate residual de6eilll, and 2091: had no improvement (in Bent'r.l, neona," far1!d WO!'lle tb.n older ch ildrM )I'. Rupiratol)' arr«1 is the most oomroon uuse ofroorlality (8 or 17 patienll who died ), with the rell due to meningitisfvent riculitia (6 patients), .. spiration (2 patientl), .nd bi liary "l'8i. ( L padent)"". In follow · up ranging 7 m....6".., 37.8'\lo mort.lity in ~rated patienl!l. PreoOp It.a tUl and the rapidity of rotu.rologic deterioration ~re the Il>0l>1 important progoostica"" .... l'oIort.al"y ri te it 71'110 in in fants h."in, cardiopulmonary arrest, vocal cord panly." or ann wnluwas within 2 W(M!U of presentation; compared to 23<;\0 mor· ulity in pIItienlll with . more rradu.1 deterioflltion . Bil.teral vocal eortl paralysis was a particularly poor pr(lfrnOSticator for ,"poNe to . urgeryf'. OTHER C H1 ARJ MALFORMATIONS CHIAR/ TYPE 3 Ran. The mot! ICIvere IOrm. Dilpl&Cement of poIterio r r...u strudUreII, with cerebellum hemiated through fo"men magnum into oervic.1 canal, often with a high ce ....·;· c.l Of' lubottipiul ene.epha lomeningocell. Ulually inoompatiblt with li fe. CHIAR/ TYPe 4 Cerebell a, hypopluia without cerebellar herniat ion . NEUROSURGERY ... Developmental a roomal ,es ,., 4.7. Dandy-Walker malformation At.",;a offo' 8111'n. of Magtndie and Lu.c:h k,". Thl, l"uulU in &&frlesi, of tile ~r­ I I I~ posurior roan cyatcommunicating with lin enla rged 4th ventricle (.orne retrotl'l'i'beUar .nchnoid cyaU mi mic Oandy. Walker, but theAl! do not heve vennia" agene.is and the c)'IIt does I1l!& open into the 4th ventricle) lObelia. venn's with Hyd.""",phaJuaQ«un in 9O'Jl, ofcl.U$, and Dandy- Walker malformui(ln is present of.n caHI 01 hyd.rocepha!IlI, Associated ab normalit ie. in 2-4 ~ eNS .bDOnJUllitia include .gents;, oft'" o;(Irp'" caIto-u rn in 17,.... a nd occipital encephaloc.le in 7<JIo., Olhu lindi"p indude heterotopi.., apina bifid" syringomyelia, microoephaly, den::ooid cyau. poreneephaly. and Klippel-Feil def<lnnity. MOlt have an enI. Tled post.erior rou. ",lUI elevation of the torcul. r herophili. Syattm>e .bnonn.li~ include"": r.d.1 abnormalitiu (e., . angiOD1I1, cleft. palatft, roacroslOHi •• r.cial dyl!morphiaJ. 01:\11 • • IIbnon:aaUuu (• ., _coloboma. retinal dysgen e- .il. microphthalmi.), and cardiovascular l oomlliea (e.l . septal defect.l. patent ductus Ir· teTiot .... lorti, f;OITClItion. clextroo;ardia). Note: be .w.~ of the lihlihood of I ean:ii3C: abnormality when considerinllurgery on theae patient.l. Treatment In t he IbMn.. of hydrooephalUl. thue .... y be follow«l. Whell t~atlllent is ~8' lary.ihunt the pwterior f.... cyst-. In the rare patien t wi th aqued..el.llatena5;'. shunt the lateral ventri<:lea all(l. Sh untinl the venlric ln alone ;. c:ontraindiclted because of the ri,1t ofupwlU'd herniation. Prol11ol i, 7~ 1 00'lIt tha"ce of l urvival . Only 00'l0 have nonnal lQ. Ataxia, spastic:i ty. and poor fine motor c:on t rol arl common. SeiIU,"" ooeut in I~. 4.8. Aqueductal stenosis Aqueducl.ll s tellO'llS (AqS) produces what;$ tometimn ",lied t rivenlri<,:ul ar hy_ droce phal .... charatteri~ by a normal .i~ 4th ventricle Ind erJerged third.nd lateral ventritLl'A on MR I or CT. Most ""." occur in ch.ild~lI, however some p~aent ror the first time in adulthood. ETIOLOGIES a congenital ma lformation, ""y be nlOcial.ed with Chiari .... Iformlluon or neu· rofibromatosis 2. acqui red A. due t.o inflal"JUl)9tion (foll owing hemorrhage 01' in fedion, e .g. I yphil .., T.B.) B. neoplasm: esp~i.Hy brainstem utroeyt.omu{ineluding I«ta l gllom... ~ (XJgf 422), lipom .. C. quad rige min al pl ate a rachnoid C)'Ita I. IN INFANCY AqS i. 8 freq uen tea UH of congenital hydrocephllus (HCP ) (up to 70!l0 ofca.es"'J. but OC<:8BiooaHy may be t he WIi.Il of HCP. Patient.l with co.nital AqS ulually hive HCP at birth or develop it wi thin - 2-3 m~. CongenitalAqS may be due to an X·Hnked recellSive gene"'. Fo ... r t~ of ron genita l AqSdetcribed by Ruaaell (.um ... l riud'O); 1. forking: mul tiple channel. (o!\en n, rrowed) with norroal epi:.he UlllInina that do not ",eet. leparal.ed by normal nervous tissue . Usually uaod"led with other oon· genita l "bnonnaHtie.; (spin, biMo. royelomenlngo«le) 2. periaq ...educ:tlll gliosis: lumina l narrowing due t.o lubependymala.tn>ty!ie prolir. eration 3. t rue ltenO'l i. : aqueduct hiltologically nonn.l 4. u pturn '" 4. Developmental aQoroBliea NEUROSURGERY IN ADUI. THOOO AqS may be on overlooked eaU5e of "normal preAure hydr<l"ephalus" in !.headultfl. It it u[Jk,n(lwn why .arne CMea of AQS would remain oooult, a nd mA,;ife/i ~ only in adullhood. In one seritl of:;:; case"', 35% b ad duration ofsymptoma < 1 yea r , 471t> for 1-5 yun: lbe longe.8~ W>i!;' '' 0 yrs. Although moat folio ..... !.hi! longstanding benign cou ~ there Ol'll rt!poru of "Ievue<! Ie? and . udden death . Symptom!! See Table 4·13 . Headachf 1'181 the QlOllI Cllmmon symptom. lind ~ ad charae .... rialiC4 of HlA 1I000000;au,d with e!e~ated ICP. Viauru ~h.ngu were next , lind liBuaJiy etlM'.lfod of blurring or 1051 of acuity End""rine cb lngu induded menstruol irre(Ularities, hypOthyroidism, aod h irsuti6m , Signs Papllledema was the most COmmOn lind· ini: (53%). Vi~ual fLel,u were normal in 78~, lM remainder having l'1:!duced puiphe ral vi, .ion, increased blind spota, quadranlic or hemianopic f'eld euta, or OU:Oto1ll8ta. lnwlle<:-lual impairment waa pruent in " I Ita6136'11o. Ol.her signs included; alma 129%), "pyramidal ttoct signi" in 44':; (m"l ld hem;. or paraparesilll2'2%), 6pntkjly (22"1. or BabUl$ki's (20%»), an(l3n';a (9W». E VALUATION MRI ill lhe t1!~lof cholee. MRI will ~how ~be absto.oce of Iha nonnal now ,."id ill the Sylvinn aqueduct. Con l rn l s hou ld b8given Lo n, l~ut tumor, T REATMENT (OF NON-TUMORAl. AOS) Although treatmeo~ of the prifllllt)' leaion h."" been atu.Olpted (e,g , Jysi~ or"que· dllct.al ""plum), thi~ haa fall"" intndi. ravor with ~be improved """ QlC)' "fCSF ahunting. CSF i3 uRuaity ahllnled Lo the peritonellQl or the va!clll~r ~Yfit~m, however ahlintjng to auhaT8chooid ~pa~ Ie al~o f"'iL'l,bl~ (once. OMlroction at the levi. ofth a rad!llQld grtInu· latione iuLIJ ~n ruled out). A 'I'orkiltU~n 6hunt nloy work in adult eas£Sil, however pe. diatric patienlll wit h oba~ruet've hydrocephalus may not ha"11 >UI /ldlHlua~ly developed auhsraehnoid ~pace for I..,;. to funcllon properly, FoUow.u p o(ot iea..ll ...." y ... ars to rule-out tumor ... recQmllli!ndM. 4.9. Neural tube defects CLASSIFICATI ON Various elassification IY6umS elDSt, thi' OIIe;. j\dj\pled from Lemire". 1. neurulation d@fl'<ta:non-clO$ureoftheneural tube n!B ulU! in Opf'n lesions A. CT8niomchi~hiai<l! Lotal dynaph;6Ql . Many die aij ,pon taneoul abo rtiun R. an en e e pbaly; AKA e~enCO!phj\ly. DUO! to failure 0~f"8ion of th e anterior neuropore. NeltberCTaniuJ vj\"lt oor ~alp eoverll Ihe partially de6lroyed brain . Uniformly fata l. Ri,k ofrel'urn!nce in fu t ure pregnancies: 3'ifo C. ,neningoI\l)'i!loeele: mOfl;I Cl.Imrnon in lumbar n!gior, 1. my! lomeningoceie (MM) : _ page 115 2. myelocele 'iL postneurulat ion defel'u, produces . kin-covl!red (AKA cl~ ) k$iDn~ (some m.. y al80 be ooru;idered "m igralion "bnonnllJitie. "•• u MIO<A» A, crani.. l NEUROSURGERY 4 . Developmental Bnomat. ..il '" microcephaly: U~ below bydrimence phaJy: loss of significllllt portion of cerebral hemi· spheres which a re replaced by CSF. M u~t be diff.... entiated from maximal hydrocepha lus (Sft po.ge 180) 3. holoprosencephaly: Set bdow 4. l iue ncephaly: ""'f be/t)w 5 porencephaly: _ bdow to distinguisb Nom sch iuncephaly 6. agenesis ofl:Orpus callosum:.n b<!low 7. cerebellar hypoplasiafOandy-Walker synd rome: Set Patlt 110 8. macroencephaly AKA megalencephaly: U t b<!loUJ B. spinal 1. diastematomyelia, diplomyelia: seeSplit cord mal{ormalu:m, page 122 2. hydromy~lialsyringomyelia: Patlt 319 1. 2. 'u Migration abnorm a lities A I lightly different clauification scheme defines the following u abnormal ities of neuronal migration (!fOme are considered posl neurulation defect • . .."" "bow ): 1. l; _nce phaly: The most severe neuronal migration abnor mality. Maldevelopment of cerebral convolu t ions (probably an arrest of cortical development at an early fetal age). Infants are severely retarded and usually don't survive:> 2)'T11 A. agyri a : completely smooth s urface B. pac h ygyria: few broad &0 flat gyri with shallnw l ulci C. polymicrogyTh. , small gyri with shallow sulci. May be difficult to diagnose by CT/MRI , and may be confused with pachygyria 2. b et eroto pi a: abno rmal fod of gray matter which may be located anywhere from the auboortical white matter to the aubependymallining of the ventricles 3. ""hh.en ce pb .. ly: A. den that com municates with the ventricle (as lTU'Iy be<lemonstrated on CT cistemogt"llm) B. lined with cortical grey matte r. Thi.s i9 the key to <lifferentiate from p o ren _ cepbaly, 0 cyst ic lesion lined with ~onnect.ive Or glial ti ssue that may cOmmunicate with the ventricular syste m. often caused bJ' vllJICular infarcts or foUowing ;utracerebral hemorrhage or penetrating trauma (induding repeated. ventricular pWlclures) C. pia and arachnoid fuse D. t,,",oforms: open lipped (large clen to velltride) and close lipped (wallo fused) HOlOPROSENCEPHALY AKA arhin en ce pbnly . Failure orthe telencephalic vesicle to cleave into two cerebral hemispheres. The degree of cleavage failure rDuges from the severe alohar (aingle ventricle, no ;nterhemisphe,;c fISsura) to semilobar and loba r (less severe malformation s). The olfactory bulbs are usually small and the cingulate gyrus remains fused. Median faciOCilrebra! dysplasia is common, lind the<legree of severity parallels the extent of the deavage failure (see TobIt 1 · 11). Trisomy is often the cause oftb,s malformatioll, although normal karyotype_ ate tommon. Survival beyond infa ncy is uncommon, moat s u.v;vo", are , eve rely retarded. a minority are able to functioll in society. Shunt dependent hydrocephalus develope in 80me of thea" children. The risk ofholoprouncephaly ie increase<! in subsequent pregnancies of the 8ame couple. TaDIe 4-14 Tile lI ve I&Cle9 01 severe " '" 4. Developmental anomalies NEUROSURGERY MICROCEPHALY Definition: head circumference mare than 2 standard devia,jol\ll belnw the mean fnr sex and geSl.8tional age. Terms thalare sometimes used synonymously: mionx:rania, mi_ crocephalus, NCIt a Bi ngle entity, many afthe «mditions in TabU: 4-14 may be a!lSO<iated with microcephaly, It ml.Y al80 result from mal<!rnal cocaine abuse"', It is important to differential<! micro<:ephaly from a small skull resulting from craniOllynOlltosis in which s urgicsl treatment IDay prnvide opportunity for improved cerebral develnpment, MACROENCEPHAL Y'" ,.. ,DO, AKA macrencephsly, AKA megalencephaly (not to be confused with mru:rouphaly, which ;8 enla rgement of l he s kull (",e page 919)), Not a tingle pathologic entity, ~ enlarged brain wltich may be due to: hypertrophy of gray matteralone, gray and white mat.ter, presence of additional structu res (glial overgrowth, diffuse gliomu, heterotopias, metabolic storage diseases, .. ). May be soon in neurocutaneous ~yndromes (especially neurofibromatosi s). Brains may weigh upto 1600-2650 grams.IQ may be nnrmal, but developmental de· lay, retardation, spasticity and hypotonia may oc<: ur. Head circumference is 4- 7 em above mean. T he usual sigTI8 of hydrocephalus (frontal bossing, bulgi ng fontanelle, "setting sun" sign, scalp vein engorgement) are absent. I maging studies (CT or MRI) show normal ailed ventricles and can be used to rule out extra·a~ial nuid colle<:tiont. R ISK FACTORS I . early administration of prenatal vitamil1ll (especially OA mg offolic acid daily'" ") may ~~ the incidence ofneurnl tube defe<:kI (NTDs) (confirm that vitamin B" level~ are normal, see ptlgf 9{/4 ) malernal heat e~;lOsure in tbe fonn ofbQt.tubs, saunat or fever(but not ele~tri<: blankets) in the f,,,t t n mesler was aijsociated with an increased n sk ofNTDs" 3, use ofvalproic ac;d \ Depakene®)during pregnanty iss»ociated with a 1_2% risk ofNTO'" 4 . obesi ty (before and dunng pregnancy) increaee!l the nsk ofNTO.... " 5. m~l.erna! cocaine abuse may inCTease the nsk of mi~roo:ephaly, disol'de" ofneu· rona! migration, neuronal diITerentiation and myelination'" 2. P RENATAL DETECTtON OF NEURAL TUBE DEFECTS .5:«!.!.m a\pha-fetoprotein IAFP) (See Alpha .{rloprolrin On page 5-01 for background ). A higb maternal serum AFP (.. 2 multiples of the median for t he appropriate week of gestation) between 15-20 woou gestation cames a relative risk of224 for neural tube defe<:ta, and an abnormal value (high or low ) was associated with 34%ofall major congenita i detects" . The sensitivity of maternalseruIJI AFP for spina bifida was 91%{10 of II C8Se$), it was 100% for 9 cases of anencephaly. However, other senes show a lower sensitivity. Closed lumbDlj.8o ral spi"" defe<:ts , accounting for ~ 20% ohpina bifida patients" , will prooobly be miQed by serum AFP &ereening, and may also be I'\li$se-d on ultrasound . Since en. l.ernal serum AFP riee!l during nonnal pregnancy, an overest;male of gestational age may cause an elevated AFP in1Prpreu..:!~ . norm" t, .. nd JOn ,,"""r"8ti"'~te """Y """ ..... norm911evel to be inu-r_ preted 8S elevated.., to"" U1tr aSOUDd Prenatal ultrasound will detect 90-95% of casea of spina bifida, and thus in cases of elevated AFP, itcan help differential<! NTOs from non·neurologic oauses of elevated AFP (e.g. omphaloce le), and can help to mOre accural<!ly estimate gestational age. Amnioce n tesis For pregnancies subsequent to a MM, if prenatal ultrasound does not show spinal dysraphism, then amniocentesis is recommended (even ifabort,on i. not oonsidered, it may allow for optima l post-partum Care ifMM is diagnosed). A.m.D.i.21k nuid AFP levels are elevated with open neural tube defe<:ts, with a peak betwoon weekll13·15 ofpregnancy. Amniocentesis also carries a ~ 6% nsk offetal Iou in this population. NEUROSURGERY 4. Developmental anomalies 4.9.1. Agenesis of the corpus callosum A failute of commiuu l'1Ilion oceurrin, ~ :2 weeu .ftu con<>eption. The COflI .... tllllo. I ll"" (CC) rorm. from l'Ol tn.un (gen u) to I pltnl um" . thu. in m08l caaea there mil)' be on anterior JlO rtion (genu) with noapienium (the conyerte «ell ... Lelia frequently). IW~ult.s in txp&Glion of th, thkd ventricLe and te p. ration orlh,late".1 ventricle. (w hich deve lop dilated occipi tal !lorna li nd atria, and concave mediol bordeTll). me ide nee I in 2,()()()"'3,OOO ne\ul.rndioIO(ical exami nations. As&oe ia ted neuropa tho logic fi ndin g." pore_ph_I), microgyria interhemi.phe.ric 1iJl2mu and li poma. or lbe COrpUI callosu m (Ht page 96) art.ineo",*phaly optic atrophy ~obom.. hypopl ••if, oftha limbic ' ,Item bundl" ofProbtt: aborted btcion inp of corpu. .,.Ikwum, b'Jlge into late",1 ven_ lrid. 10.. ofhorizonta] orien lation of d ngu late gyro, t<:hiz.en«ph aly (He pap 112) anterior and hlppocM)pal comm iuwu may be totally Or partiaUy a'oosent't hydroceph"lul o;y&t& in the recioll of the COrpUi a ll osurn I pin" hilidA witb or without rn~omeningocele "bsenee oftne septu ... peUUCiOUOl: ' " ptJgf 122 Po... ible p r esen t a t io n hydroceph.lul microceph"ly aei lu~1 (rare) precocioUl pube rty disconnKtion syndrome: 100"" likely with ~ CC defect th.., in congeniUlI May be an in<:idental linding. and by itse lflllay have no clinical $igniflCar>ee. How_ ever, m.y be occu r al part ofa more ... mplex clinical ayndroD\f! Or chromoeomal abnor· mality (e.g. Aicaro i syndroroe: .nesis ofCC, seilures. retard ation , pst.<:hes of retinal pigmenUltion). 4.9.2. Spinal dysraphism (spi na bifida) DEFINITIONS" s;ma bffida oa:uIla CongerWII l absence 011 5jli'Ioos process and Yllri1b1e IIlIOOIlIsd Ie...... No ...iiii ~e oIl'I'IItWIges 0InN". b5$Ut ($NO b*ool. The following two entiti es are IITOuped togethfor und er the term spilla bit'id a .pe.... III (aperla from the Latin fo~ "open") Or apilla bind. cYltic • . menf~te CorIgerWIIk!ed: in vertebrlllrtflH WIll epIle dISIe/I5IOn 01 mriIgH, Iii no .t>nQHr\ll~1y 01 ~Ml"'IisIue . C/rIe t.iftl1la'III _ rIIIIIOIogoc deId. myelomeni'lgocelt ~I 6e1ecl in v&!Iebr&Iardles wilt! eys!ic diltUlliorl of mri'oge$ and IlTul;luIil 01 f\n;IiOrIallbnormal'fy 01 spiIIl eord 01 caUIIIlQUN [see~. SPINA BIFIDA OCCULTA OcCUI"l in ~ 20·SO'h of North Amt rk l.nl. Often.n inciden tal finding. u ..... lly ofllO clinical im por\llnce wh en it o«un alona. However. it II)II YOCClllion.lly beassoci.ated with diutematornyeli a, \.ethe...o cord. ]i porno, or de rmoid tumor. Wh eo IYlllplomatit from one of the IlUOc:lll\ed c:onditionl, the ~senl.&tioo i" tha t or '" 4. ~veloproenUl I anomalies NEUROSURGERY tettlered tord (gai t dinurbance, leg weakness and atroptly, urinary diaturba nce, foot d~ (oralities ... , see Tf/heret! t»rd .yndromf, page 120). The derl!(:t trUly be palJ.>llble. a nd there may be ove rlyiog C'J lsmloua mani festation. (.ee culo:rnrour " igrruolo: 0( dylnlphi,m in Tablt 4· 17, ""ge 121). M YELOMENINGOCELE EPIDEMIOLOOY/OENETICS In cidence of.pina bifida with meningo«le or myelomeningocele (MM) 1.1 1-211000 live birtlll (O.I .O.21to). Rislr inc rea_ to 2-31to ifttler. i. one previou. birttl with MM .•nd 6-81to after t ..·o "fTec\ed ctilldren. The nlk i•• Iso IncruHd in f. milies where cloH relllUvel (e.g.• iblinp) hav, given birth to MM clUldren, esp.<:i.Uy ...·hen on the mother'•• ide arthe family. Incidence may increllK in ti nle' of wa r . famine o. economic diu.atera. but it may be gradually ded ining overallt;l. 1'ran.million fo llowt nan·Mendelian geneticl. and i. probably multiractona!' Hydroce pbalus in myelom eningocele Hydrocephalu. (H C P ) develo p' in 65-86~ of J.>lltlen u with MM , and 6· I()<I, of MM patienU have ciinicelly overt HCP at birth" . Over ~ofMM patientl whowill develop HCPdo sa before age 6 mos. Mo.t MM patientl will have a n a"""jeted Chian type 2 mal _ formation (~Type 2 (ArnoId)·C h iari maiforJ'J'l(JliM, J.>Ilge 107). Cloaur.ofthl MM defect may conve rt a lat.o.>nt HCP to ""tive HCP by eliminating a route oftgn!U oICSF. PRENATAL OIAGNOSIS See P... dflKliOll o{nfurallu~ dtft!CU on fIOIge 113. "",al MANAGEMENT AOMISSION 1. assessment and managemen t of lesion: A. mt!lsure she of defect B. aseeN whet her lesion is ruptured Or unruptured I. ruptured: . tart antibioties (e.g. n.reillin and gentamicin; DIe 6 hre afur MM closure. or continue if Jhunt anticipated in next 5 or 6 days) 2. unruptured : no antibioties neeesslU"y C. «wer lesion with toolfa. then ,ponges soaked in lactated ringers o. normal taline (fono a atenle &:I ute n ng around the lesion if it i. cystic: and protruding) to prll'o'ent desiceation O. Trendelenburg position. patient on .tomach (keeps pressure off lesion) E. perform su.-gieal closure within 36 hre unless there i. a contraindi<:ation to , urger)' (.io> ultanlOus . hunt if overt hydl"ll«phalul (HCP) at birth): see 1'I'm i"4 of MM dNU,.. below 2. neurological . . . ssmenl and manaK"mlnt: A. it.o.>ml related to . pinal lesion I . watch for l pontaneoUS roovemelltofU>e LEs(good spontaneous melVe-ment correlates with better later functional outeam"') 2 . alMss Iownt level ofneurologic function (_ TCJblf 4·1$ ) byd'e<:Iti"8 .... poole of LE. to paioful ltimulUl: .Ithough some infantl will have • cle... demlJ"Cl.tion between nor mal and abnorma l level" at leut l how.am. mixture of normal. aod a utonoroou. acuvity (...uing from uninhibited anwrior hom motor neurona)" a. dirrel'flnlil t ing ren.. movement from voluntary mly be difficult. In general, voluntary movement i. not . tere-otyped with repetit ive tti muh.. and ran.. moven>ent usua.Uyonly pe.. iatla.long .. the noxioUi lti mulua ia applied B. itema related to t h. commonly lllOdal&'<l Chiari type 2 cnalform ation: I. meaaure OFC: risk o(developing hydroc:eph.lul (_a bood. U.. OFC griP'" (_ P'J#' J84), . nd alao look fo r abnormal rate of growth (e.g. > 1 cr.Vday) 2. head UJS within ~ 24 hn so.. NEUROSURGERY ren... 4. Developmental anomalies us 3, 3. check for .nspiratory stridor, apneic episodell ancillary alI_ment and management' A. evaluation by neonatologist to aue&S for other abnonualitiu. eapeciaJly thOM' that may prech.de l urgery (e .•. pulmol;lary immaturity). The~ i. an average incidence of2-2.5 additionalanomalin in MM patienr.. B. bladder. start pat,enton regular urinaryutheteriutiona. obt.in urological ronsultation (non-emergent) C. AP & lit s pine film" asses. KOI 'OOIi. (base liM ) D. orthOped IC tonUllalion for !leVI "" k,yphotie Or trollotic I plnl deformlti.. and for hip Or knee derormitiu Tabll " 1S SURGICAL CONSIOER ATIONS TIMING OF MM ClOSURE Ear ly dosu re of MM dered is.D.l!l. .... odated with improvement of neurologic fWlc, tion. but evidence luPPOrti lower in.feetion rate with early closu~. MM I hould be dosed within 24 hns whether or not membrane is iotact (afU:or _ 36 hrs the back le$ion is coloniud and there;, increased risk of postoperative inf~ion). S imultaneou s r.W r e pair a nd VP s hunting In patients witbout hyrlroce phalus . most su rg..,ns wait.t least _ 3 days after MM repai r before shunting . In MM patients with clinically overt HC P at birth (ventriculomegaly with enlarged OPC andlor symptoms), MM repai r and shunting ml Y be performed in the &ame sitting without increased incidence or inreelion. and with shortu hospitaliz.atiorr" ·... It may also reduce the risk ofMM repair breakdown previoualy IIftn during the interval before shunting. Pa t ien t is pOl it ioned prone, head turned tori&hl Cto expose the right occiput), right knee and thigh ne~ed to e~Jl"OM right n~nk (consider u.. ing left. nank to prevent confusion with pppendeetomy..:a r l. ter in lif~). POST-QP MANAGEMENT OF MM REPAIR 1. keep patient orr aJl illciaions 2. bladder c.atheteriution ~gimen 3. da ily OFC measurements 4. ifnotihunted A. regular head UJS (twice weekly to weekly) B. keep pltient nat to I CSF p~u~ on inci. ion LATE PROBLEMS Include: 1. hydrocephalus! may mimie - anything li. ted '" 4. De~lopmentaJ .noml li .. ~low . Al.Yl.6XSlW.LEJlJJ.I.. NeUROSURGERY SHUNT MALfUNCT ION when. MM patien~ de~rioratn Iyri ngomyelia (a nd/or Iyringobulbil): lin JH16~ 349 tethered cord (8M rtlhtr~d corcl.,.lIdrome, plge 120): ~ all pfltient.f with MM d o. lUres hive. tethered cord radiographically. hut only I mlnori~y arelymptom.t.lc. Unfo rtunl~ly the~ i, no good telt to eheck for Iymptoml tie retetheriog(SSEI'. may deterioratel"" A. acoli08i. : early un~therini of cord m.y imp rove .eoli08is <_ScolU:illi4 ill u!lh~rfd <:rI,d, pfI~ 120) B. .ymptomalie tetherin, [, of\en manifNted 8$ neurological deterioration of delayed OrlMt-t. medullary compreuioo It foramen m.gnum (lymptonl!.tic Chi.ri 11 m.lforma . tion , 1ft page lG-71 2. 3. OUTCOME WitboUlllllY t~atmen~, only 14-3K of MM inf.. ntl IUrvi~ infancy: these usually repretent thel...t Mve~ly involved; 70'10 will h,ve nonn.IIQ' •. 5O'lt are .mbulatory. With ItIOdem tre.tment, of MM ;nfanu .u rvive. The most common caUile of e.rly mortality are complication. frOIO the Chi.ri m.Jfonnati<::n (re.piratory arrest, as· piration ... ), where late mortality is Ulu,Uy due to . hu nt m.lfWlCtion. 80% will have no .. cnallQ. Meotal retardllion ;. mOltdoeely linked to .hunt in fection. 4(1..85% ar<l ambul.tory with bracin" hoWfl~r , mou ch_ to UlK! wheekhaira for ease . 3-10-.. have normal urinary cont~. but molt mtly be able to remain dry with intermi ttent cath. eterization. as... LIPOMYElOSCHISIS Carol.pm.1d yora phiam with lipoma. Six fonnsa re described", th~ fol1owing3a~ clinkaJly important .. poseible e.... ses of progressive neumlogj.c dysfunction via tether. ing (_ Td~nd arrJ .,.ndro",." pa~ 120) ancllor comp ression: 1. (jntra)du ral lipoma 2. lipomyelomeningocele (Ift~) 3. fibrolipoma of the filum t.ennina\e UPOMYELOMEHINGOCElE A subcutaneoul lipoma. that"",_ through a midline defect in the lumhodo .....1 r... cia , vertebral neural arch, and du.,., and mell:" with an IIbnormlllly low tethered cord". 'l'hne .....y be tenninal. do .... l. Or trallsilion.t (between the two). The int.,.durel fatty tu",..r may alao be known 115 lipoma .,r thec:.uda equio • . l n addition to bein,lIbnormelly low. the conus cneduU.ri. i. split in the mid line do .... lly usually at the IIIIIJJe lev.el as the bifid Ipine, end th.i. dors.l Dlye!OIChi.il may utend su· periorly under intact . pin.l.rches'". There ia a thick Iibrovucular bend t.htjoin. the lamina oftbe most cephalic vert.eb"e with the bifid I .. mina . Tbil h.o.lld coDitrict. the cneniogooele aac.od neural u. .... e. caUtin, a killlt in the"uperior , "rl"II<;I of the menin· IIJCf!le. The du ra i. delli_nt at the level of the do ..al mye"-'hisi., and reflecu onto the pl.code. The lipoma paSSI!I through thill dehitoen<:l to hKoOJe attached to the dor..llu .. face of the placode, and m.y continue COI!phalad u!;lder intact arch.. with the pouibility of extenlion into the central ca.o.al.uperiorly to level. without dorsal lOyeIOlChi. is. The lipoma i. di.tinctfrom the normal epidural fat which .. looser and more areolar. The.ubar.chnoid .pace typically bul,N to the aide contr.I.t.ral to the lipocna. TheM lipomas accou nt for 2K of COV«ed IwttbOlacral maMU. PRES£NTAnDN In a pedi.tric seriN, 56,. preaented with. back 1DIlM, S2";Il. wi th bladder problema., "nd 10,. beaoute of foot deformitiN, parelyoi. or le, pflin". PHYSICAL EXAMINA TION A1OlOIt an patient.l have cuta~ .li(O"lata of the auotlated .pin. biflda: fauy .ubalt.aneo.... pad. UoeIIted ovar the midli"" end usually extend, asymmetric:ally to one lida) with or witho ... t dimple" port-wine Stainl, abnomul] h.ir, derm.lsin ... open;ng,or NEUROSURGERY '" akin appendages" . Clubbing ofth ~ feet (talipes equinova rns) may ~UT. The neurologic eKarn may be normal in up to 50% of patients (most presenting with skin lesion only) . The most COmmon neurologic abnormality ""as 8eUSOl}' 1069 in the sacral derma tomes. EVALUATION Plain LS spine x-rays will show spina bifida in most cases (present in almost Bil by definition, but some may have sefOlentation anomalies instead such n butterfly vertebrae). AbnormaLitiu of fusion and sacral defects may also be se<!n . The abnomlally low conus cao be demonstrated on myelogramlCT or on MR!. MRI also demonstrBte$ tbe lipomatous mUa (high signal on Tl WI. low signal on T2WI). All patients should have pre·op urologieal evaluation to document any deficit TREATMENT Since sympl.Oln$ are due to \ 1) tethering orthe spinal cord. especially during growth spurta, and ( 2) compression due to progussive deposition offat, especially duri ng periods ofrapid w.. ight gain; the goals ofsu rgery are to release the tethering and redu"" the bulk of fatty tumor. Simple cos",etic treatment of the subcutaneous fat pad does not prevent neurologic defIcit, and lJIay !Oake later definitive repair mOre difficult Or impossible. Surgical treatment is indicated when the patient reaches 2 months or age, or at the time of diagn osis if the patient preaents later in life. Adjuncts to su rgica l treatment inel""' .. evoked potential monitoring and laser. Overall, with ,urgel}', 19'1> will improve, 75% will be ullchanged , lind 6% will worsen. Foot deformitiee olten progress regardless. D ER MAL SINU S A tract begilUling at the sk.in surfllce, lined with epithelium. UsuaUy Ioc8ted at ei· ther end of neural tube: ceph alic Or caudal; most common location i, lumho$ll.cml. Prob· ahly results from failure oftbecutaneous ectoderm to separate from the neuro~toderm at the time afelosure of the neural groov ..... SPINAL DERMAL SINUS May appear as a dimple or as a sinus, with Or without hai rs, usually very close to midline. witb an opening of only 1-2 nun. SUrTl)unding sk.in may be uormal. pigmented (·port wine~ diseoloration), or disl.Orted by an underlying mass. The si nus may terminate s uperficially, may connect wil-h the coccyx, Or may travenle hetween normal vertebrae or through bifid spinee to the dural tube. It may wid_ ell at any point along its path to form a cyst; called an e p id e rmoid cyst iflined with stratified $quamous epithelium and containIng only keratin from desquamated epitheJium,orcalled a dermo id cy3t ifalso lined with dermis(conUiningskm appendages. such as hili< follicles and seba~u . glandsl and also containing sebum snd hair. Although inDOCuous in e ppearance. they are a potentIal PIIthway for intradural in· fection wlUch mlly result in meningitis (sometimes recu,nmt) and/or intra thecal abscess. Le"" serious, a local infection may occur. The lining dermis contains normal skin appendages which may result in hair , sebum, desquamated epithelium and choleeterol, withln th" t,·"d. lui. Ii re~ult, u,~ ..... "~" .... "f1.4,, .i"u~ trae1. ,.. ~ inil ..!i", ,ULJ ~ ...., eli""" ... ...,nl" (chemical) meningitis with possible de)IIyed uechnojdjtjs ;tit enters the dural sPlIce. InCidence ora prf's"med sacr al sinus (a dimple whO$<! bottom Quid not be Seen on skin retmction): l.~ of neonates". Dermal ainuses are s im ilar but distillct fro", p ilo nid a l cysls whkh may also be congenital <although 80me authors say they are acquired), coouin hai r, BrB located 8uperficial to the postsacral fa8l:ia , and may been!))e infected. lfthe tract expands intrathecally 1.0 form a cyst, the maSS may present as a tethered cord or as an intradural tumor. Bladde r dysfunction ill usually the f'rst manifestation . The tract from a spinal dermal sinus always courses ceph alad as it dives inwerd. An occipital sinus mlly penetrat.e the skull and can communicate with dermoid cy~ts as deep as th e ""rebellum or fourth ventricle_ EVALUATION Thes-e tracts are NOT tel be probed or injected with contrBst U thiS can precipitate infection or sterile meningitis . '" 4. Developmental anomalies NEUROSURGERY ElIaRI i~ dJrectt:d IoOw(utb detllClinllablIOnuali!.iee in .phincter runttion lanai and unnaryf. lumbosacral reflne.. and lower extremity 1le"0Qtion and function. Radiologic e va luation When lean at blrlh,llikJI.I~.lI.U'1 i. the belt meanl to evaluate for 'vim. bifida and a poIIsible nlll.. in. ide the o;8nlll. Ifleen initially followinll biM, lin MRI .hould be oOLained. Sagittal ima&d may demon$t.r~te the ttllct .nd ia pOint of.tWo.hmenl. MRlal*O Optimally demoNtc.t.eI m..uea (lipomas. epidermoids ... ) within Ihe CllnaJ. Pillin ,,·tII),1 lind CT Ira unllble to do:tmOr\&lrate Ihe fine ttllct which 01/lJ' .. ist between th skin lI11ld Ih<l dura. PI"n x·ra),1 mult be done when embarkinll on ,ursery u part of open;ti ... e p1ln . uinS, III p~lI"r'tion for It.. possibility of II rompl,te Ilm;nKICIl\Y. TR~TMENT Sinuod abo ...e Ihe ,umbolllocral ,..,gion ahooJld be IUTfl""'U" ,..,moved. Mol'll ea udl1ly located ,;nusea ere I lillMly controversial. Although. 2&lI. o!vruwned Acnl.inUHI liel!n el birth will regreaa to II de~p dimple on follow·up (time not specified). il i, recom· mtlnd.,d th~t 11.11 dermallinnllell should bllur&ic.Uy explored and fully exc:.1Ied IIri!u to lhe development of neurolCliic delitit or &iJTl& oflnfKtlOn. The r Hult. foIlowi llil inlndu · r41 inI~tion ar, never _good. aiwhtn und"'rllken prior to infleUon. s...rgm within th4 week of djusnl)lli~ ilappropriate. Sinuu. that U!rminale on the tip oll.he COC<:)'l' Mlrely penetrate th"'du ra. ftnd may not need to be tnoated unlc~ local infKtioll DOeU ..... Surgical tecbnique CRANIAL DERMAL SINUS Stalk begins ....,th a d imple in the occipital 0' nasal region . CutAneoul.tigmata of h",mangioma, 8ubn,Jtaneout dermoid cyst. 0 ' .bnormal hair form.tion mayootur. Ottipila.lsinu&e5 extend <:IIU~.Uy, lUld ifthey enter th".kul\. theydosoel>udll to the wraoh., herophili. Preoentation rna,. ' ndud" recurrent toa.:t.Hi,1 (usually S. ""nrwo)or _ptio: men.i.11git.i, . .Evalultion should inelude MRI to 100». for intr!lCraDial ext.e"'lion I.lId .,...xi. lted ~ nomalies , including an intnlmonial dermoid cyst. TJoeatme nt WbeD opetllt;ng 00 • cr.rrial dermal sOn" •. uroe II sagiualtv based Incision to pumit do-ep eJlploration. Th& tract must be followed eompletel)'. Be p~pared to enter th .. pOlIl,(!rior foasa. 4.10. Klippel-Feil syndrome Conllcni\al f... ion of two Or more«!ovic.ll1 ~e~rH_ Rangoeo froln fusion ofon ly thle bodiN (conpnltaJ block verubrae) to fuiion of!.hl mtlre veub' H (iocluding posteri· oraJ",mlnlll). Result. from fallureol nonnal ~tation ofccrvtc.1 sornitef betw~n 38 weeks llllation. In~oI vltd vRfUb...1bodies ueoften flau.cned IlQd .......aaIM dioclpllcU .... abMnto, hypoplutit. tiemiv",lUbraa .....y also DOeur. Neutlll forumina are 8malle, thin nonnaJ aGel oval. Cervka J lterlOSi.Ia ....... Com plitt> .bnn~orthe patteno, t iementa with an enlarged foramen m'fIlum and fiud hyperemmion postu re I.ItaUed In. ieocepbal)' and il ,arl. lneio;lenceofKlippo:l·r",il il unknown dIN! 100 iLl rarity alld tbe fact that it " frequrnlly uymptomatk Clauic clinkal triad (an 3 at'" pHUnt in < 6011>): low poIoterlor hairline, ,oofU""d neck (brevictlJli.), aod limitalion of neeIt motinn (may nDt. be e~ident if < 3 venebne ar. fuMd, iffusion illimitl!d only to the 1 _ et1'VieaIl_lJIO. or ifhYJll'rmobllily of non· ruNd """iI!n~ compensala). Limit.tiDtI ofmovlrnent I, more wmmon In rotation than flexion.f:lltanl1Dn 0' lat>eral bending, May a«u r in COI\iunction with othu fonpnital o:em",llpine al'lOmaliH t>a.eilar iDlprfiSion and atlanto-ottipitalhDioo. Other dini"",l.ssociftt;onl include fICOl;· 01;' io 6O'lto. f.eial .. sym meuy. tortinoUMi , _tlbinl or the ofCk (~aUed pttlryVwa colli wbeo II!Yrre). Spre~I'a d efnrmity in 25-3S'it {raiHd IleIPull due 100 fal lure o1the ",pula to properly d l'AOC'nd from ita recton 01 rarmetion !\ilh in the ned< to itt normal position lbout!,he Um' time elllle KlIppe.L·Feillnion oce ..... l. IY"k lnwl ]mirror mo· .,,<,'h .. NEUROSURGERY n. tions. primarily of hands but ()(Xuionally arms also) and less commonly fadal nerve pal_ sy. ptosis. cleft Or high arched palate. Systemic congenital abnormalities may al80 OCCur induding: genitourinary (the most frequen~ being unilateral abllenoo of a k.idney l, car· diopulmonary. eNS. and in ~ 30%deafnells"' (due to defective development of the osseoUs inner ea rl. No Iymptoms have ever bHo directly attributed to the rused vertebrae. however symptoms may occur from nonfused segments (less common in $hort-segment fusionR) which may be hyper mobile possibly leading to instability Or degene.ative arthritic changes. TREATMENT Usually directed at dele(:ting and managing the aQO<:iated systemic anomalies. Patients should have cardiac eVllluation (EKG). CXR. and a renal ultrasound. Serial examinatio"" with lateral flex.ion~xtel\Hion lateral C.spine x·raY5 to monitor for illlltability. Oc.:lIsional1y.judicious fusioo oren unstable nonruaed aegmen~maybe needed at the risk of {urther 1000s of mobility. Alaosu p<J~ 142, for recommendations rega rding athleti~ competition. 4.11 . Tethered cord syndrome Abnormally low OOt""'S med· uHarie u90Ciated with a short, t.b..ick· Table 4-16 Presenllng aigoa and aymplom." ened filum term ina Ie. or with an intradurallipom. (other lesions. e.g. as Lipoma extending through dura. or diutematomyelia a/'1l ooneidered III separate entities). Mast commOn in n,yelomeningocele (MM) . Diagnosis must be made clinically in MM. 88 al most all of these patients will have tethering radiographically. P RESENTATION PTes.enting signs and 8)'1llPtoms in patients with tethered cord are shown in Tabl~ 4·16. MYELOMENINGOCELE PATIENTS If 8 MM patient has increllsing high irJ:idence oIscoliosis arid ~ due Ie incIusio:wl scoliosis, inen'!asing spaaticity. wo"', of series by HQltm:an enlng gait (in those previously ambu· latory). o;>r deteriorating uradynamics-: • always make lure thM there is II worlting shunt with normal ICP if painful. should be con~idered tethered cord until proven otherwise if painleSl. should be considered syringomyelia until proven otherwise may be due to brainstem compreuion ($ymptomatic Chieri II malformation. M~ fXJl:e Ion reqUIring posterior fossa decompression Scolios is in tethered cord Progressive scoliD6is may be seen in conjunction with tethered cOTd; early untether_ ing of the cord may r~ul~ in improvement ofsco\i(l6is. however. untethering mus~ be done when the scoliosis is mild . When cases of s 10' S(;Oliosis were untethered. 68% had neurologic imptovementend the remaining 32% were stabil ized. whereas when scoHosis is leven'! (., 50°) ~ 16% deteriorated. TETHEREO CORD IN ADULTS Although most casel of tethered cord present in childhood, casH of adult tethered cord have been reported (_ 50 publi.hed ClIseS a s of 1982). For comparison of adult and childhood form • • au Table 4·17. n, 4. Developmental anomalies NEl/ROSURGERY " E VA LUATION Rediograph,icaUy; low con .... medllilana (below L2 ) aDd thickened /ilumlerminaJe (nonTI81 diameter < I ".m; diam'ltars > 2 mm are pathological). NB : apP" ..... nl mum di· ameteron c;r-rnyeJogram m'IY '1Rry with concentration of room ' l mllt4!rllll. It isd'fficult UldifTenmtiate a t4!tbl!red cord fl'Qnl a congen itally low lyingrord {filum diameter i ~ &eo"'alLy normal in 18tlilr). P re·op evaiuatiolJ PrIMlpt'rative ill.\I!(JlPttoIl1'Ol i •• trongly recommended, e8llecia II)' if the I'P(ient ronlinen! (po!Itoperalive chang es;(1 bladder function are not unl\Ommon, po6IIibly due to Itret.d".ing oflh" lawe. liberl! oftbe cauda equina). _\til T AEATMENT Ifth t only abnormality IS II thickened, Bhortened fIlum, then .. lim ited lumbosacral laminectOXl'lY may suffice. with diviSIon of the filum once identified. IfaiipOms is fa.und, it may be removed with tbe filum if ilaeparal.lla easilyfrorn neuraj t.iuul\I . Di.lltitlJU illh in g feat .... res o r the filum t<!.rmillaJe The filum Is dIfferentiaLed f'r<>m nel"V~ roots by presenoe oftbllucteiistic lIquiggly vtssel on Buriace of rtlum . Also, under tbe micros~ope.. the filum 11M Ddistinctively wh i{er app"'aran<:e than th nerve roo-tII, lind li!/amentoua_like . 1I"IInda eaJI be ..."n ",nn;nlC t.hIVugh it.. NB : ;nl... -op .1"ctriO>ll a Umula Uon wnd "",urlling of.n .. l . phlno"", EMG .... e more definitive. OUTCOME In MM , it if; us ually ImpmlllibJe 1.<1 pennanenl.ly un tethera a,"I, however, In a grOw_ ing MM cbild, il may be thai after2·4 IlJltetherinp that tbeth;ld will be fi.nlahed grOwing and tethering may ees"" :0 be II problem . ClOSe. that are un.Let.Mred early in childhood moy rl<\:ur laLer, e.reciall, dunng !.be adole""en! growtb·spurt. !/lciden<.:e ofpollt-op CSF leak; 1&9&. Adull form : " ".gica! relelOlie .elum of bladder function. NE.UROSURCERY i~ UIIuidly good fo. pain ",lier. Howlflver , il is poOr for ~. OevalopmenuoJ8J\omalies '" 4.12. Split cord malformation There is nO uniformly lICCf!pted nomencllltu,"" for malfonnations characteri~ed by duplicate Or splil spinal cords. Pang et a1.'·' have proposed the following . The term split cord malformation (SCM ) should be u$ed for all double spins] cords. aU of which appear to have II eommon embryologic etiology. Type I SCM Defined u two hemiC(JJ"ds, each with i1$ OWIl oentral eaRs]"nd aurl1:mnding pia, each within /I separatedurlll tube separated by sdural -sheathed rigid osseocartilaginous (bony) median septwn. This hll8 0ften (but not consistently) been referred to asdillote m· lllomye lia . ThereaTe abm>rrlllllities of the opine at Ihe level oflhe 6plit (absent di&<:, dol'* sal hypertrophic bone where the median ·spike" attaches)"", TwO-tll' roB have over lying skin abnormalities including: nevi, hypertrichosis (turt of hai r ), lipomas, d imples or hemangiomfl.'l. These patients onen have and an orthopedk foot deformity (neurogenic high arches). T're.atment: 6ymptoms are moat commonly due to tethering of the cord; and liTe uau· ally improved by untethering. In addition w untethering, the bony septum must be removed snd the dun reconstituted as a single tube (these spillO!s aN! ol'l<!n very distorted a nd rotated, therefore start at norma! anatomy and work wwardsdefect). • DO NOTcut the tethered filum until afkl: the medilln septum is removed to llvoid having the cord retract up against leptum . Type II SCM Consists of two hemioords within a single dural tube, sePllr ated by II nOllrigid fibrous median ""ptwn. This has 80metirnes been referred w 88 dlplomyel iR. E~h hemi· cord hlUl nerve root. arising from it. There i& usually no apine abllormality at the level of the split, but there is usullily .spina bifidll occult.n in the lumbosacrlll region. T'reatment: cons ists of un tethering the cord at the level of the spina bifida occulta, and occasionally lit the le'·el of the split'''. 4.13. Miscellaneous developmental anomalies Some anomalies that may be seen by the lIO!urosurgeon indude the following. Septo-Qptie dySpJ aS;8 W '.11 ..... ' .. AKA de Morsier syndrome. Incomplete early morphogenesis of anterior midline structures produces hypoph.sill of the optic nerves and possibly optic chiasm (affected PIItienta are blind) and pituitlll)" infundibulum. The septum pellucidum is absent in about half the cases. About balfthe cases also I"lave schhencepha1y (_ ~f 112). Pr-esentation may be due to secondary hypopitu.itsrisrn morufesting as dwarfism, i$Qlated growtb hormone deficiency. or pa.ohypopituitarism. Occasionally hypersecretion of growth hormone, corticotropin or prolactin may occur, and sexual precocity may OCCur. Most patienw are of normal intelligence although ~tardation !lilly occur. SeptO-optic dysplasia may be a less severe form of holoprosencepl"la1y. and O«lIs;onslly may occur lIS part Of lhis anomaly (with its attendant J"KIO",r prognosis for functio." or survival, Ut PQ8e 112). The ventricles cna~ be oonnal or dilated. May beseen by the neurosurgeon because ofeoncems of possible hydrocephalus . Absen ce or the septum peUu c!du,m .. l. '7ll Absence of the septum pelluc:dum may oc:cur in: I. holoprosencephaly:.u pase 112 2. 8chizencephaly: IU ~e 112 3. agenesis oft.he corpus calloeucn: _ PGIIe 1/4 4. Ch.iari type 2 malformation: see page /07 5. basal encephalocele 6. porencepbalylhydranencephaly 7. may occur in severe h:odrocephalus: thought to be due to necrosis with ,"""rption 8. septo-optic dytlplasia: sON! .. bo"" 4. Developmental anomlllies NE:UROSUROE:RY References 4.14. v... {)O:, Me<h. f. B<Ul;"..'. It An<hooid <,~. '" .... ,nidd). "..!01 r.....,c........... ,><iIIm<., Qf ",I>1"";"'III!<l_'~~11'_, J fIIe.to! 1. M.yrU.Ao<~ .... f. _,O . "..r" ~_"""", PQ<Iolll ,_"~~ "'... or II>< _lhI ,."".... 001 klb<. J ... _ , Nn.~ '~ ~ , . 6,1'lli2. K_OR . Fnw"""MS.,W, ..... C81_..",. .r .~"".icI"l"""'<lUldmI J ,..".-. ... ~ . IJ,11.1981> Pi< .... .: ... , A. Copell< l ..U,".,,' R,.' .0/,' Pre",. _ ..,I... • od of .... ~II .. R..l .w or lO ...... J N•• , .... "" 73: '""' . ...w•• " _ ,.""".J.......""'.... """""''l "'r< ItIo , .J'~ 11 1)101, I~l. ' ''''''' _'ro""rlll. o:>o<l(Ilt<r&!".1 10«>. A ... <,.,,: ma,, ,,._ ". ~, orE!LoOid ""'' ' ' 'VIJ' po~.Qr-....- ~ t.""' ~ _<,.... tIl,,,.--,..«y _tono>od_. <>1111< I~!tl , to .,odd,. ......."r.,... s.... I'!<. ror 17 JM·'. ttoprHl,_rA· E"""""'P<"""""'......, .w:.............. ,.no.......f"Y ....,.r~ .... one! .~h"" U<IIInOIO' ioI <.ro<>. ofu. __ 0, .0. II 11 ~) . 1))1).1, 1991 "". Lit; ,.......... "" I\lboJII" I.< T..... "' ..... 01 ""."""'I'JUY 1991 \Itt'''' 1 ~.Iu 0100 IS l~ 17. " .,.It....,,.",,,,,,.,",,,,", 1((I ,)' S.62 . 1~ IC.&lMJ F.Si"'1MIotp/1 O. Wcn60 S ... oJ, I• .....,... . io' Ii"" .... D",_,I< .PIII .000000001c «w,,,,,,. N.~ ' 2 . n40.u, 198CI """'.J F. III: Tho .. Io,;",w.'r ,."w...K. ..."....... _... "(. ....... ''&I11'''',.. .... el'l\O<ol m•• ,I.... tioo. of t fp<ll!>oJ"";': Mtoon--.. ~,.. I "~, ~., '9 , ::0 . .1.1<>"" y. ,.,...."""'" Cf" JI. ,_".0: 17<I.lII). 199" I ..... ') Cola'" M. fJI ... nn M 5 6 . 0....:"""" D :u. (If ,.",,,,,,,,_ 'l'''' ) SO; 179, 19\I<411<i1<') tfu R' N<",.'.. ncCf .. o' .....".,. ..... c~ .. . J No .· /I.""""". NEUROSURGER Y ~, G'JM- I ~a): !·7. 19'>11. f""""", _la" PlllllaurQl" 1r20-<i. 1m HiU"'_MC. '_,K L.J ....... H ~ """."". I.. <01'1>11-"", ooJ """;.,.,_;.. ""''''''1l.<'1 6 39.!98(1; H.".. 0 ~ . 8c< ..'L ll. M.... 1<aY K F. .,~J ,: l.-ombck>tG .".,.,0.... "'" ): ThE !1IIt!I:ooIoI~ ,"I... ...",lojl... "'oo.l~""loIa'ol · 'J _' ~ "............ ,~, ". on. . . ....1~ 1r,cqo._ 11<1 ........ ' ....... ) p<dr.lc 9ll, " 1911 , S....... of Ptdr_ N.......,<zOtY of ~ ... """Qq ......... "OII 01 "'LIIOfoaru,l S"" ..... ,{..J.) Ptdlo,· ri<""""""'l"Il'I .. «l., Clnr .... "".';'''''IOII. N... 'r"" .,n:. M ...... 0 Do ~IIrp" of r.fon<)' ",d <",(.d. _ .l.oII<d O - 'C """"'.Spoi",nclol. I%9 s..w••""d. c.S.......... ],O N: ... _phIIlDa""l <,",. ..r",.I."" '" ....: p".r ''''pbo_'""loocIt•.J N.......... ,,* lO H I. 1972. OrtmcIPW M..." ... "'oftll<r.~I .. I/IIoII""",. ,1000. in " " ' _, CJ;>r1cil N<",."...,,)CJ ~. 1911J " LoP<Mr, M 5, r.po,....""" 0 M ........... p~ . L.m _ _ .. I " .. ~ c,1I .... ""... J "' ......... " 71,U I-5.19IIJ. "f, Coo,-P ~."..- .. """"OlIO 0 l , ",""E.... C D. 0:w0,..i1aJ ..."",1>1 1Ottl<01I", ~~"io<I> "&OJI1i"I.h<MCII .. vxIMod,ooo!i" -.•",h•.daor"...-,,, J .... O,u.o, 1 ' ~', !9il. o.n..SIC. ~oIJ...,j","i:oIlkl r.o ~. NI'f ,R•••",HL,Kcnol."JF. .. IOI" T"""''''_1 .-- ~f)'4l;MS·8 . 1~ ...,., !'on ~ Rr." "' ofc.,..",, .. ,II< Ioo<p.w ro, ..... obi"""', 19n.1982 ) M<Comlr r G: T.......... 01 r....o<looollomlo<lood '~_i. ,CUrr /Mnb ...... '2. 66' . ) 1'1,.,...,..91 OJ: 211-lO. 199\1 S'O_ S, M oo R. Bila l, ,,,J_c..1A<oo< .... I<pof. Sf"''''.'''.....1Id try.."" "", "",,", t,i!q>slo,j() l))r1!l4-JOl.lm ,..,... II:'fI Q1>&I'Iorlf ZO. 1}'1.2CJO.I . r.,o .. l.cwi. 1'1 l.~ .<".. N. s.:..,.iIU 1"."aJ N.........ri< oy .. of"'" _ 1 " , -1... ",,10 . N..• O! 1'1............. 61 . JoIO.7.'9&o!. Knr", II F,OoQdnoh I T' '--bdoi<! pio;o-pil' JJ'I",, __ .,.61 . 11l-9.I'IU. ~"",of ' ~~lrIIIC""""''''': c...~ If. ~ .~"" . pel _ "1.... SW.Zinu!><,,,, •• ~"' . II IIu ," ~ l T .• , .... c"'P"' ••n....., 0I>d lifllbC R..,"" O.,.",1IIIl E, Ciooai'i G... (1{~ "'",,",M' r.:.- .......11>.'''... II> "'pcn'• • )'<\I<> .... J "'......... " ., 66-/1. \9\11:1, M.'".... I( F, HoiTIIWI H J, _ 011, ,, . " """"n''''I\~ ofPodiornnT..1. Fotoo o. 1. ! ... 1'bti\""',"I_ SIDS. Pooi' .... i.o&>noilSrus Iki"_ .. Mit ......1.... of "" .... IDJIII"" "" ~ . Rodl· I_ " " " bobb_ ....l l.)_lrl"~ .....l<r.. _ """,. ,. •• __ ......,., :PI), 1'JlI1 ~Ibri,," , L Ttt.r.1""'''' 011Xlbbl • .,..,4d 1Io1l .,odromo b)' 1.. ...,.11.,..1 cl"'«"''''¥ A S9). S. 19111 . RU...1I 05,b!><,,, .... \.. ,·p",,,,,,,,,or......-ro of llk ...........)'>! .... . S<IoOll. Will,_ ODd WiI ...... m ~.t>loC.G'""1 GuljoC. M,11o<lo J J. MR mil CT d.oo"-;' "' .. ""' .... " 11,,.,... ,\,I R lS7 'l u. JI'I< • • ropalaol £<p1'l . ...... otl;-III · Il, 1911 0 • ...., E, Tcpo ~1 F.O.ilol O• .,<tIJ CT_.,od ...."lumldo CT d ... """""", to >n<~ooJd cyu> "'"P'' ' ' ........u.u. _OflIO>I""" ... ,~ I\~OC1OuIctEM . I """'''C A.S.U.... L N, ".>I. Op.no:" ."'0><'" or_.....;.j..,idonnotdc.IU • 1Id'~ " . . . _. R<pO~ onl ...... ~: 006-11 , 1990, R< ..IIOb..,SS . W...,..\>O< 1 UI .....W<1u ...I>II io\)-1'O''''. .. '''' h~"', N<It"""'l<ry li t 6}'1. 19V ~, • ..,. O.So'"lo·R.... C, M.. <IIoc O. "Ill" rOl''''' ,.."1_",,,;" l7 · )70.7. I~l . e"' cM J. W... ,"" K ~, WIIH. ""S, NQrrnoI,,,",. 01 'oa"", 1IIIl"'" .. "*'Il<of".... >01 .... ....... 'J""""",, The _oo""",,1e N...... " .. 11, :101-<0. 1M. T..."O F. r _ I,1;I)oo1 WK , .,ot~ Th< b<o>en ~lariool>tl_ A i .....,...io ' _ ......... ,01 ...."""""' •• .-.1 "",.....1Od _ ...pII;., ..... lo ollil4l .... ,111....., ..., _•• J~; fj91-9. '11'16, Cbodd",, ~ W M.C\IotW"". J 8 , 600p F .... Th< .ut.18""""'1"""0.", No ...... .... .or) lO.II6I·7 !, '9n, G.... G F.Duo< E I( 0....:,.,.0(.... .,.,.,..,.."'.. II)' " " " ' ' ' ' ' _ R... lokro 1I.5; 6U.7 1. 1915. ". M~ Spdl .... I O. Po'o!! C. Jonco ... M: o.-.cloptncnoll -..0.1"... 10 "'" """",of ,Iw. I",""",n ...."""' • _-o.t... 8.... 80, lI ·st 19»- 1'001 K S, LI" R fl .St/Iwo, F"',n oj . ... ",.11......." .., Ro ..... aJ7 1,-"J N.......v ,~ !3' !D·7.19IIl O. _G . ~C.llbmi ...... F. «61. a.;... l .,oI/onno, 1ott Pan I. Con ' .... p 16 r.m. I·7,:/004. No,,,........ $I11d S,So.,P II! • "'<:qIIlmJ- Ooiari I ..-..If"""""" of,", ... fIi~ 1e "' _ _ ....: 'q>on. J'I .... 4. Of!veIQPn:tenU,t! anomB lie$ c... ". ". " ". . ". ". n. ". ". ". ". n. """'~ J2: J06.9 . 1\19) 1..<")' W J. M._I-. HoMI F: OI.an "..1 _ ",,, 1"<.."'I",I. .dol,,, A "'1",,,1 • .,.,,._;,, 171 ...... rI_'lU)' 12c J77-110. 19n. 8<;"'.; C K. Cock<rllun K p. Mul' OIi." ",t.\fo.I . "' .. _ . C01I'<mpN"" 'O""121 (2(;): 1.7.l(Xl1. RI>oIoo" L: Mi<'-'V'I'of AnIOId·OI..,; ..,.If",· .... "'" '" """'" ,."h an(! " ' ' ' _ h,dromy<l io. J N<'ur-a~' : OlJ·ll. 1976. Ci"iOId S I. w I"r..1d I "' : Oscillc>p.i, lind pri""'I' ~"I1., «10]>'" C... vitw olth< lit· ''''.'' . N"",,".'1"y 29: 912-4, 11/91 . Abool ... " O. So"", K .(;0)'0' C "-" (1/,: I'o.t'KIIl of «",.. II...,n"Is In '''" _lfIOI>\liobon ond I. pOl"''''' ...;'" Ch,an mallormat_ "'I" ... 'i""" . _ h wi," MR imo,i.J. J Com"". "..", To""'V9! IOll·6.I'ISS. 8..-1:". ... " J. Wippold FJ .Shmno"J L. ,, <11" SI""fKon« of <... bell ... IOMIlior pooit .... "" MR . ..... NR 7: 1\IS·9. 1916. M", . 11s 0 I. Dj .. O. EJllin T K, <I Ill" Vlrione. or II.. pooit;'" of ,he «rebon .. "''''''' ",jlt. .,.: "",. 11m;""')' .. """ . Rodlolop- In (1). 111·1. 1991 . lik>r>du B I. He<lh•.., C 1... P A," tIl _ Tho fCIOl .. "," of 'yrioJOll)W<> .. y<b ..... Il00. biodbr>oll hom~ af.. , f.,... dt<~ . J N"'_'139'(1): 111-4.19\11. M• •" , J. " ,.., M.c..rn "'ri M." .," "'yml>,_Chi"';,ypt I m>J(".,......_ i<I<.'if0<6011 ..... In<lk "son>n« 1""'1"'1 . J Nou..... '11 '12 (6): "pM"" .. (i,,, -- 1'0>""" " ~. ". " ". ". ...." w. n. n " ". OM..-' tnalfoln.o""n .... hlla .. " ~vi_l y lfO,lOd wilt. my,Iome.;'.-k ,kI'1ft ,,"" 1I0I0.,,. J N... • ......... n: 181-1.1992. Part. T S. Holfman H ' . """"rie l E B." 111_ Eool!<' n..... wi", ... _itol <!<comlft_n or tho ""'"'d· a.....1... ,.....~. i.f..... "'illl mY'''''"' ''''''t<>«It. N<""""""1 1]' 101-.12 . IllS) PoII",,_ I F.,..,. O. K""ooh,. S . .. 0/.: 1<1< • ."..... d)'IfWJi ..... U;'" ,.,... OIl"; OIoI/omIoo_. N....-. ..." )O: 7I»· I ~, 1m . HoflmM H J. II<t>dri<l E B. H.,"""",,,, Jl P: M... · ,I.... '"'". ,,"" 1IIHoIV ..... of -""oI<I.a..".; mal· fotmo'ion on ~"..... w"h my._,n"",,". Cbild. 8",1<1 I: 2lS·9. 1'lI~ . CI]bt.. , N. 1- . k 1..1IOft< I.. a. <,til., C<-non.l "."."'" ')""'''' 0"""",1",. "10<1, ,,,, .. i,h m1'1om' ......"".... hydnx.phoi",.""" ,Ioe """'ld--Chlori "'.If_.... , R.. ppg; ..1ofth< ..... " ."dl", ,II< po~;' 01 poo«'"" .. oral ,.be <I","," dor..... N."""""".,. 11: "9--601. 1986, Bell W O.Cilsnlty E 8. _ DA. ,,0/" Sy"'l'........ Ic !<ff>old-C1>i"'; ",.lfOI1"O""": Ilevlo .. 01 , • • perle"", ..,," 22 """-•. J 10'<1"... , .116: 11:-6, If,,,,,,,,_ .. 1~7 . Ral""">!i A I.Samo<l .... G. Y"""'P") I.. .,0/" " ..... , olll!< fo'''''''n. of l-"",ht. ond Tho D""'y·W.lko, ,y" .J N.u,... ..... ll: 202· 16• 1.1.""",,,: ,,<>I.' lI"'h! F.,... ~ K _ ~ .Jl<.;.:- O. Tho INwIy.WOIk<r ....1/"""";",.' " to.",,,, 01 40 <AI<>. JN ~61 : JIJ ·n.19 "' . . ". Nott·,,,,,,,,,,,, • " 0,7 K. F.1oonor M ,, : ....osl. of II>< oqo«tOCl i" """I,,. BrU M«I J 1: ' !~-1O. .. ". ". " " M. U. ". 0> . ... ... ". ". V_ _ I . H1_R,"""'·' ....... oI_6o<' ... ~ >t. and _ ! ""....... hr6<o«~u, l" ,110 oldo,- '" 4. Development.al a nomalie$ Nou'''u.rc 1'Io ,<~ io.,.,. 0\9 ' '19·J'. 61.1~1 , Do-My<. w. z"",.. w. ~.I ..... C G: Th< f..,. pr< . d", .. ""- ""I., Oi'ioonic ,11"lf""""" of mtdl&. f.. '01 .nomol... for ho~"""""", (0111,,,,,.«phlly). hoIl",rb)ol ' 156-63. 196&. VOII!< 1J: EI"""ol .oni...... "", Ihc fo'ol, N Eod J Mod n7: )99-407. 1992. Wtrl<fMM,SI1>j1 I",S. M;"""lI"" : ~ ....1 foil< Kid <>p<>SU'" on<! ri,;; of 0«>1«" ". ,,,'" ,.be d.reru. JAMA 2~ IlH-6I. 1991 . C<nIt~ I", 0 - - eo.."",: II.e<:om_ioN fOf ... or foil< .dd " ' . - !lUmbe, or 'P'' ' ~,ffda <&SOO ond 0I1oer .... ",1 ,"'" ""Ienl. MMWR 41 : RR·I •• IWl Daly L E. Korle P N. Molloy " , ,, 111_ I'0I0 .. ,....1. ,"" noun! 01'''' ""(e.... 174: 1691-1702. ,oUt" M;I ... oky ". l<1"""''' M. Ro<hma<> ••<I .1 .. MIlO!' 001 ......"",.. , •• ne! .. " .... "be ""ft.cu. J"M~ 2(;1: 381·~.lm . P.II"'" G M. Vol"""", """,pi", Mid• . IJr Mid J 19a. 1300-1. 1989, M M.U.,n k C. S"'pioo S... oI.: ...-.111" i" .. I." .. '0,i>J, or .."",I 'obo ""1« ... JA M ~ 27': 1089·91 . ,~, S~wG M. Velie E M.S<~"<, 0 : Ri.. of .... ""'1 ...... do.r"",·afkcte<I p"'p'.""I<t 'mont-.. """""" . JA_17S : 1(11),6. 1996. Milo"""y A: Pudic" .. ·,oI ....... b'lv.rl ..... ond """on be""r." of holh ond low ",,'ornol .. "'.. ol · phI.fotoJ"'Ol<i. ""-ire;" .JJ.V<,on P'1'''''''''''', Su'1:0tooo .. Gyn«oI 161 : 191 · 7.1~9. S.""" B K: ",pha.(otoprnl<in .. «<.j",. ,,~. P.. dl ...-3): 111 ·96.1986. Be" ... , I. 81,. K.1o",_ R 0.0"" " $om< pr\lblomI "f olplq·I_,. Kf«"'"I. LaD«! 2: 1296-7.1978 . D.v,dso/I H 0 ." _ R.S,,"', Jl E, "JO""''' of 'bo_ull'''~''1: M,,,,,,,,,,, "''''''''''''. """. "'I· 1t&d\OlOcY "S' )71.]. 11lS.I . \..O<t<t I D. "lvOfd E c: ~. 01'111< <OfPUI ul · ic<um. B""" ~ I : "'· 1O.I~. l.o<t><, I. W""''' M . S~l .. bif"",· ~ ''''''''''''1 "'I"' ....... • " "'b 011 01116 60: 1086-91 . I'ISS. Ski" S C. Soh .. to Hj<I<octphl"" in my<Jonw"'ft. ""... . Child. 8",1. " .1 )·9. 1919. $Iwntd W I W: .............. , of ,lor "1'_<ni~fO" «!,.hlld, ]" Mn_"'''lO''''I<. Ml:1..o.no R 1... (ed.). G",,,,",,,, S... ",,". 1'«'* Y""' . lm: PI' 1&9· 410, Shatrotd W I W. Tholl<P"<1lul ,,,,,,,,,.. ;on of .... ....... Iimh "", .. lo.;" ..... ' A~" R CoIIS~,_ (foI11))oI: 106-n.I~ . E"",1n N E,Rooent.t.ol R 0.;:"01. <I~I.. Shu", pioocmt'" "'" tnyelooneni"yX<1o « pair. Si",.I .. • ................ ""II'<"tl'l "''''i"l. ClPI"," N". SJ" " 14S ·7.IIlSS, H.bboIl>h i0oi Y ,1I0ffnwl II !: fMl1 """",or my· oklmoo,oJIX01o ODd tion of VI' . h.",: T""b";q.""'" "",I ... ","",,,,.,...,- 20: 2 1· 3.1987 Unoo SI.s-.. eruon PC: Evol:od to""""'"0I0fY """,,'iol. in mo.. Moll No.<OI " . 11·91,1%6. lWinz£R ,R _ _ .\ E.SoarffTB,"d'_ T,",· <"",p;ul <Ofd f"'''''''"" ... "i.,,,,,,y.,,,,.1< ... pai" Rodlolot:r Ill : 1s:l-60. 1979. Emery J l-.l<tod"" R G, Upo .... of OI>e<""" «J"'.. ,"",_t fait, ' ''''''''' ,.b "'; '" ..... <O$pIooI 6y>'*1*11, .... 0.: .. Med Cbllof Nwrolll {Supp~: 62·70, " cu..""" ". w."., n. N... , ... '1: JI : 1S9-63. 1989 . Pto<h 8 : Tho Amold·OII,,] m.If"""" ..... """'_ phoa< ..... . Ar<h rI .. <OI 12: S21_lS. I~ . Tl ..... 1 M ,PlJe.Spdl"". J: /'IounH'adlolop-. lrd <4, Willl.m• • nd WiI~in:.,8ol' I"."., 1996. PoII .. k I F.J>u1 D. "'~hI" L<ld!" 0.1<","" N~ H _ i0oi J G. Robert C M. U""'1 0, 8<,,1.,,"'1' ...:I"" "".",i. ;" ";"1" J N.~,01 rI ..., ....... 1'101' . ~ it. "Y 37: 1312·S. 197(. 1..<",;,. R J. No"",1 ,ob,,.;.,,,,,,,,. J "MA n9: "s· ". '"' Dy$t<C N. M."" ... " II . V...c..' do, J C:S, ..... _",011"'; ""11""""'_· ........ ly ... or_ ,~ . O. ,~ ...",..... """'Jo<m<".,.nd I.... '."" ",,<rom • . J f.II""'io,h_"nll«""'~"of·1m_,k " ly. J 1'Teprt""", 1.1 .imuI..,...,.. ,.,.. ".a.n.. ,~ NEUROSURGER Y " •" ~ N .,d~IIT p . II4 .I..oneDG. Iot "ll _S l ....... -'lind .... 01 """ .. I ~,....pIoi3m _ ...."'.. cluld_. nU.t. e lSbo J: 1n.~J . I919 . SolO K, Sh,,,.,jI T. 50 .. ;0 H. .. «I ~ s.,~!lY ___ f_",).~ .....;r"' ...... of_&<"~.I;". '~Ii,...... .. .... ~ .. _.i' ' ' 5.aI,. " . . . j)OII t1dId. No .... 5", "t.II , lOll', 1'o",.UI[ R.Chrfll'J D.Hohpool'J ....,_ ... lIfO" <p>:tl ... >eo«h r"" 1 ob<>on:nalit ... 01<_... u; •. J 81, 7U-jQ , ,.,,~ . ~Sw.R""'",II<CB . 5i:._I ..... JE>C_ _ · •• ,ul r..."", 01 ". lt/IIl<f· ..0'" Ilpotno (Iopam)' .l_"~' R..,~.""kl""" """ ' " ... AJI'IR . , IOl· I',19U. 8...00: D .... S(iIuo L. $pi.., Ii.,.,..,.. 1<1 iof'"" """ <IIt« ....... • , ... """'.s..,..G,......, OboIu III, Jl)lS.l91\4 !;o~""rct /I 1", l..an£ I R. ~Io<E ..... G 0: !(BliP"'· 1'<;1 'l""f<jMr." _'fel ....,. or.,_w.., - . • ~ ... J lJond"rII s.."~.,, . 114(;:». '97~ NEUROSURGERY • • V"""""'JR.\<d J ""'~I ..... ,.., . 2M~ ., W. D. s....c!rft. "u1oclc1phlo,191i:l " ... T S.Ca~ w S. lola";' W M •.,ooI .. ~ •• .~,~ """ """.." In chilclral "'~~ my .." ....... RIoIioIoJoaI t. ....lp'.,. .... -.,coI _,....." JI'Iw, ..,,,,,6L -1061·1'. I~U. PIn, D. W;U",'I"' J E: T......l<4rord ' ) ' _ io 0.,0«"" '00. '" ,~ oduJ .... J 1'01 ......... ,,'7 J~·41, 1982 ho, D. PI .. 101 S .... _ 0 .......... 101: Spb. <0«1 ....11....,.. I00' !'»11 t ... ~'"r I/W"'l' of, .. "",,· , ...... Jot _blo """" «Wd .... ,-..pI) 31 : (,;1 ·110, 1'I91. . . . 1"""",....,., _ 1ioIf..... H J:C_",,1'tti( 0.<1.1 . SplU ...... ... II~ , ,,",,I ", ...;r..o''''''''l'or...,!>t:I<>&<...,l.r"'_~t_",..r"""""",,_ ......,~ )( .IIO , I<I9l. '". ",.n _ _ I( po!l"''' III ~". W." .S ....".,.,., . ""~ • • • Srn;'1fo r«opInble "'~If""",'k n . """.o ddpiu •• I9U • 4. Dellelapmelltolonamal)el\ '" ~ - I,.. , ,~ ...... ....;, , 5.1. Contrast agents in neuroradiology IOOINATUl CONTRAST AGENTS Wlt4' ...olubla eonlralt ltfIent.l IIlve ,upC!.neded aide. llan-waWr·fQluble anee . uth .. Palltopaqudl (Mbyl iodophel1Y lundecyl.te or [ophendylate IIlE'glurtUne). • C. ution: iodin.ted Q)nln.1t (IV or inu-I·arterial) may delay tXenotion of m e!.romo.; o (Clueopll",t4, AVllKitmed), In 01"11 hypoglycelllic agent u,ed in di.betes ~ype II. and cln beu.odlted with I.ctic.eidosi.and renal failure. The manufaclun'r recommend. withholding metfonnill 48 hn- prior to and fallowirl( ccmtJ"lUt administration (0. lance. if the ... ito ev)denceordeclininc re .... 1 function following uae or~anlr8 !t). Metlonn_ [II .hould al50 be h4'ld ~ 48 hollrs before . ny I U.gery, and should not be reatllrted posWlp until the pIItient lias fully /'eCQvered and is eati'li Md drinking normally. INTRA THECIU. CONTRAST AGENTS 'J'he,primary .pproved ",eM e mployed ror intrntheal UBe t.oda, is iohex"l (0",· nIpaqudlH_ Mw...). madverte 'lt intra thecal inject ioD or ion ie contrast agenu • C.ution: seriou1 reaction. can oa:ur with in.dvertent inlrathecaL inj!!d.iQn Ie./(. fill' 1Il,)'e1ot:JllPhy, cill.emography, ~entricu lography , .•) ofiodinated contrail media thai .re not specifically indicated wrjntrat~lu8e (inclu.ding Ionic cont rast agentll II weI! a. some non-ionic agenta I. -C. Optir.l)4. Reno-60 . _ )), Thil can ClUS<; uocontrol1able sei2.U"", ;nuace....,bt-.L m-morrh.tp, <:erebn.1 edema. <'Oma. patalysis, anchnoidit;', ml'oelonWl ftonJc.clonic ruu""le SpaII.,s), rhalxklmyolYl'i~ with .... bMqu4'nt n",al failure. hyperthenni. , and re&pi .... tory compromise, with a signiflCl nl r.talily nte'. Manag;>ment suggeslioQS ioc:lude: I . immediately remove CSf' .. conl . .. t irthe e rror il recogniled ... hlll the opportu · nity i. avail.ble (._g. withdraw nuid througll ",yelO(Tlplly oeedle) 2. alevllte be.d orbed ~ ":i"lto keep Qlntl'l.at oulol he.d ) 8. if there i. a question abuut whllt may hllve OI:CUlTed (i.IL it II not cartain ifan inappropriate conb'aat "ent ... at u-ed) JUld blood lind <:SF with contrest for high · perfo'1Il8n/it liqllid chromlltograplly fOf Idt:ntifi<:ation of "rent" 4_ .ntihilumin.., e .g. diphenhydr.mine (8en.drylill) ISO "'II deep 1M 5. respiret.ion : tuppl.mellul oxygen .• nd if needed. inluhlotM>n 6. conuol HTN 7. IV hydratio'l 8. TV l!.eroids 9, IftI.t.ion!fpat.ient;'qita!ed 10. Ir.at fever with eertaminophen and ifllftdftl with. coolinc blanket 11 phermacola,;c pe ..\yJ.i. if _ _ el")' 10 man.ga mu.de 'Cl.ivity (e , . a tomidate) 12. enuoonvultant medicauon: IlIOn th. n one ecent I'''y be nqUl .td (IL,. pheuytoin .. phenobarbital .. a benl(ldiazepine) 13. conaide r un.nhe l1(lt(l bndll CT tea n· m.y help..-. if((lnt,..,t h e dift'usad in· Ina.nielly, I7uI thi. requira plactnlf pjltlent nal e nd may 11:14. be .dviaable 14_ InH.tion ollwnbar l ubarechnold drain l~. monitor. electrolyte., ftntkonvulllni 1....11, cru tina kinaR.(C K) 16_ repeat EEGe 10 lileS' _iture activity while Mdat.edffMItalyzed '" 5 . Neuroradiology NEUROSURGeRY lobeJ<ol (Omnipaque®) A non·ioni~ l";iodinated com· pol,lnd. It has replaced metri:l.8mide. Concentrut.ioo5 €Xpres$OO as follows: e.g. Omnipaque SOO contain~ the equivalentof300 mg of organic iodine per ml of media (300 mgllroll. UsuaUy reS(!rved for IV contnst CT scan of brain primarily for pa. tients with previouY dye reaction. e.g. to Renor60. Uores and cooC('ntrationll are shown in Table 5·1. wtratbecal U$e: Na: only Om. nipaque 180, 210. 240 and 300 are labeled for intratheca l use . 140 and 350 are n2l FDA approved fOT intrathecal use, however, some neurllTlldiolOjiists will use Omnipaque 140 or diLl,lt<!d 180 e.g. for CT ventrkwography . COlISider discontinuing neurolep' tic dl"\lgs (i ncluding' pi>enothiazines. e.g. chlorpromazine, prochlorpera· zine, and promethazine) at least 48 hours prior to procedure. Elevate Hoa .. 30' for the first few bours afU>r the procedure. Hydrate orally or TV. U..... witb cal,ltion in patienta with sej~l,Ire history, severe caniiovaacul.r disease, ehronic alcoholism Or multi. pie ..:lel"()5is. lohe¥ol uodergoea alow diffusion from the intrathecal "pace to tbe systemic circulatioo and is eliminated by renal excretion with nO significa.nl metabolism or deiodination . Ma:rimum dosage : a total dose of3060 mg iodine should not be ex· ceeded in an a.dl,llt dl,lring a single my_ elognlln (r.ome say I,Ip to 4500 mg is OK)(e.g. 15 C1: ofOrnnipaql,le 300. 15 ml ,,300 mgllmlm 4500 mg ofiodine). Table 5-1 lohexo l coneentrations lor adl,llts most centers use Op\or.y5. see reX! . lolow wolh 250 rnl tlOIvs ot 0."5"," NS I(> '$!\y<Ir. '$ po. "", 180 WlII be ~ _ on CT,....:I $(Ime US(Il-3 rnt 01 1~ or r:f~UI'" l E1CPf. (dtIuIe apprnxrnalely 2 parts CO<>- u.S! to 1 par1 praseNalMo-\r ... normal saline) N QN· //IlTRA THECAL CONTRAST AGENTS For inadvertent in~ralhecal inject.ion of contrast agents not intended fo r intrathecal &te obo"". Diatrizoale mcgJumine (e .g. 1,18e, Reoo·~, Reno-di p!!) Nol for ill lrathoc .. 1 ...." (sloe oboveJ. A tri·jodinated benzine derivative similarto Conray. BoO! have been avai lable for a long time . Due to tbe fact th at it ionizes, it is ~and byoerosrnoJar. Widely used TV, in nel,lr oradiology for TV Mnlrast enhanced CAT scan when there is no history of prior re· action to TV tQntrnst agenta (I,ISI! iohexol in patienta with previous reaction , sow obowl. IV contra8tenhanced CTscan of the brain in adult patient with no history of previou$ dye reaction: A. 300 ml TV drip of Renordip® (30'l1> 8Olution, i.e. 300 mg/ml) over - 15 ",ins B. 50-150 ml of Reno-SO (60%50]l,It iol11. 1'ypicaHy: ISO ml is I,Ised body C1': boll,ls of 150 ml of Re nor60® (3 vials of50 ml each ), followed e.g. by 250 rnl of 0.45% NS tohelp preventdehydrat;on. UsuaUy given more slowly lodiab'n· its and the elderly whe re there is increased risk of reDal fa ill,lre II love r8(li (Optiray®) U~ • NOl ror int rathecal use (ret Clbot.!). and eoncentration$ include: NEUROSURGERY s . Neuroradiology arteriography: Optirtly 300 (lov".80164%) or Optiray 320 (iovenwl68'l&). Total procedural dose should oot usually exceed 200 ml IV contrast enhanced CT I<'an of b rain : A adult: 50-150 ml ofOptiray 300, 320. or 100-250 ml ofOptilllY 240. Typically: 100 ml ofOpti ray 320 e. pediatric.: 1...J mllkg ofOptirllY 320 5.1.1 . Iodinated contrast allergy prep lndieated for patienta with previOWl hi8Wry of ..... action to IV iodinated eontrast rnB.terial. Minor prevIous reactiOf1s such all hivell and itching . hould Olen! preparation with this regimen whenever p<>6IIIible . Patienta with IInaphylsctic ! hock Or severe edema cauS' ing compromise of the airway ~hould probably 1>01 receive IV iodine e"~en with thi~ prep, unless absolutely lI~aaary. Caution: th e patient may still have serious reaction (modified'). utilize 'IOn-ionic oontrast medium (e,g. iohuo]) whenever poII.'Iible steroid ($I" pogt 8 for further details ofsterDid doting) • prednisone 50 mg PO: 20-24 h rs, 8-12 hi'll & 2 hra before study • equivalent dOlle <:Jf&>lumedrol® (tnethylprednisolone) f~r TV use would be ~25 mg diphenhyd ramine (Beoadry~) 50 mg, EITHER 1M 1 hr before, OR TV 5 min before st udy optional: H1 antagonis:, e.g. cimetidine 300 mg PO Or TV I hr before Sludy have emergency equipment a vailab)e durin8" study 5.1 .2. Reactions to intravascular contrast media BETA BLOCKERS Beta blockersea.n increall'l the risk of contrast media ,..,action8. a nd may mask Some manifestations of an anaphylactoid reaction. They al$o make use of epinephrine inadvisable since the alpha effects of epinephrine will predomioat.! (bronchospasm, vasoconstriction, increased vagal tone). If treatment is required for hypot.!nsion. OlS)· try g lucagon 2-3 rog TV bolus, followo:d by 5 mg TV drip OVer 1 hour (glucag<>n has positive inotropic and chronotropicefTect that i$ oot mediated through adrenergic pathways). I DIOSVNCRATIC REACTIONS AND TREATMENT For treatment ofinadvertent intrathecal injection ofionie contran agents,:lee fIOIl~ 126. HYPOTENSION WI1l-i TACHYCARDIA (ANAPHYlACTOID REACTION) 1. mild: 1Tendelenburg position . IV fluids 2. ifno response but remeins mild: e pin ep hrin e (use with caution in patienta with COl"Qllory artery disease. limited cardiac reserve, hypertension, Or unclipped cerebrsllUleurysm) A. 0.J.O.5 ",I "f 1:\000 SQ (0.3·0.5 !ilK) q 1:;...20 UJim. (...,w.: 0.01 "'~ ) B. OR, ASEP recommendations (especially for elderlyor patienLa in ahock): 10 ml of 1:100,000 TV over 5 to 10 min (put 0.1 ml of 1:1000 in 10 rnl ofNS, or dilute 1 amp of 1:10,000 to 10 ml with NS) 3. moderate to $f!ver~ or ....Qrsenin8" (anaphylaxis): add: A. rv colloidal nuids. e.g. hetasl.arch (Hespan®)6%(colloids a re required si nce there is extravascular shift.ofnuids due to seepage, then agents also caIT)' a Bmall risk of aOerg'ic reaction) B. epinephrine (..... ",00",,). May repeat It I C . 0 1 2-6 Urnin per NC. Intubate ifnl!<;essary D. EKG to RIO ischemic changes 4 . if shock develops: add dopamine, start at 51lg/kgllllin (~" page 7 ) HYPOTENSION WITH BRADYCARDIA (VASOVAGAL REACTION) 1. mild : A. 'I'rendelenburg JlO8ition '" 5. Neuroradiology NEUROSURGERY B. tv nuid. 2. if 1>0 ~IPOru~, add, A. atropine 0.15 mr tv. may rep~at up to 2·3 mg over 15 mille PRN. VII'! with u ... t ion in patients with ... nderlying hean dillea.. B. t:KG andlor emiae monitor: eapedaJly if atropine OT dopamine are uBed 3. ifl>O rupon"": add dopam ine •• tart at5 I'r/kglmin (.n 1X'Il. 7) URTICARIA L. 2. ro.ild : . elf limited. No t reatment ne«Mllry moderate: A. diphe nbydramlne(Benadryl<!) $0 mg PO or deep 1M (aVilid tv.tann ..... anaphylnxi . iUelO B. elme Li di n e (T agamet«l) 300 mg PO or tv dil ... ted to 20 ml aDd gi""n O"'er 20 min •. H t receptol'8 wntribute to whu.l and Oa re ofruetion 3. ""Yere: treat aa llbove for moderate readion , and .dd: A. epi nephri ne t- 000"") B. maintain tv line FACIAL OR LARYNGEAL ANGIOEDEMA I. epinephrine: I « aoo~. May ",peat up to I m, 2. if respiratory di.tr...: 0 1 2·6 Um;n . Intubate if nece. S&ry 3. diphenhyd ramine: I « ooot.oe 4 . eimetidine:.u o~ 5. if angioedemail accessible. add iee pack 6. maintain IV line B RONCHOSPASM I. mild to moderate: A. epinephrine: I « obotot. May repeat up to I ml B. if respi ratory distreu: 0,2-6 Umin. lntubete ifne«sury C. maintain tv line D. inhalatioll3L therapy with a IJ-adrenergic agon;lt. e.g. albutenll (Pl"'OYen· til®) if respiratory therapy is availablll, otherwise, me\.ered dOH inhaler e., . pirbuterol (Maxai.rGl) OT metaprotertnol (Meta pre Ie). 2 purrs 2. MVere: l~at as above for moderate reaction. and add: A. aminophylline 250-500 mg in to-20a: NS.low tv over I~O miru. Monitor for hypoteruion and arrhythmias B. intubate 3. prolonged: add the following (will not have immediat.e e!Tect): A. hydromrtisone 250 mg tv B. diphenhydramine: 1ft obcM: C. cimetidine: I « oboue PUlMONARY EOEMA L 0, 2·6 Umin per NC. Intubate if necessary 2. raise bead and body 3. futoMmide (l.asixe) 40 I'DI tv 4. EKG 5. if hypo>tia deYeln.. (fDlly manifest aa agitation Or oombativene.u), add: A. morphine 8- 15 ml tv. May ~au" rupi ratorydepreuion, III! prepand to in· tubate B. epilllpbrlne: _ oOOw . • CAIJI'ION: UN only if MI can be RIO all cause of the pulmanllT)l edema. Patienlll with acute ;n \.raeran'al pathology may be at riak ofneul"OKf!lI;c pulmonary ede.ma (I« pose 7) SEIZURES IflH'ilUIl! is notlH'lflimited . • tart with [oraaepam (Ativ~) 2.... mg tv for a n adul t. Take precautio... for .t.lul epi lept;"" (IJft pof. 265) and p~ to othe r d ....p .. in· dkated (I« pose 266). NEUROSURGERY '" 5.2. CAT scan Attenuation of the x- ray beam on Ii CT Scan i.o defined in HGunsfield units. Table 5>2 Hounslield unll, 'f'Iwse unit.9 are not abll(llute. and vary 'canner '01' II I8mple CT between CT scanner models, ..... ith II SlImple beiog shown in T"bI~ 5·2. If there are no calibration marks on BClln, ooe Cll n estimate average adult globe (eyeball) is 25 m m diameter (through. its equator). Hcl '" 23% wIH cause an oeule SOH to be isod_ with brain 5.3. Angiography (cerebral) Risks Risk varies with the natw"(! afthe patholOgy being investigated and w;th the e~pe­ rienee of the angiogTophy team. Overall risk of II complication resulting in II pennanent neurologic deficit" '; 0.1%. [n ACAS, there was II 1.2% oom plication rate ($u P"8~ 873). General information' In gen<)ral: non-vascular deep lesions cause changes in venou s structures. BUperficiallcsions affect arterial Btructures. The classic future of II malignant neoplull'I (e_g_ glioblastoma multifonne) on angiography is an early draining vein. Bovine circulation: anatomic variant where the oommon CIlTotids arise from a comm<m tn.>nk "rrthc oort.o. Hypoid : having only one anterior cerebral artery las in a horse). Al lcock ttlat: evaluates flow through the posterior communicating &Tte~s by ver· tebral angiography during commoll carotid compression. Fetal circulatio n : 15·36'1> of patieoq supply their poste rior cerebralllrtery on one or both sidCli from the carotid (via p-oomm) inl tead of via the vertebrobaeilar syetem. 1'0 help find the middle meningeal artery on lateral ECA angio, follow the ante rior _O'<)p of the ~phenoid ai r einul. Caroti d-baai lar anastamolJes A p"r eil<t.ent primitive trigeminal !lr"tery (PPTA) is!lCCn in ~ 0.6'1> of cerebral angiograms, and is the mOBt COm mon ofthe persistent carotid-huilar IInntam08eS. Arisu from the leA proximal to the origin ofthe meningohypophyseal trunk and connects to the u pper basilar artery. The VAll are usually small. Occasionally the p-comm8 may be hypoplastic and the PITA may provide s ignificant blood supply to the distributions of the distal ba5ilar artery, the posterior cerebral artery and the superior cerebellar arteries, particularly jfthe basilar artery is also hypoplastic (Saltzman type I ena tomy). A PPl'A '" 5. Neuroradiology NEUROSURGERY may be auociat.cd with v'Ku l" anoOl.l ies.• uch U .oe urysnu Or AVM •. Rarely, aoeu· r')'1JII1 may directly im'Olve thelle venel!. May "$0 be ''''!leiatoll "'ith lri~minal neural· gia (H~ pa6~ ;119). ANTERIOR CIRCULATION --..., ANTERIOR CEREBRAL ARnRY ( ACA) See Fi&""" ,5·2. BrallChee: reeummt Dr\.o!ry (of Ue ubn er ): II01l. arise from Al (one of the largu medi, ) lenticulG11t riaU!8. re mainder of lenti .... ulOltriac.es mDy ariooe from tbi.1a~1 - head ofcaudote. pulamen. and an· !.enor internal capsule 2. media l orbitofrontal ,rtery S. fronl.opolar artery 4. cinosomlll"lin'" A. internal frontal brandle. L /Interior 2. mlddl, 3. poaterior 1. 8. P'lnleentMlla~ 5. peric:aUoul arte.,. (rootinuation or AGA) A. IUperior ,nternal parietal (pretunHte) artery 8 inferior ;nlernal P'lrietal.rtery MIOOLE CEREBRA L ARn.RY (MCA) See Fil/urt 6-3. Bn.ocbtll ....,. "'idely. 10 relativ. ly tOl1'ImOn ong: 1. medi.1 f3-6 per sidel and l.terallenUc:ul..tri.ta Aneries 2• • nterior telllpo ... 1 3. po$tenor I.ImporaJ " l.tenolorbitofrontal NEUROSURGE.RY Ii Neurorad.ioloC '" 5. ascending fronta l (candelabra ) 6. pn'!<:(!nU'al (p rerolandic) 7. cent'l.l (rolandie) 8. anterior parietal (postrclandic) 9. posterior pariellll to. angular Figure 5-2 Anlerior cerebral arteriogram (lallra! oiew) FIgure 5-3 Middle cerebral arleriogtam (Ia!eml _J '" 5. NeuroriJdiology NEUROSURGERY (ltoprint«i CO\I~y of Euut>an Kodak COQl .... ",,1 , 1IlIeri'l' caudal' vein w_ Ihalarn05IIia te VIII) Slginal :... I ..~ '"~ su~ anastamotk: ve!rI (01 TrGlardj dImdlateralv, i'lIemal cereblal y. ( posIerior se-plal V grW~reblal ==~ ".::::- J -,~ ""., (of Galen) vein 01 poS!erior hom - slnig-tdsrr"lllS j def!!l middle cerebrlll'l!ln basal cerebril ve.Io (01 RosenlhilQ 'rIt~O/anastatnoIic TC .. k,nsverse cauda~ vtUl$ Ve91 (oi llIbbtl IVs = insoIar .... ins Fig "" 5-4 In!emit! carotid venogtam (laWai vi ew) llertebral arl,rIts PICA SlgmefIt$ am 80letiormedrllary jon s laletal medullary 1m z lOr1SillorroeQ.rlary (W/Cao.Gal loop) M z 1~ (SUp!3tonsalil) (wtaarllalloop) cs" cor1ic:aI se~1 1 Fig"" 5-5 V"rI&brObaSll a, Merlogram (Ial."al v~) NEUROSURGERY 5. NeuroNldiology P OSTER IOR CIRCULATION P OSTERIOR CERE8R.AL ART ERY ( p eA) See "'iSLl~ ~.~, P OSTERIOR FOSSA VENOUS ANATOMY g~al cerebral YeI'1 (Galen) 1X~1 t41rebel~r ' . - - - SI.p!ior pelrosai $inus anterior mec1ul\ary y. pelrosal"m VM of I/le !a1~raI ..cess oj lhe 4lh ventricle 5.4. Magnetic resonance imaging (MRI) 5.4.1. General information DEFINITIONS' AbbrlWiations ..." T!lble 5-.3 Range 01 acquisltloo dsl8 ...,,, ""'''' "'" .."TR (la eSC) (Ie ~ IKI) (TfI< 1000) prolo1 denslly (TR~2OOO) Of ".., SIlln denSIty T , weighted image (T 1WIl Short T, - high .igmll{brigbll. ~Anator:nic image", !OmeWhllll'l'H mbles CT. Shorter ocquisi Lion timll than T2WI. ?roton nch tissue (e.g. H~O) hoslongT" 'The only objt(:\.S Urat appellr whiteon TIW1 are fat , melanin. lind subacute blood (" 48 hnI old). Whitematter is higher signallha o grey motter (myeli n has _ high fat con· tlmt). Most pathology is low signal on T1WI. n. 5, Nosurorodiology NEUROSURGERY :::: :: T. weighte d im a ge ('T'l Wl ) ("'"R T l - hiCh 8igns J /bright). -PAtholcciullmRle", Malt pIIth<>lovy .bow. UpRB bilCk .l&r\i.I. in th.ldinr • .,rroun ding edema. .."' ........ 866) .... hi,h S pin d e D9ity illUlKe AKA bIIlAnced ima~, AKA prGlon denait)' i~p. Part"'"1 bttwun TlWI",nd T2Wl, CSF. gr~y. app.ol<ill,)a~ly i.oodense with br.in (meM in whit.\! "\lH~rct.m)'.ti· nating diseruoe). FLAIR Atrnnym for ~"Lu.id-Atl.l!nWl!.M lnve ..ion ~efY. CSP appeaNI darlL MO'II I..icln. Including" MS pla'luu. other wh ite matl.l!rle!liOOll. WrMn. edama, and acu\.e lnr.ret. apJM!or btillht. PetiVVltricular lesion. such as MS plaques becolllll! _ (UMlpicuou" Ec bo tra in {AKA rast spin echo (FSE» tr il held COf'Ist.anl . I.e ia progreasively inenued utilizing ",ulliple echoes (8- 16) r atber thlln 1. Image approawes T2WI but with lubsuintiaJly ndutad Iioeql.lisitiOtl IHne (rat il brighter 00 FSE, whith m.y ~ I1!Ctilied by !'at IUpp~;C)n tKt\niqullll), "GRASS" image Aero",..., for ·C rad ..."t Recalled Acqu~ltion in a Steady 5111W", A · fast" T2W I uti· pan.ial flip a~Je. CRASS;5 a GE lnIMIDark. othy manuradunI!n uSl!! dUfe"'"t nlme5 . a.1I FlSP. CS~ appelll"ll "'hit.. bone ill billdl.. lind nowmg vese" lire ",hil4.1'yp;CIII Kq\Ii"t;ot\ dar..: Til ,. 22. TE • 11, Mille 8", UHd e.g. in ca ..... ical MRI to pcoduc.a "ruyelogr8pllic" lmlge, imp ....u ability to deli ...... te bony ~Ur1l. ~STlR~ image Acronym ro.- "ihon. tau ;nven""., ....:overY'. Swnmate! T, '" T f ! 'gnala. CaLlIIeII rat to drop out (lOnIeti"," II-acall~ ra~ l upp rftOlloo imIIgel. , 11(1"" gadoliniu m enhance· rtlent 1.0 Ihow up belter in .~.. orfal. UtoefuJ primarily in spine and ...-bit.. H~inlla MR" . C O NT RAlNDtCATIONS TO MRI P repaDcy aDd MlU, Dunng the lirat l rimuter. MRI can Clute rubtorption of prod· .. UI orcon~pUon (..uK.mlte). Thera.A. no " udin to deta rmina thalOf\i tann efJeclli ofMRI On a fet .... al'ler the firlll.nmester {the low ri,kofMRI in this,ilu8lion II problbly pl1'(... bLe 1.0 the knowo dan~rI orion;lin& rMfiRlion of.·ny.{including CTl"~ eadolin· ;wn eonlnll it ronlrW~tad dun",.U oIprflT\,nc.l', and lit not IPpt(lVed for u"" in *II < 2 ye.n. SntNl·fftdinl mut' be inlem.l p\.Od for2 dly, after adminisuation of Ka· do!in;u," to the molbar. NEUROSURGERY 5 Nlutor.diolorr '" Cont.nindieutioM to MRI! l . cardiae pacemaker, implanled neuro.ot;mulaL<!l"8, """h lea. im],lllntt: may U"IOI! ~m pol'llry or pennammt malfunction 2. ferromagneti" lIoeuryam clips (Ut II....""' ); .r;ome «!nt!'rllucl uOe all patients with aDY typo! o(aneuTY"m clip 3. meUl11ie implants OT foreign bodies with large compooentofiron or cotxllt (may move;n field, mlly heat up) 4. metal1lt fragments within the eye 5. placement of a v~la r otent, coil or fll t.er witliin the pau 6 week:! 6. sh ra pnel; BB', (tome bullets are OK) 1. reJlIliv~ oontrawdicatioua: A. da"atrophllbic pBtieDI.S: may b., abl~ to sedat.> adequately to perfoftU nud)' B. rntically ill patH'!nt.s: ability to monir.o. And BOO!!811 to pllit.nl are impaired. SpeciaUy designed non.magnetit ventilator may be reqIlLN!d. Cannot Ill;(! m<lH brands ofele<:tl'Onic fY pumf"l/regulatoMl C. obeae patient.l: may I\Qt 1,llyaieali), fil inUl many do$O!d bon! MRI acanoe ..... Open bore .canners IIlay circumvent thil but mallY util !>.e lo ..... er lield st~n gr.h ma~eL!! and prod"",e inferior '1uality ilD~ge, in llL1';;e p~t;&l U! D. metal irnplanU! in the region of,nl4!re&t (or IlrevioUB Burgery with high ~petd drills ..... h,ch may leave meUlI nJin~J: may produre 5u!Ceptibility ,,tlfact which can distort the image in thaI area ANEVRYSM CLIPS AND MRI MRI conaider~tJol\I in patients ...·ith a cerebral aneu,),,,n, clip' Tabla 5-4 Magnallc remnance 01 ane urys m cli p'" I . the d/lnger oCthe MRllllilgt1et.ic: field </luring the "lIeUl:Yitt> clip to be pulled or torqutd off of the anellr)'Sffi or to tear the ..,k .rlifBC~ produ~ed by the metal or the dip in the magnetic litld 3, beatgen.era~ ill the regioo of the di p: not elinicRlly . ;gni»cant 2. the Th" moTe fel't\lmagt11ltlc the dip, the IlLI'gu lhf rorce exerUld on it by thema(!llelic lield and the gre~ter the image di.lltortion near the dip. Sta inless ateel (55) i. da&Sifi~d PH m arteDBWe (ferromagnetic) Or IIUJltenitic lnon·rerromagnetk). CO)balt.-baSl'dJluperall(>yl lUe ru)Il·felTOm~gnetie and include ElgilllY (Sugit.a dipl), Phynox (Yesargil), and \·ari-Angle (M cfadden!. Tobl~ 5·4 ahow. thenUlgnetic ~mnall<:i! ofvariou$ dip. which it .... lelfd totheir lerNI.uagl1uic- proptrtiell, If in daub!. al the. time ofBMurysm lurg"I'Y, apply the following si mple test: nllo·ferTOrnHgnetk dipll canno~ be lifted Qr dragged with II 5II1.II11 magr>f'L. H EMOR RHAGE ON MRI One of the JtI09t c:ompjea: lll!lioll.ll to interpret on MRI . Su p~ 8ti6. 5.4.2. Diffusion-weighted imaging (OWl) and perfusion-imaging (PWI) O.inin8 usa8e in ischelnic brain disease (80me MRI machinu da not )'et have the n\!CUllary Vadien" fordiffuaion weightin8 or the apeed needed for both DWI and pv.'Ij. Dil'fusinn _w eigh ted imaging:. DWI illen.itive to random Brownian motion Ofw814!r molocule&, and an apparent diffusion roeffident (ADC) iA detennined for each areD based OJ' 5. Neuror$diology N~UROSURGERY .n. number olvtrilblH {lime. I ll ..... unent.aliofl ... )". f'nety dlffuJin, w l~r (~.I. ill CSf) appta1$ dark on OWl. Areas of acute brain is~h.mia show up as lncnaRd algnallnll'! ... ity on DWI .. ithin m' nu~" I', DWI mlly also be able 10 dLstinguisli (')'totQllic from vBI5O~nit .,d em o"· " (_pagt 85), HI)W~"~r. racton o!.her lhan (Ot,1 i~~mi .. (.'1'. ,lobaL ischelllip, hypogly..... mi •• ltat\!5 epitepUcul ••. ) eat! produ<:e AOC decline lod 1.1>. OWl ;nlllgel rmllt therefore be interprtr.N in relalion to the dink.] -"lllin," . Some. bul nOlllll ", TIA .... ~iat.ed with abnonnalltiH on OWl . Oill'usion deftc\5 do not indkate irreveriibleirUury. bul imueates till$ue that ill !\ear cell dutll. PerfW!;oo imuIPIll' P:o~idf!l infonnation rel.ted !.o the ""rful;"" '\.8LUI orthe microcirculation The ... are sewrll rnethod.eurrendy In u~e ...,th the bolUJI-<:llnlr1lnapPrtlach he; ... , t.he mo. t widely employed" , Ultrafangradient ima,in, UI u~ 10 foll_ the gradw.1 rtductllm loG nor m.1 fol1!IWin. Administration Of COn1rh1 (u!I.1II Lly •• dolinium), A .i~­ nlll .... uhoOul CUf'I. is der.voo lind is compAred loG eonlrast In III lI.ury . V •• In theQry. OW l nnd PWI maybeeomblntd I<lloeate .~ ofperfl'Sion deficit 0fI PWl th. t e:<cl!4lds the lOns of diffusion defICit on DWI, I.hu. idmtlfyin. . .Ivageable brainti... sue ..1 rislr. of iufol"Ct;on ("pI:llumbn", Ht polJ' 806) •.•• III sereen for pounti.1 candj· daU!1l for thrombolytic \.herapy" 5.4.3. Magnetic resonance spectroscopy (M RS) Thi • .e.:tioll . pec'f"ally COVerS protan (H'J MRS .... hith ~all be performed on .. lmostony MRI Kallller (eaped .. lI)" unita ., 1,5 1') ",im the appmprist.e INlnwllrll. Specl.ro6oopy ofo\.her Dude, (e .•. ph08phorou~) t.o be ev.lu.u.d only with s peci.lirec! eQuipmenL T,bI.5·5 I MRS SINGLE VOXEL MRS A • ..,.11 aR:1I is sel!'Cted 00 lhe '1l:OU1" MlU and the apeclrOfiCOpi<:. pe.... for that ~o . ... displayed in reltOnaOU as, fWlCt.i0Sl orparl4-per 'lQiUio~ ( ppm l, Therd"o .... may be .u~ 10 IIImplill' emir. CUnielllly importllnt dwt· .cwn.tic pew uti d.hM.t<Id in TohJe 6·5. lUusr~nvE PATTERNS Norma l brain; SH PI'IP''' 5 .1. T\uuor: SuF.,ure5-7. 1 NAA . C<'- _ _ _ _ _ ,.11actal.e, f li pId, f choh ne(ruJ. of thumb: WIth ,lloma., the lUther the choline, W hi. t - the rr-ck up to vade 3, thereal'..er nKfQIIUl reduce!! Ria. Ii"" choline Ievels."d U..lipid peak rull,. be ut iliwdJ. CVA: , lactate pe.k pn!domina\.el . Cholwe i, characllriuiclIlIy law. Abaoceu" : Reduced NAA , Cr &: dloliroe peaka, and ",typic.l .,..aka" {$\I~nate, acetat.e.. .. 1 from bKtenal.ynthna il pathopomonic ror .b.ctu Inot always prellentJ. LacUI.e may to. elev.ted M o11tip le .cl!!"",;,: Bland pattern. NAA _llghtly reduced. Lactate and lipId _lightly fltvato-d . Choline oot el .... sLed. NEUROSURGERY POSSIBLE USES OF MRS I. differentia tin, .b_n from l'leoplll8m 2. poIt-op enh~nceD\ent va. reculTe nce of tumor 3. di.tingui,hinr tumor from M5 plaque.: occuioDaUy c.annot be differen tiated • . in AIDS: may bt: able t.(I help differentiate toxo from lymphoma from PML(PM L: I NAA, no . ignifie.nt illerene in choline, ladate or lipid) 5. !.he promie. ofd lfferentialinr tumor infiltration froID edema hll not been bonw ," 6 . loroe utility in distinl{Uiahing tumor from ndi.tion MCfOllia (SH ~ 535) " " • " • ." -'" ~ OJ> 15 U U U ... ' 0 01 00 (A) NORMAl SRAIN Figure 5-7 PrC>lOn MRSoI {A) nonnaI brain, ""II (6) high Ii''''''' glioma MULTI-VOKEL MRS Colorroded KIn with &eleded overlay for NAA, eholine .. [email protected]\>« risk ofumpling error. 5.5. Plain films 5.5.1. Skull films Tabla s.6 Norrtull d imension. 01 . he aellll iurcica ( _ Pl9ure 5-8) ~ S ElLA TURCICA o {depIhj {mm) NORMAL AOULT DIMENSIONS ON SKULL X-RAY Teehniqua: t",. late.. L, 91 em u.r~1.O lilm Max Min " •5 " An 10.6 d.istan«, centnl AY 2.5 COl anterior IDd 1.9 tD1 lu penor 10 EAr.!. See FiI"'" 6 ·8 for mUSlTation oflbe diroentiont. and Tob/.~ 6·6 for nOr· ma l vIlu ... Deptb (0 ): defined .. Ihe gn!atel~ mua urement from Iloor IG diaphraama seliH. Lenrth (L) : defined a. !.he gn!att.t AP diameter. ABNoRIML FINDINGS Pituitary adenoma. tend 1.0 enl'rfl:e lb. sella, in «Intnost 1.0 ~ ..niopha.ryngiomu whkh erode th. posterior clinoidt.. Empty ..lIa .yndrome tendll to bIolioon the sella . ymmetrically. and "so ~ noterode the clinoid.. 1)8 5. Neuronod)oloty NEUROSURGERY al50 ",f' ahspell seUa 8U.tiM'- opti~ nuve glioma. It o;an tongenitally In H urler·.$aynlirom<! (a mllCO- oco;,W" polysaccharidosis). MISCELLANEOUS Water's view: x-l1I.y tube ungled up.~S· lperpendiculli r to divusl . AKA submental verteK view. 1'91"01 '5 'tiel" ; K· ray tube angled down 45' . 1.1) vie ..... occipo,a. BASILAR IMPRESSION ~ure 5-8 M.nu,emaOl5 01 Several conditiol15 whose nomu are often (eNtlnem. sella IU'dca (lalora! view) OUllty) uged Interchangeab!y(eKact defirutionsara nOI en· tirelyagreed upon for all oCthe!;l!); 1. plnlyb8.llla, abcol"Ulal bll6ilar angle. OCHllle mOldkal i.:llporta,,~ (usO!"d in an· thropological dalal. May Cr may nOI btl s!i/!oci Med with basilar !mp~8!l ion 2. baallar ;mp", " ioZl (B1): UP"'lI.rd di&placeme nt offo ra men magnum IlIl1rglrur (i nc ludiog ocdpit(ll bon. l and urviclil ,pine lineluding :Jdo[ll.Qjd process) inlo Pfossa. Some use thi s term for upward di Splacement of dens only. May be selm in: A. tonpn"ital condilions (BI is !.he mon tommon congenilal anomaly of lhe crani<lce.rvi.cal jundion. it ii" often aceomp.&nied by other 9.nOfl.lalles'·I.'-1 L Down'. !\)'ndrome 2. KlipPl'I·F"il ~yndrome ]stt pGSe 119) 3 . Cbiari malfoMUation (.n fHlC~ 1M) 4. ayringomyeHa B. acquired conditions I. 3. rhe umlll.oid ar1.hriti5 (in p.&r1. due do 'nccmp.elence oftransve .... e ligsmenL..aee Brullar imprtuwn in rh eUtllOlOid orlhrilU. page 339) 2 . ~t-:raumlltie basilar invaginAtion , AKA c r anlalseUli nl:: upward indentation of5kull b!W! usuallY due 1.0 a~uired IIOftenmg or bone. often allllodat.e<l with atlanto-ottip ital fU$ion. Soma consider this synonymous with BI. Seen in": A. Paget's dlseDse B. o$teogeneliis imperfecta C. osteomala<!ill D, rickets E. hype.tpan~idlsm Same IO"asu remenl.& of ...... (rerer to FiG" '"" 5.10, page 141, and Figu,",,5·9 below/: I. Mc Rae's line ("MeR" in FiellrY. 5· /0): drown acTOlls rammeD magnum ttip of clivus (buion) loopist!Uon )'". Should 00 :> 19 mill ( avera~ : 35). No part of odontoid should be SOOv t !.hisl'ne (th e /DOIIt sccumta fo~ 2. C hnmber laLn·.lin e ("CL" in Figurt ';· 10)" : posterior hard pailite \.(I p05terior margill offonmeo lIIagown lop;&thlon,. l.cno Ilio n 3 mm or half ofdena should be above thill line, ..ith 6 mm being definitelY p,uhologit. Seldom UKild be.cau8e opi sthion i' ofu!n hard to we on plain film IIna mayaJso be invaginAted ) 3. McCre£or'. bilKli.,,, Flgu", 5-8 AP Yiew ih,ough ",al'k>cervk:al lul"lCtion' (~MtG·ln FisurI5·/0"f"': POi' FOOL ", FISd"IgOId'. divUlric line. F~L ~ FiScilgOld " tenor margin of hard palate _.~ line, " ~ , .)CIaI 0Wft>a/!g '" C1 CIt> C2 (SI!' to most CAudal poinl ofoo_oi~PIIIl·7Zl) ciput. No more thaI> ~ . 5 m.m ofdeDll shOuld be above thia 4 . Wac k e.,belm'8 e livu8-<:a. nalline t·WCCL· in FicUNl5.10): tha odontoid ahould be tangential to Or below the line that utends the coune of the cliy us (the clivus baseline). lftbe divus.is ao NEUROSURGERY 5. Neurondiology '" colICa"" or OI)nVU, this loNI!lin" ~ dr,wn to C(I"n""t tlte basion ttllhfl ba~e or~bll poIItarior clin<lida on t.h clivu," 6. (Fl..,hi<lld '",) dlgllat rlf! 1I0fl(~YOGL"in F;'un6·9):joins dipstncnolches. The nann.1 duta~ from thlil liM ttl the midd Ie of the atlanto-occipital jerint Is 10 mm tdet;rened In 81)". N<I put <lroxlont<lid should be libov, thislwe. More accuraUl than the !timutoid linll {FBML 6. .' i ll(:b gold'. bimutul d l ine ("YBML" in Figl<1"r 5·9): join8 ti;. or ", ..tQid pn)ceiISH. The odontoid up ."erllillll 2 rrun above thifi lirll! (rsnge: 3 mm IM!l0w to 10 mm llbove) lind thi,litle .I>ould trots th,lIlhUlt(l-oteipit.lj<li..1 5.5.2. Lumbosacral (LS) spine LA-5 i, nonnllily the lumbllo. disc ,pace with thlllf1!lIlOSt "frttul height . Abo_ .,.g, N(>J'mlJ/ LS .plM '"~twu"""",,,", 327. AP view: 1000k fur defact Qr non visualhlllion Ofthf ·Qwl'. IYes" " 'hkh i. dUil to peeli. c\e.erollion wlUch may oecur .. Ith lytic tumo •• (rommon with metutau( dl.waseJ. Oblique villw" look for diarontlnuity in n""k of"Srott)' dot" ror dero!(:l in J>WlI i"!.eran;eularia. 5.5.3. C..splne NORMAL FlN OINGS For radlolftlPhitllignl afO! ..... itlll ~pine trauma , _ Tablr 25.1, Plllf 706. and guidelintl" ror diagn~Jnr dinical h1/;tability,.see Table 25·11, pIIgc 13• . ro.. CONTOUR LINES On a lall1ral c.:.pine "·.Ili> tl>o. ... an!" ronl.Our lin ... (AKA arcu.!.e liOQ). Non..aU), f8C"h should ronn II smooth, pMle "" .....e UN FiIlUrl5·10); I . po6terior mIlrIPna.llin. (PML) ; _10113 poIIUrio. Cl)n~ lunace. or" ....I~b ....1 \.Jod. jllll (VB). Marks the uteriOf' llIargin or'pinal eanal 2. a"!.eriOl" margiruolline (.4.' 1L): alonr anterior cortical surfac:ee of VB, 3. "Pi nQI. ",;n ll . lin ", (SU,: along base ohpinou s proalS ...L Tb. pIIII!.erior ",argin of the . pinal eMal 4. pclllLerior spinal.ll line {PSW: akmr lips or s pinaul pro<:I!Io5N R~I..A TION OF A 1l.AS TO OCCIPUT See~ 119 lOr erikrill for atlantoaaial di,IOCllu..n. REl..AT1ON OF AnAS roAXIS Atl an to-d llDtal i n terval (.ADO '!be ADI il the d~tal>Ol! between the aot.e.rior margin of the dens and the clO6e!l1 pOin~ "rtheantemr arch orel ("Cl bUlton"lon alatval G-spine " .... ), Ute Figurl5·10). The normal mPill1ll1 ADI uvanoullly in the ran~ 01'2 to .. mmll.". Commooly a~· c:ept.ed upPf'r IiJ;a.ita ItA! show .. in Tabi~ 5·1. Atl . .. IoUi..... u bh.... lioo IAAS): Two POK;brlitiee: Tabte S-7 Normal I. AD I :> norma l' may Qtt.\I.I" ... itb inmmpewnc:eorthemns~e. . li"PlenL (Ammon in rheumatoid arthritis /.Ite AOI P"lII! 3381. may llao roUow uaumal_ ptl6C 722) , ....." 2 normal ADI ' i .. tb_ prllHTlUQfan odontoid rractura "" /X'R' 721) .,~ "'V" . b .pe<t p N>-CIen a . pa«~l: Wideninrofthe upper speQ be,. 2.5...., tween the"n~r arch orCland IheodOfttoid feen o n tau .. r C· . pine nulon ,,·11Iy. ll i, not bown ,(this inc:re1lHd nlObi lit)'''''prftIIntaalonpuon or lWty oCt.he \r8M~elV Ileam""t andlor the ISyt,) "'' ' eI! , . ."....... ""'" poII.terior lia'~tou' ~p," "'. S. Neul'OT'adlolop -- ..c,. NEUROSURGERY WCCL , .. AD' KEY (see te~ fo,ootalts) ACI" aUaNG-deolaI interval MeA " McFUe's ~ne MeG " t.lcGrego~s line CL",Chambeilain'S Une WCCL ~ Wackenhe!m's cf'NUScanalw fl.gu r. 5-10 Sponul contour 1InII$ IIOI'l linus vsed 10 dilqlOSl'l basilar lIw ~glr>Bllon ult." ';ow I"""-'!I~ C>'~ jun<:IIorl CANAL DIAMETER Normal canal d'amew. 00 laternl Capine x-.ay (from spinulBlllinar line (SLL) to pullte rior ""neb.nl b".!.y with 6 foot wbe to mill dJstance)A: 17 '"' I!I onm, In lIIe p~noe of osteophytic IpW'8, ~BS\Jre from the back of the Spur to tbe SLL. Cervic al s pinal stenosia: varioul cutoffs for !.he normal minimum AP d iameter h,,·. been 8ugge!t.ed1;l. On a plain lateral C-a piM ,....,.y tbio i$UliualJy measured from the posterior vertebral body (or !.he posterior aspect of an o~t.eoph..vteJ to the spinolaminar line. Some ull<! 15 mlll_Maet agree that ILen08l.$is p rnsen~ when lhe At' diameter 1$ .. 12 m.m in an adu l ~ (,UPfJ8~ 3U ror ool"Tf!lMion with myelopathy). PREVERTEBIW.. SOFT TISSUE Abnonnnily increased preV1!nebral tissue (PVST) on late.al C_spine xr>IY may inditllte t.he preseuce ora verte- 1 0ft. Teble W NOm"lal preverlebral ,oft Ilssue bral fractW"e, d islocation, or ligamentou l ,, dis ruption". NonuaJ values are shown in Tobie 5-8. NB : the IU!Ilsitivity ofth.esJe measurement'! ie only ~ 60% a~ C8 and 5% aLC6" . Increased PVST i . more like· ly with anterior than posterior injwie5" . FaJae pD.itivllS may (Je(ur with bessl skulVfaci al fr8~tUrl!'B, e~peciaJly with NEUROSURGERY .5. Naurorad iology '" rTliclure of the pterygOid pI9te~ , INTERSPINOUS DISTANCES C·~pine AP: a fractl,lUldi,tacation or [jgarnent d1i!ruption ","y be diagnDSe<i ifth~ inteNlpinou~ d'5tAnta is 1.5 l in'eII lh"lal both "djaunt levels (I'lle""u,...d from «,n1£' of spinous pr~ l"", Aleo look for II mallllignment afspinoWi PI'D'I'I'$!Its below" certain level which may be evidence ofrot.auan due to a unilAter1lOl1y locked fa .,.t . C-sp'n e lateral: look for "fanni ng'" or -n aring'" which ~ lin "bnotma] lipread of one p~iT of "p'nous pl"OCt'lSoOel that may alao iodicate ligllmenl disruption. PEOI ATRIC C-SPINE C1 (ATlAS)(8e<! F;' ..,e5- /1 ) Ossi fication centers": usually 3 I. 1 (&ometi mes2) far body (001 osr;.;lied lit \:Iirth, OPI"lar8 on x_'"Y during tit yr) 2. I far each neu ra l sTeh (appea r hil"tel1lll,. ~ 7th fetal week) SynckoncU1lseal1 : 5ynchondro!JilI of tile ~pinou. PI"(I_ ce!&: fUSES by ~ 3 )'TS age 2 nl!!'l"Od!ntrnlllyndlOndro~",, : ruse by ~ age 7 Yl1I synchondrosis: of sillflDUS Pfocess F'1Iuf6S-11 C2 (All iS) C,.,e FIB"'" 6-12) 4 primlll)' naificat;on cenlers: odootoid P""""" ve.whr,,] body 2 nE:uml arches A ReCOndlll}' QSljl6cst,on oenlo!r 3pppaOl at till! iummit of tile dens between 3-6 Y"". Iilld fuse~ with dr.os by age 12"'. Syncbondro!iEtl: aonnaJly fusa between 36yeal'l;orag~. AP VIEW .... ~ neura P~I "'ieC1 g- [alias) neurocenlra) s ynchondrosis . """ . derllocen!rtll syncnondrosls ~I ~ nau I1eurocenlral synchondrosis FIou,. 5-1 2 pecillmlc C2 lllXls) C3·7 Co!rvical bodies a.re normally wedge shaped in pedi9t.ric populstlon (narrower anteriorly). Wedging decrealu with oee. 5.6. Myelography L umbar myelogram Using iohexol (Omnipaql.lO"!® 140 Or 180) /U showo in Thbl~ 5-1. Cervi cal myelogra m with wate r w lubl e contril8't v ia LP Use iohexo\ (Om.oipaque® 300 or 240) n sbown in Tobit 5-1_{moen spina! need(e into lumbtar !ubaraehnoid Il'pace, tilt the bead o(th~ my~lllgr.Im ta1>le down with the pa_ tient', n~k extended and then inject dye. Ita conlplelectrrvical block i.'I5~n, bll\"e pa. 5. Neuroradiology NEUROSURGERY t'~Qt flex neoek. Irttle block ClilIlJOt betTue~d , patient may need Ct·2 p\lllc:tuJe (IT MRI (firttobt.ain a CT ",hith may 8ho'" dye above theblock VtlltCWlnQ! be appreciated (In my. eIOlT,phy . IQQe). Poet myelQgra p hic. CT u,errallY Iellsi tiY ily and l pe<lifidty of",yeloiTaphy (.u pagt 2951. U, cues "fcom. plete block on myelQSTim, CT ",ill ontn , how dye.distal to the apparellllll.eofthe block. 5.7. Bone scan Te<:hnet.ium·99 ("-Ttl pertKhnetate ill radlolllOtope that IfIIJ' be attached to v_ io ... l ubst.r&te . r(lT use in bone .cllnninJ' It mllY be ueed to libel polyphOlphate(nttl,y uled l«I.y), diphQlphonite" (MDP), OT HOP (the rnot~ "'Idely agtnlll~ cutn'nuy). Bone ICIM ",ilh technetium·labeled compound. depend. 00 the p..sente of oateoblaillc activity for thede~iUon of tracer into the bQol~ GIlIium may alao t;.e uSl'd 14 look fOT mort d]fllnitOlt.oo~hti •. ApplleatioOi for bone 1C<l1ll indude: 1. infewoo A. O!1teolDyeli U-l orth•• kull Dr I pine (verubral OIItoo Dlyeliul, aN ptJI8 244') B. dillCitis; 1ft pap 247 2. tumor J\.. I pine nle\.8$t_=ut p~ flJS B. primary bone lum ~ 01" the spi ne: _ P"P 6 12 C. 6kuU (uman: ~ fKlI/t f8Q 3. d;.\ot'QeI involvir.g aboormll bone metabol"m A. PlIJlet"5 disease; ohhe ,kul! (1ft PQ6t 3·U ) or Ipine (1ft" ptVJe 3411 B. hyPerOiltosis frontalis interna: ~ ~ 483 ... craniosynOl!-tQsu; ut Pfl#. 99 5. r.. tturn; spille lsu P<>I{t 701 ) or I kull 6. ·10'" back problema~: to help id~ufy ... me Dr Lhe above esamplel (.... p<J8t 2!U) 5.8. References R, ...._ £.Honl;I_ Io4 .W .." eK ....... _ _ orionc _ _ ;,,",~ """ond_,....... ..... I. . pIof. C_ .. IiDu. ,.. ........ ~,p<]"16 0I)·,. 19U. 8aI"OI Ii P. R,a L. Soijof.... J<IId 1L _ _ ••,iMII<nI _oI"""" ....".. noocI;.,.,.~ P'O(ICftIt. """ -... ....1_ J "" ........... lO. 'If>.ll . lm_ I I. __ Il _ """ _~ .....1<oUot: 1U<1io.- .... ,.. _ _ .... .-.joI ... )I 1" U. ,..u~JM ,. 4. A~ . . ."'" .......,r.,.,...,""•. .. Ij. """1OOo T H.,", OG. "odI.., ~ .. .... .C. y Mo!.llr.s-. ....... IVII ,hU_ .... " 10 ~ 9, 10. _""tl1 "",,,,,, . loe. . SoII~.C. , . UUI\.. !IOOl: p"S6. 8010"".. .. 11. .......... s. 04."";' _ . . .. .".,f'Irto ........ ,...) ,.. £ot:l J 101.,. m '''' _ _" NEUROSURGERY "" H. 8 _ _ FS.S<hod<o pw, ...... 1'Il*riao _ __ $t_ ' W. ' _ f .s.Gctoo.ok>R G. .. ",~ ....... ....... ,.....,. ..... "". o..m-._1pI<Id ......... ~..." ...,...,." ~ S" ohlS. 1011·5. 1')97 "'t ll. a - FS. _ _ C . .. .,t _ l l l If· """""_;pit<I MR llioh.. _!;kc<ld1t, ... -....,. U. l l ~ , 199\1 M..... M,. . T~OC. IIo.o.d ;. .C. ....... E_;.". 01 oori)' tv "'A ,I><np)" ....... diflII · top-""""'_ _"""puf"'_""~ MIII ~""oIOc!" n: 17 1792..... 1999 _otn _ _ ., _ _ .._ .. _ M .........,..' I, _""A."loMol ....... m.·_ ,_ _16, 0II_1oI . \.JlOOC$<"~8 •• , ... ~ _ _ ,i_os .... _....,.,.<bpl: M_ " , 1<001-..11 1l69·76. 1991. _IIF.Fe",..G .s...wt.." ...... ~ OompIka­ IId_ ll F.e:;-..LLs.:_O f ... ., " .. _ .. MIII,.... _ _ ... .. sa..l1od _ ....Froe:;· .. _ s..''''''''''}·115-M. ___ I__ ItIllIt , ... I\I\19. UOi"'.<lfd~~~I. I'I....-.:r S ' · II 50""'. II ""·I(M)oI. 1"1 ..... of.-bnl ... d .. _ ...... ofl"l>k. AJ. loOl. W·'J, I .... 1731)..6 . ......""'pIIoI.podI~ """"""-....~~: W.'.'''1 Dooo I£ .G_p c: r ... "" . ..... o..uc.l_ ron...... ~~, ~ ): · PndIon1IW. G _ RI. "" ... _ Iot:~ _01 101111 . _ N.... '*'CJ 3l 11)l-6. I99'i plOJo "Jl'IR U; IJ I)"9.1M"1 u..... 6C, IImtCC. T",-\. e.•, .." ,..,._. f".."..IoI.AIt>«>GW· ...", _ _ of<llf_ potf..... _ ...- I < _ •..--"'O<II1ot ... It R<pOn"'lW<I_ . J~"""".lIIi 10/1· 1). 1997. """'k VC.KopI.>MCE. M............. ..,".... I. . JII_I&fto<IlJl.o.. .u.... T ..... N.... MH .. 9ol)'JI. l'9M. _1_,.,oI,,""'_."' .. S. Neurorlldiotogy ". M""", K A E.. ••• 6<"" ~ ""'()T , L")fi"J (jI W. .. 0;,10<", ... or.". """ltal .,.... w '", oot<I 00 ... ttI ~ l. fI'c1, ... O>i<I", ~ ,,'h J _ 4M:.fO. 1 '7I~ p<n>I<oo )611' ~ ......... II. MoIltt ,., O,I(nt]O<7I1.S.".,J , Tt.. _,~ •• "'fIOI .. ' .... o._ip, .. , Gi.lon"" •. :-...' -. .." ~, " " " ':4. JOI.' S..... 12_1,19'19 1Ioh,., s P. K,k," M O. M.oIIi. ...... ~ SIo: ..... , Rod,IoIl • . W 'Y ' >I\lpc.j!>'l" " .. , ~ 111-l>.lqsS. ScI... od< k H tI, S" ... W H. (0.1>.). Op. ... ~ ........ ....~rrI ..,l«h"'q_ 1...".G" ",, ~S"a"." . W .. Yort , lqll £1""'" "', ......;.1 ",800,_ y . .. .!.. T_· it III)'< ..... OIIy io po"........,," ....... , ~ ""..,. ,'" wi.,."., f_"", ,,,d,_,,,o' ""<""",,or dl.,.-. . .............. , >ad _ i s. S..""" I'm) 0.:_ 1( , I{;,.-.:' C li1i1j" '" p<n'<fI<:bnI""", " .. ...................... "",,,,,f,,,,,,,.i<oou ... 1II> .,.,.. •• W ..... "'j"') ". ~[ ....... M... 2. · ,11,.2. ""-!IIi. ". " " " " 111 .1 ... 1( A. FI .... ~ D.1'I"' '''cC!<:>I oof, ,...... , ...I~ .. . _1\11.1 •• '" I";""'of ... , ..... oa/ 'P<"'~ I I\I~'} 19' iTJ·9. 19II1. N';"i<!o.J 8 . "'i<I~hT P.GorMn C. " ... ~ n.. .. III· ""d,""'~dw...c.."..,.{...""of ..""... bdloiolp' Ill: I iJ-<o. 1977. 1I1l..,. D,.;,The_" .,....;...,I.¢n< ",.,fMaMII ~,,'"' 0;....,.'100 . 6, Nellroradiology " n. " " " <ltildn!tl. Rodi"""", W. 1 Iz.. •• It11. The Cet>onl S,""" I! _ _ ~ S.. OC1Y.'<G,j 'no ..... " ... .,._''' .... , 1 8. L~.""il>OOlpIo; • . IWl. J~ G, 81«k..- H H; P.......,........... _of .... .... IIIc:b.i~ . .. "' JII..... '~ .. DL >OW ,., <~ Th<~ lnir" n . 1z..3\, __ .f.b_I".... ft .. «n-kol ",' r><, ""II 70. 'D~, IQro. c..mben.,. VI E: 8 ..11. '"",,",,"'" I,p....,bbio): eiwre "" ..1o;wnon.1I ...,.".IJ' o f _ip i ~ _ ..... "~ r<U";,," >Pi"" aool ",..10.>4. '"'''~'' lnlllo! V.ld 81011>1«1 I I 0;"" ......u.a .._ . 1~J9 M~JOf II Tho \o& .. '11-%, f..-_ 01"""" " 111''''' __ "'II,,, of Ibo ,~.u in !lot dl'l""'" , ..... . ,J MNkIIZ, '" w ,l .. I..,!I<U· 17 ' -3 1.1900'. VoaGWu J C. 101 . ... ... " Il .DDI.. I( 0: lfadloloJJy ""~_m""..,_IN.I~.""'.I" TkrnnIeo. nob, .. ju ..""" &lid ... . _!nOIiIlol. F...... I'\ItIIW,i • •• foI ... . 19J1.CM!U' l! pp19-61 lI ... t VC. llopl:J"' C E,S. .... nS. I>iI""",l<m· "')1 ofl)l>.I... .mp<e .. ;OII •. - . . , . 15:!19. 1961 II.ondo I, V............. I. Mo,; .. II... al ~ _T<-pd,.. ~...,., 99oooTc"",,.,.,.pIIo"" _ ..1",~ t>Pl, ;" ...............1<&1 ptlaiI:< 500ra N.....all; lD1_ 10 . 197• • NEUROSUR.GERY 6.1. Electroencephalogram (EEG) Common EEG rhythms lIrf!shown in Tobit 6·/ . The primary use ofEEG i~ in !.he diagnosis and n1DnBgemen~ ofseizur\'. diiordetll . Non-c:orlVuJ~ive use of BEG I, ellilcntiaUy limited to monitoOril1g for bun;~ 8upprullion <su~· /OI"! (e.g. during C1lrotid endarteuctomy )o r for d ifferential dingnOliis of diffu!'l! en~~phDlop.t.hy, Including: 1. differentiating psychogenic. unrespons;veneas from orga ni~: a n'mnll) BEG indioate!! either psychiatric unruponllivenu~ or locked-in 8yndrome 2. Mn_nvu!eive ~ tatU8 epHcpticus (seiJurea): R.b- Ta ble 6-1 Common EEG rt'IY1hml sente or romplex partial sta tus 3. Bubclinkal focal abnormalities: espetially in patients too ill to be u-anBported 1.0 CT. Loo~ for e.g. PLEOs l.su ~Iocu), foclil slowing ..• ~ . specific pattern, diagnotltic for certain pathologil!'ll; e.g.: A. periudic laterali?;ng e pileptiform dillChargeJ (PLF..D8): roay occur .... ith any ac:ute focal cerebra l insult (e.g . herpes limple.: entephillitis (R SE), lIbM:ell$, tu mor, emholieinfancl: .een in 85% of calleS of HSe: (on~t 2·5 d ane.. pf9Sentation), if bilat.et"sl i • • disgcll'ltie orHSe: B. ."baeut.! adel"Ofting pDnen~ephalitil (SSPE) (paihognnmonie palt~m): penook b.lgh volUlge with 4·15 ~ IieparntiOll with Il«Ompanying body j{:riur, no ~hange with psinfulatimulltion (differential djagnosia includes pcp overdOlic) C. Creutl{eldWakob diseAse b«J108f 227); myoclonjcj~rks. EEG ~ bila!.CrAI ahArp Wave 1.1... 2 pe r iecond (~a rly - slowing; lal.l!r- triphMie). May ~ semble PLED •. but are reactive to p~lnrul Itimulation ImOtit PLED. au not) D. tripha.ie WAV"'" not r~ally sp""ific. MIIY beseen in he""tieentepbalnpnthy , post.-lInoxia, and hyponatreml9 5. obje-ctlve mea3ureofaeverity of encephalopathy ; u8ually used for anoxic enceph. alopathy (e,g. periodic spike. with sei~uNS ind.katf! &<:;'" chance ornonnal neu _ rologic outcome , with high mortality), Nphll coml1. bunt auppresaion, and electrDC(!rebral 1 ilente an all pOOr prognO'$ticatorl 6. differentiating h.ydrllnencephaly from severe bydrocepbll.1Ul ( _ Hy1ronf"",pll. 01.1', poge 180) 7. u a tUnical eonnrmator.l' test in the determinat ion of brain death (,sec pall~ 166) BURST SUPPRESSION I_Je<:tric intervals interrupted by bursts of a..~2 Hz e1~;rir.a1 activ ity tha~dimin· iah to 1·4 H ~ prior to ~lectrical s;l~no;:l'.l . Often u~ed a8 an ~ndpoill t {or titrating fleu r(lprtr teo:tivt drugs such as barbi turotes, etomidate... (e.g. IU page 807). 6.2. Evoked potentials Cli11 iCIIJ indica tiollll for !voked potential. (EPa). 1. di agcosu. : (MRI has largely replal.'ed EP. fnr these 3 indica tion,) A. acoustic neurOma B. "" bdinic:.a llesiolUl of multiple , dl!l"Ollill C. brn ins!.Cro lesions NeUROSURGERY 6. EJectrodiagnostia; '" 2. ,nlra-operati ve U$oll bu ~Iow) Table 6-2 Evoked pot ential waveforms (nOle ' values may diller Irom lab 10 lab) ",." '''' Possible- geMrtlou M COChlear microphonic .~"i~1 ~!\I'P5 P7 .<zl'V~2S" ,.It I III! II~' I V P, cislalVllinerlll. Pl Jlf(liltnal VIII or ooc:hIear I1\.1dOO$, P, lower jIOI1I (1 superior olivary c0mplex). P, mid·uwer pons. Ps upperpoosO:- inleriorcolIiculus IOmS Nv (on frEp where E. ~ E.Ib"S poi01) UESEP ~ C3'-FP---""-"" '"' < . ~~9_VP22 eart1 - ~f\-N~~ ~ "" ~ 1"''-/ AKA EP: o:nIry 01 volley ..' 110 listal braclial pieXIIS, 1'4" (on CvrFpz); roo! entry lone (cervical region), N13 cerW;orneCulary~nc\loII. N" prinarysensoryearlex, P~ (early) motor earle., P~ (\al.) IPSP "reaction" to NIS Fz-Ep I I II I I I "mS LE SEP o.7.fPz ~ ~ r--.~ N2S-WN27 -:- I,U5uV Cz.FPz ~ 40 l5-TI2~ t I I I ~12 (on ls·T,ll; luml»S¥;fal pIexvs, POll (011 CrF.z); sensory COIle. (analogous 10 N18 i1 UE SEP, reYeIStld in polarity !or ? reasorr), Ng (on CvrFpz): ' doIsal column rlId~ N t I ~mS ..- 100 striale & pre·striale occipital C«tex. wilh contr\bUlOnS !rom 1ha1amoixN'- PAVER INTRA-OPERATIVE EVOKED POTENTIALS Also, ste p<JB<! 3 for anestbetic requi rements for inlraop.!rative SSEP monitoring. EPs may be used for intra-operatiye monitoring (e.g. monitoring hearing during resection of acoustic neuroma$, or monitoring SSEPs during $Orne spine surgery). however, thei r delayed npture onen mahs them ofJimited U1lefulncss in pyoiding aCUle inlrp·op. eratiye injury. A 10% increased latencyofa major EPpeak , Or a drop in amplitude,. 50% i$ significant and should cause the surgeon to 8..PCI1$ all variable. (retractoNl, instru· ments .. J. lnlra ·operatiyeSSEPs may be used to localize primary senYlry corte~ in enestheti2ed patients (ao oppoBed:o using brein mapping te<:hniques in aweke patients) by looking for phan J"I.!Venlol potentials acrou the central oukur:r'··. EP monitoring during s pin e s urgery SSEP 9: monitor only posterior column function. and while this correlates well with ... 6 . Ele(:uodiagnostics NEUROSURGERY o:>Verallaplnal tord funeliOn and ar~ a lTetted by manipulation or the .pinal cord and l~­ chemie ev~nt.l, they mal' r~in un~hanged with aome injuri" to the anterior cord, ~anscran;al m otor e voked potentillia (TCMEPa) : tran&a"anial electric .. l or magnetic stimulat ion of O'\otor cortex and delcending motor 0::<0n8 with rerording ofmGtor pltentiuls from di8~1 ~pinal cord Or m.uscle group!! , OUl!. to thl!. large potentials, th e acquisit ion tim" is shorter lin d feedback 10 the iurgeon ia almas! iruooediate. However , due to pa t ient m01li!ment from tho muscle contnlttion s. contim:oous recording: bI Uilually not possible {except with mOn.ilOrinjl' the re1IponU over the spi nal !;Old ), U~ful for iu rgel')' iovolving the sp inal cord (tervlcal or thoracic), 110 utility filr lum bar spille surgery. In addition to g:en~raJ EP anellthet.ic require",eolJi, n.mmmugcuhH blockade ,,,u8t mini_ n:>i~ to pennit a. 2 out of4 twitchel. De-cending evoked potentieJ. (D£P): (form erly refelTed to by the misleotding tern:> al oe uropnic molor eyok~ poten t ial,). Ros~al5ti!l\ula tion of w apina l corti wit.h n<:ording ora caudal n~"rogenic response from thl! s pinall'OnI or peripheral nerve, IIr .. rnyogeni~ r"l'lponse from a di1t.a1 mllKle. OEP. can be medial....:! primarily bl' IIIl1SOl')' oervt'B IlIId the""fOJ"~ do not rep.....senl true motor poten lial.s. HQweV8, ;r.lwwn 10 be sensitive to s pi nlll cord chlL~gft5 and may be "...,ful wh"" TCMEPo cannot be obtained , ABBREVIATIONS Abbre viationll1.l5ed below: BSAER .. brain ~tem " " di1Al1')' I!voked rO!b~: lJEILE SF.P .. upperilowI!T ..xt .... l'Ility senso!)' evoked pot.ential: PR YER _ pe tte rn ""versal vi · Bual evoked response whi~h cequir"" patiP.ntcoop<!ration and visual attention as op posed U) Ila.\h YER wh ich rna) even be done through d o....d eyelids. See aliO refe rellCf!ll'·· . Table 6-3 Normal vulue, for evoked pOlenUals" T~' "''' UESEP LESEP PR YER (nole: values may dl Ne< trom lab to lab) Pamnettfl lIINaumi -- Normal ¥8111tS -- "". ~2.511k1 Com~' dey I-Y pe.D: !alelq' 4.01 mS H.pe3~ 1a1eflC, l.\51!1S 4.63m 2.&61115 V nbsolote I~~ IH-V peaIIli!1erqo S.1mS 6.27 m5 tfs·N'1 pealIlalMCY 9.38 m5 PuP. pe~ 1i1!!ocy IS.62mS 2O.82mS jlIOklrqaIion $U~ lesion belween pon$ inO coIicuII.G. oIkt" K_11e neu,oma proklngallOn ~t:; Ie:siotI be~ IoMr pons"& midbrain, may be seen irllo1.5 11.35111$ P.., absoMe lalerq 3720mS 44.16mS P,oo absolule laWlCV .3 S.D. P,OO i!118'~)'e dfle,ence 6-10 mS 1~·eyeddll'l$'lOO is mom~"~hluil field Slimulauon. Monocular delect so.ggesli ~ de!edif! Ul.loloplic oerve anlMor to CIli~5m (e 0. M.S" g1i..eoma, ~pre$IOOI'Il8lifW cegeneralion). Bilale!i! de!ect does nc)llocali.l:e. •• IIOIm" ... Iues on _ _ ... cnliCl l "alUM 6.3. u~ as eutaW I... aDnDImli _ Eleclromyography (EMG) There lire two po.lrtionB 1.0 thl! EMG exam: 1. conduction lI1eI,,;Urements 2. o .. edle exam A, ioserti01l1d actiVIty B. activity at refit: IhouJd be I lle nl when need le Is activity iuo3l1uieteoi ~talionary a nd in :\Crtional DEFINITIONS Fibrillati on potenti"" a: following den~rvetion ofa NEUROSURGERY mu~rJe 6. E lectrodisgflostica (""condnl')' La II n!!;TV" '" injury). individualm utcll llbe .... begin firing independently . .EarliHJ,()/\IIet 10 daY". lOOIetime. up to 3·4 week.. after denervation. If tM nerve re<Xlye ..... it llIIIy reinnerva~ tM mu..:le. but with larger motor units N!. uiting in longer duration a nd de<:rea~ num· bon. F. .....,.: ~rve it . timulated. cauling or1hodromic and antidromic cond uction. Fwa"' l latency may be prolonged In rlldiculopathy (not IIIn.ili"'I). SNAP: te nlOry nerve nction potentiall. M YOTONIA TheN! are . number of myot.onic condit.ion•• induding myotonic dystrophy. There i. sustained con traction of the mu scle. Clnuic EMG IInding: ·di .... bomber" IOUnd due to myoton ic ditcha rgu. LUMBAR OISC OISEASE Al.o .... pagt 292. SNAP may be normal ... the injury i. proiUmal to th. ~n body which ruideli in the do ... al root ganglion (in the neuul foramen). Pa. upi nalmullclo! fl· brillntiona mllY Ottu •. Following disce<:tomy for udiculopathy: motor poll'ntials retum fi ...t (if~rvl injury were · compl.te·, it would u.lle 1 month to return) if lost. senlOry potenlial, retum lut or may not relum paraspinal potentiftl. m.y no longerbeuseful because the muacll'tl are cut during surgery PlEXoPATHY Reductioo of SNAP with DO paraspjDw. musele fibrillal io,,- (the donal ram i Gi t proximally to innervate the paras pin. l•.• nd aN! involved ~ W with rootl..iorv). MISCEt1.ANEOUS EMG PEARLS FOR NEUROSURGEONS The short head orth e biceps femoril in the LE;I t~ Ii.... t muscle inner-lted by t~ po!rooeal division oftbe !(illic ne ..... e at or just above the poplil.e$l fOUl ju.t after the aplil4l offfrom the sciatic ne ..... e. In cases e.g. offoot drop it is a good muscLe to tesl to determine if there it a po!ro"",al neuropathy VI. a more proximal lesion (i.e. above the plplit.eal fos •• ). EMG ii not extll'JDf!'ly sensitive for radiculopathy te.g irritative radiculopathy m"ht not be picked up). more !<) in the cervical region than in th.lumber region. However. when positive , it i, very epecifi<:. M ...... 6.4. References o.-pnl_ H """_ ...to ...... ;' ...... '1'_ ""IcIoI _ I. M_. ~"",,,," 8 1i" C D. (ed.l. o....t..ll u, ... _. New YOtt. 19":,. n}-ol). '_af_'_ .. 1. c;",toriEM.~S· Lo<"i .. 1. J""'~"-"''''''''-''''''--''C-. _'-'11 6, . lOO1·S<. ' 9I< WooIM,C N.Enol _TC.O_ WE; Lo<aIiu- 148 ,_ .. _ i r ' " - l ' ..... _ _ af-.- 6. ElectrodiagnOitiea «tdnI_ ........"""bydot<a~af . _ " " " " '.... M I I - . I .......... _ . J Nfto· ~51 ·C16-,.,..I 9'9. a..-KH:E""'ocIp<t<ntiab .. ' liAocaI_ l r... af_ J*U) NI:IoiIIJM«I lO6: 11000-50. ""_K".£_"'..........<I-.._.. ,~ int 1_",,_,...1 NE",IJMotI lO6: ' 21»·11. '9$1. NEUROSURGERY '" -" --- .. ~ -', Also_ pag.153 for plumbi&m (lem! poilloninll frotn At.al ned bulLelli. 7 .1. Ethanol The acute and ch rOJ1ie errKU; of ethyl alcohol (e~h.nol , E tOU) ebuH on til, nervoua .Yltemal1lprotean •• andarabeyondlhI8l:opIofth.i.te~t(nol.tolDl:ntion the Afl'ecb; of EtOH QfI othar ol'la.o .ylteml). Nell1'(lmulC:war a fTKUllndude l .cute in~""Uon: ' " ~IIIW 2. ~fTecUi of chronic. .leohol abu ae A. We .... ;e..e·. e a e.<ph.lo p.lhy: IN ptlJ!t 151 n cerebellar degeneration: due to delL'eneratioo of PurkillJl! cells in th@cerebeUar (Orte •• pndominlUllL), ill th...nterior .uperior verm i. C centl1ll pollllu,. my.linoJyai" _ page 17 D. llroke: incre..ed nair; of I. Intra~,ebrl. 1 lI. marThaC': &« P"8f: 852 2. jac,h...ic slrok~ 3. poaibly llMur'l'llDal SAH: &« paiJe 782 E. periphera l nevropat by: _ ~ 554 F. • ktLeUII myopathy l . tlffCU of elcollol wilhdrawl l: u.u.aUy!letn LA hebituat.tod drinlten with cUilation IIr r'l!duction Df eUw.hIIl intake A. alcohol w;thdraw.l .yndromes; _ below n. 1ot;2Url!$; up \(I33"ofpa~nt.r; h""" a generelize<l tonic_clonic !leilure 7·30 hn wr ceuatioo of drinking (!lftAlcolltJi w;lltdrowallliizul't~ . JllIII! 261) c . delerium lamens (DTa): ue ~Iow ACUTE INTO)(lCATlON The primary elfKI ofElOH 0<1 the CNS 1& depresaioo of neuronal eaTa ble 7- ' Blood ethanol coI'ICantratlonr. citabWty. impul5f! cond:.octioo •• Dd (In noOoi' 1oo/1oIIc pa.lletl1I) neu rolr.nlmittu releaH d.... I()ditlKl (blood EtOKJ CIInkll lIIlCl elfecaon the cell memlW'ano!S . Tpble 7· 1 MI;MlI the clinical elflKlI .-0,,1«1 Ibm IIlIIOO, ....·ith Jpeocifie EtOH aHlcenll'1lUoos. Mell.aby erred; the J~trilY of in. pniqnlcion. ~ !!Iaication i. greater when blood.1eo,. 21.1 1feSIo"..-:I oerebt.... ~ hol leyelll al'<! .-i.ing th~n when ralline. lion: ~ III's\.Igr!aII. ~. In lI"Ionjuna<llcllon •• indiv idu.1a ~.1LlW with blood elh.nolleveIJ. 21.7 rwnolII ,. totS \ISWIlJ ,. . 110m '"""'tory C!ePlH (tOO mgldl) are defined Allec.lly io· I()xicated.....d II numbe~ ohutn h.ve chenled thl. to AO maldL How ..... u. eqn levw of 10.2 mmolll (47 mgldllllte.-u.t.ed with ItlClUted ri.kofinvol... ~ t in mDtor vehicle lI«Idenl.l Chroni~ alcoholi.m leads to increalled I()lel'1lnctj in habituated ind;viduals lurviv.1 with levI l, Rxc-.dinc 1000 '""til h .. beea reported. . ...-, .,. '.' " ". .., _1IIIOlI:RI:!an: ~ - ALCOHOL WITHDRAWAL S'I' NDROME Compen18lion for the CNS tllpraua nl elrecUI or EtOH aco::~ in mrooic alcoholi. m. Coneequently, rebound CNS hyperactiv ity m.y rellull from f.mng EtOH level •• Clinical !IIena of EtOH withdraw.I,,1I duaified .. mador o r minor Ithe devae 6r.tltonomic hyperKllvily lind the pr~noe(.bHnceorD"l'll difl'erenlilltel lh_ l, as well .. ,.,1)'(24_48 NEUROSURGERY 7 Neuro!OX.oology '" hrs) or late (> 48 hl'1l). Signslsympt<lml include: tremuJousness, hyperreUeocia. insomnia. NN. autollomic hyperactivity (t.a<:hycardia, s}'1It<llic HTN), agitation, myalgias, mild confusion. IfEtOH withdrawal ~eizurel octur, they·wnd to be early (II!<' ~ 261). Percel/tual dioturbances or frank h a llucinoais may al80 occu r early. HallucinO!lil consis~ of visual and/or auditory hallucinations with an otherwise clear sen!l(>riuUl (which distinguishes thi$ from the hallucinations of D'l'sl. 0Ta cen occur 3·4 days after oossation of drinking (IU Ixlow). Suppressed by benzodiuepines, resumption of drinking. Jl-adreoergic antagonists, or ~.agonist8. PREVEI"ITION OF ANO TREATI.AEI"IT FOR ALCOHOl. W/7HDRAWAl. SYNDROME' Mild EtOH withdrawal io llIanag~ with a quiet, supportive environment, reorien· tation and one·to-one contaet.lhymptoms progress, in$litut\! pharmacologic treatment. BeozodiQzepineli BenzodilUepines (DOls) are the mainstay of treatment . They reduoo autonomic hyper. activity, and IDay prevent sejzure& and/or 0Ta. All BOZo are effective. Initial dOles are shown in Table 7·2 and are higber than those used for treating anxiety . Symptom triggered do~ing with repeated evaluation utili~ing a standard· iud protocol (e.g. CIWA-Ar") may be mOre efficscious than fixed ·dose ttchedules'. Avoid 1M administration (erTatic absorption). Table 7-2 BDZ doses lor EIOH withdraw sl· ., Adjuncti ve m e dica ti ons Associated conditiolUl commo<IiIy as 8P1>1Q111'1ale b.l9O<I "" palienl _ monly see n in patienUl e"peri· 'lntiog alcohol withdrawal BI"IOrI" n.lf·1i/e with 1 _ acllw rDWIt>QIilas syndrome include dehydration, fluid and electrolyte dislurbanc· es, infection, pancreatiti$, and alcoholic ketoacid"'is. and sbouJd be treated accordingly . Other medications lLSed for EtOH withdrawal it5elfioclude: 1. drugs useful for controlling HTN (ca ution : these agents should not be "sed alone beceUlle they do not prevent pT<lgTe$IIion to mOre severe levels of withdrawal, and they may roa~k symptoms of withdraw all A. B-blockers: also !zeat most associated tochyarrbythmi 811 1. IIkru!l!!.l (Tenomtin®): reduces length of withdrawa l and BDZ requirement 2. • "void pn')r" "nolol (""ychotox;" rMctioo~) B. a-agon>sta: do nOl use together with lI·blockers. Clonidine (SH JJOIe 5) has been exteru.oively studied, and can be given in pat.ch fOrnl (takes _ 2 days) 2. p~enobarbital : an alwmative to BDZ.. Long acting, and help$ prophyl8.llagailut se l ~ures 3. badofen: a Smallsludy' fouod 10 mg PO q d X 30daya resulted in rapid reductioo of sympt<lTOJl atle. the initial dooe and continued abstioenC8 4. "supportive" medicationa A. thi.w:ni.o&: 100 m!" 1M q d .. 3 d (can be given IV if needed, but there is risk ofadvene reacuon ). Rationale: high-concenLratioo glucose may precipitate &Cut\! Wernicke's encephalopathy in patients with thiamine deficiency B. folate 1 mg 1M, IV or PO 'I d .. 3 d C. MgSO. 1 gm .. Ion admiSflion: helpful only ifm agnesiWlllevels are low. reo duces sei~u re risk . Be sure renal function is nonoal before administering D. vitamin B,~ for macrocytic anemia: 100 I'g 1M (do not give before folaw) E. multivitamins: oi benefilon/y >fpatient is malnourished 5. seizures: ~e JXilJc 261 for indications for treatment '" 7. Neurot<lxicology NEUROSURGERY A. phenytpjn (Dilantin®j: luad with 18 mglkg .. 1200 mgl70 kg rUe page 271) 6. eT.ha.nol drip: nol widely u.~d . S% BlOH in 05W, ~tart at 20 cdhr, and tilrat<! to .. blood le".lof IOO·l5Q m~dl OELERIUM TREMENS (DTS) When D'l'~ occu r, they ~uaJly begin withill4 d8y~ of the ~t ofEtOH withdrawal. and typi[8lly persist (0.1·3 days . Signs and eympUlms indudJ,: profound disorienta tion, llgitation, t remor, imwmnia, hallucin!>tiona, severe autonumieinaubility (taoby-cardia. H'l"N, diaplwre3w, hyperther· mial". Mortality i8 5-1O\\' (highor in elderly). but can be reduced with tnlotment lintlud ihg troating ~ted medical problem~ and t~t.ruent Ibr aeizures). Haloperidu] and ph~nolhia:unl>B mAy e,ont ....1 hallucinations, but can luwer the Mli. lui'll th",shold . HTN BIId tachyarrhylhmial . h""ld be tnsted as outlinellbove under Ill , c..,h"l ..-itbdr8walayndrome. WERNICKE'S ENCEPHALOPATHY ( W E ) AKA Wemicke-Konlakufl" eneephalopalhl'. ClallSic triad; em:ephalupathy (consistIng of global ""nfuaion), ophlhalmllplegia, and atula eNS; 11113 are pT1lllent in only 10· 33% ofcuu). Due to thiomine de ficiency. Body 510",5 ofthhllninearead~ua~ only for up to - 18 daya. May M seen in: I 0 certain BIW:~pl:ib]1! Bubset ufthi!lllljn.defici~ntaIC(lbe>l.i<:ll . Thiomln.. dencieo~ here iadue to ~ tombinal;un ufinlldequatl! iotake, reduced absorption , decreased hepatic &wal:'l, ~nd impaired utili~ation 2. hyperemNi8 (oa jn lume pregu ancieU 3. s tarvatioD: including anor~~ia nervusa. rapId weighllo~. 4. gastroplicotion (bariat rk surgery) 6. neotOdialysis 6. can"""' 7. AIDS 8. prolOllged rv hypera.lin:..~nt&tion Oculomotor abnormalities ..,....,ur in 96'11> and indud .., nySt"fPtlu8 (horizontal > "ertj~ cal), lateral rectu s palsy, cun,jugat.!·gllZe palsies. Gail aLaXia i.IIseen In 87%, 8fld results frolll a oombination of pOlyneuropathy. Cl're· t>ellard.Ysfunctiun. 8fld veatibular imwirroenL Sy.t.erruc 8ymptomo may indu de: vomiting. fever . M1U : May , h(IW high s iJ,'llal in 1'2WI and FLAJR images in the pa'raveDlricular (madlal] thalamus,.the floor ofth1l4th ventricle. and pe ri aqueductal ~9y of the midbrain . These changes may resulve with t realmeDI'. Atrophy of the mammill ary budj"," may alao be seen. Normal MRI does not RIO the dlagnO$u . Treatm ent Wernicke'. entephalopothy (WE) III a medical emergency. When WE i. $ullpect.ed, 100 mg thiarnine$hould begiven 1M Dr IV (oral route ia unre/iable,sa llbow)daily for 5 daY8 . • IV glucose CIIn pr..clPltat.e acute WE in thiamine derkle"t patients, :. give thia· mine fint. Thiamine adJUini~trat.ion improves eye findings within hl>Urs to day,,; ataxia and confusion improve in day~ to weeb. Many palienlll that Bumve are left. wic.h horizontal nystagmus, ataxia, and 3Ih\ have Kurnkoff'...yndrome {AI<..... Korukorr! psytho9i,1, a diubling memory disturbancc Invoiving retrograde and 81Iterograd~ amnesia. 7.2. Opioids Includes heroin (~hkh i. usuolly iTueeted rv, but the powder can M 1ID0rteQ liT' ... moked) aa "'ell a. prellcription dru~, Opioids produce small Jlllpiis (miOllIll). Ovenloee produces: 1. rerrpirll.1Ory depll!$!ion 2. pulmonary "<lema NI!UROSURG5RY 7. Neuroto~icollliY '" 3. 0;:0l1\.li • . hypotension and bradycardia 5. ."izurea may o«u r wit h: propo:q>phe ne, m eperidille (!leme rol4t) which may .1&0 aoUM deleli um, IIf>1i the Itreetdrug combinatioll of"'1'". and blues" (.et pagt 259) 6 . r.tal overdOMl may occu r with 8ny agent, bu t I, mOTe likely with Iyntheticopioids luch as (ent a.nyl (Sublimate'll) among "'$era unfamiliar with t heir high potency IUver sa l 0' into:dcation " A tQt dOH ofnalol<one (Na rclIn<t) 0.2 mg IV IIvoid. sudden complete f8verul oh ll opioid .. frecta. If no .ignificanl reactioo OCtu", a n a dditional 1.8 mg (for 8 I()t.al do.e of2 ml) will r'fjverM the toxici ty afmon opioidl. If nHded. t he dose rna)" be rePl!ated q 2-3 minulH ... p to. to .... 1 of 10 mg. 81though even 18rg<!f doleS mly be needed with propoxyphene, pentuoeine Or bupreoorphine (Bupren... aCI). NaioxOlW! "'ay pr1!<';piltlte narc:olic wic.hd rawallyruptom. in opioid dep'!I\dent patient... with a.:u:iety or ~u.uon, piloer"Ction, yawning, l oeezing, rhioorrhea, nausea, vomiting. diarrhea, abdominal cramp!!. m....,l" spMm •... which an! uncomfortable but not lire !hr..knin,_ Clonidi ne (Cata pr.f4) may be h~ lpfu l for &ome narcotic withd .. waJ lymplOme. With long<! r acting opioids. especially methadone I DoJophio~). repeat dOlell of na loxo"" may be obviated by th. UN of nalm"r,,"e (Rove.), a 10"C..din, narcotic ao· tagOni5t which i. not appropnate for t he initial tr<!atmp.n t ofopioid OVen!Ollge. 7.3. Cocaine The ineNn ing use of.:oc:aine in its vanou. forme (including Crick) is resuJtinc in a n se in theinciden... and reeornitioo ofib deletHio ... eft"ect.son thCNS . Effecu.on other body '~tem s (tachycardia. acute myocardial infa rdion. al"thythmias, ruptureof ueend· ing aort.a (aortic dissecuon), abruptio placenta. hyperthermia. intutinal ilOChl!mia. Iud· de n dea th ... ) are well d()Cum~nte<! ","where, IlIId .... e not further d~-.:I here. Cocaine is utTaete<! fromEryllu'orylOll COCCI If!avell(and other Erylhro:ttyloo ' p«ies) and is th u ~ unrelated to opioich. It blockl the re-uptakeofnor-epinephrine by prfll)"l>8p. uc adn!nergie n,,"'e term inal,. It ;. avaUabl" in 2 formt: roeIIine hydrochloride (h<!lt ta· bile aod water solubl". it il usually taken PO, rv or by l1.li",,1 in l umation) and as the highly punr.ed cocaine alkaloid (free base or crack cocaine, whic:h i. Ma t It.able but in· &Oluble in waler Ind i. UIWlUy smok~). Peak toxicity occul'l60-90 minutea after ingestion (except for "body packen"). 30-60 minutel after snorting. lind mi nutea after rv il\ieCtion Or smoking (frHbaae orcrack}l<'. Ac ute pharmacologi c e ffe<:ts o r cocaine Acute pha r maoologic eff,.., .... pertinent to the .... "'OWlI~t<!m i ..dud", I . m~nt.al .tat....: initial CNS .timulatioa that fi ..t manifests as a M'nH orwell.beina and .upharia. Sometimes dyapharic a,;t.at ion results. ooxas...... lLy with dele· dum. Stimulation i.lOllowed by d~ ....... iOll. Paranoia and toxic ~ychosi. may o«ur with OV~niOllge or chronic use. Addiction may OCC\IJ' 2. pupillary dilat.ation (Illydnasi.) 3. hyperten. ion: from aw-.. ... rgi~ di.mulation NOD· pba nn lco)ogic effects related to the ne rvous system I . pit .. it.ry deteneration: from chronic intra.naaal use 2. Cflebral vuculiti., leu common than with amphet.ami ..... 3. Hi zum' pot,ibly rel,ted to the Jocalanesthetk Pl'OP'!rtieI of cocai ne 4. cenbrov_ular a~ident (CVA. ttrok,),' A. intra~erebral hemorrhase: _ 1"'f"Gce..,bral Mmorrlw&e. E;1,'olOtl~1 on page '50 B. lubarachnoid iM!morrhage'" OJ: pouibly .,a mult of HTN in th<! p..-nce ofaneuryt.ml or A\I1>II, however. sometiroH no lHion it demoMtrated on angiOflTBphy". " Iay pouibly be due to ",rebral vaKuliti. C. Itchemic strolee'': may mult from vasoconl t n ction D. thrombotic s troke " E. TIA" 6. .nterior Ipinalartery syodrome" 6. P.ft"_ of maternal rouille ..... on the fettli ne .... ou. lyatero include": microceph· aly. di.eorde.. of neuronal migration. neu ron.l differentiation and myel ination . ... rebra! i.. {amioo. s" ba..chnoid and intraee rebral h"mol"tll . . . and l uddeo in· '" 7. Neurotox.iooloey NEURm,'URCERY fant death syndrome (S IDS) in the postnatal period TREATMENT OF TOXICITY Most cocaine toricity i8 too short-live-(\ to be treated. Aru<iety. agitation or &ei~ure8 may be treated with IV benzodiuepines (e.lI. lorazepam. _ p4lJe 266). Refractory HTN may be treated with nitroprusside (Mf! page 4) or phentolamine (Regitine«l. ISU fXJIJe 469). IV Lidocaine used to treat cardiac arrhythmias may cause seizures". 7.4. Amphetamines Toricity is similar to thotofcocsine (1ft obowl. but longer in duration (may Iallt up toseve ral hours ). Cerebral vasculitis Dlayoccur with prol onged abuse (Ut pogt 63)wl\ich may lead to Ci!rebral iruorotion (u<' poge 774 ). Eliminotion ofamphetamines requires adequote urine output. Antipsychotic drog& such 06 haloperidol (Haldol®) should not be used bei:aWle ofrisk ofseizures. 7.5. •. 2. ). References a..m... M E.Simon R P.C .... nb<'. DA . Ethanol j 27.2(0). Md tho...,..."", . y... m. ~ EqJ J M«I )2 •. "'1·)01. 10. "" H. Co«h .... P9:AI<oI>oI _ _ <. S,,·..... 'S·168_ 11. ''WI. lohr RII ;T .......... oftkohol .. "I>.Io . ... pi .. 'i .... pa,;.., ... M.~ oOl n Proo:7'I)' 771_11. ,in _ i 2. 'W}. •. l.<o<M<IIb<" R,W""""T'! : S<' ..... n.~" i 'h ..... <0 ..... ' • _ _ A«h Nflo ..... ' 7. "r"'...... Il. SlH. I990. }. S.lh."" J T. Syk ... K. SCM.ide',.,." J. "QI.: /IS.. ......... nI ohleoh<>l .. ;I/Id...... , 11>< oe" ..... '",i<o' '4. "'''''0'<- .. ;""""wol . ........... n' f.. 01e0/l<>1 "",. (CIWA·At). B. J Addi<l 14: ,)').7. 1939. ~. s.o~. R . M ~S"'i th .'do.,iu<!ttUI .... n' fco-._ If"'. M P.R~ . M 5 ......... I»4i. wi ....... ".. ' A' .... JAMA 2n' 'S """"...,dOubk·OIilOl .... roIl«I "9·13. '994. ~"" "oC.~ .""" F.Col'fillO E. .,Q/, R",i<! 'OPII""""" of .'<0lI01w,IIJd,.~. ' ,y""""",, by boo I, 9 elokn, AmJ Mod ' 12() ~ 226-9.2001. TtalO>CII' o f o _ w~t.lrow" . M..r Le'I<.ll. 75·6. 1986. W"_WD.Y""" ..... len.nMJ •.,.I, MR1," 0<>1 .. "'U1Ii< ••·. <...,..'{'!IIII~7 . N.. oo\ou 611~): NEUROSURGERY '6. 17. dtu" MO'.,.O<tioM to of _ . M«I LOIl<r lS: 4)-6.19911. ""'<leo- R D. £<>10M; C M. S,""",~w,tI R C . ., .1" 'Ttl< """"''''''.,.. """'f'I'c"ionI of <0<1 ..... s..,.. 1"... .-01 n, 3,9-<,. '991. Uc:h,<ru<l<i PJ.R ...... DB.FtId1l"WlRS: ~h' ..... I><""",hol< pu.<ip"' led 1>7 e<>< ..... .-oinJ. A,etI_ .1 : 22' ... . ' ~ . O},<>,k. N M. CciIo/l" A R T.lIoonow D L. <1<>1.: Co<. ,"<-.»4oc«1 .,.,...,.,..moI N","~ A" ",...i .. f..... in , ... "",onl ~jllO<)' of 1nt/t<1anl'I _0'Y'''''? N'"1"OW'J<'131: }'Sol6. '99' . 5th......, K .... CohonJ ... : S" _ _ b<mot· mOl< lR"'piI''''' I»'<O<:li ... ....",; .... M<b N........ ,", 705.'~(!.. l<:.i""S R.SNI! IC M.n...11 N. ""',: Co",· bn)QI.,."" <Ompl;n,ioo, of ,... "'" oflht .. ""~. f""" ofol~oloOl.lJ ,,",,"'ne . N En&I J Mcd 31)0 699"lO4 . ''190, ModyC K. M.tIl" B l . M<h. l'"' H 8 •.,<>I, !'ItwoloCi< «>mpli... ,,,,,,, of <,X" .... M. Ncurolou .11. ""'-9). '91!I. Yolpe I J, Effoco of «x ........ "" <I>< r", ... N Eo&! J M«I 117: )99.01)7. 1m. 7. Neurotoricology ,_,,,"n, '.r). '" 8.1. General COntciOllsnUlI hao two romponenta: arOU8QI Bnd conl.ent.lmpairrnenL of ar0Wl81 ca n vary frolJ'J mild (drowsinet5 Or som· nole llce), to obtundation, to nupor to coma, CO nlll is the seVfn!st impairmen! of arouul. and;B defined Il$ the inability to obey I'Ommands. speak, or open the eyn to pain. The GJosgow Coma Scale (GCS ) is shown in Tob~ 8-1 (note: the scole Is inUlnded UJ asseu level .lrttdoonsclcu&n_. tect>nically, tnIs io • SCI'" 01 _ e •• "O(> ma'lmpI'" ""''''PQnI~ range at I<Jt.II pants: 3 """"01) 10 ' S (nmnaI) _ _ i$$1Ihg eye oper.1<19 ., pHI, ...... perl!>l'e<»llllimukl, (ll'le \If\'"""" associelecl 1'11111 CItIIUa! ~ may e....se eye _,e) ~ ,.., mo\OI' ,eJilO'!S4l. imp,manl 10 ~ ..,;nal <»rd lIan_11On ofconsciouHoe!18 and ;s not designed ror following neurologic deficits), Some cenleni realrd a "T" next to the toUlI&eo", far 111'tienta whose verbal axis cannot"" Ullessed becau,", ofintuha t ion', 90% ofpatienl.s with GCS s 8 and none with GCS~ 9 meet the above definition of (Omo. Thus. GCS " 8;1 a generally accepted ope rati(lna.J definition of coma , A $CIOle for use in child ren is shown in TobIe 8·2'. Table 8·2 Clllidren's ComB scale' (for 8gB <4 yfS) , same as adull Glasgow <:OmO sc:alot ,~c epl Joo _ , ,e$pQflM:' "nge clklIlII 1l<I0I1I1 3 I_51) 10 lSI_mal) Coma ,,"ultl! from one or Dlore or tile roUuwmC; dysfunction ofhigb_ bl'3in~tem (eenlnll upper pons) Or midbrain bilateral dienCli!pha lie d)'llfunctlon dirru.se lesions in both cerebl1ll hem;&pheres (oortic.lll orsubc:nRical white matter) PosTURING '!'he following: term, an iMccurat.e In the Implication ofm. location of the lesion. DE«Irticate posturing implieo a more. rO$traJ le~ion and prognosis mly bf' better. ikcorl.icote po~lUring: CIBmliea\.b' attributed to di$inhibitiDn by removal OfCORiCO$pi· 0111 pathways above the midbrain. '" 8. ComA NEUROSURGERY Overview: abnormal flCltion in UE lind cxte!\ljion in LE. Oi!t!lU: 8low nexion of wrist end finec<'" with edduction in th e UE_ Erlen,ion, intern,,1 i'Otalion, ph.ntarfluion in LE. II,.,,,, Dece r e b,.lI t e po8turin g: Clfl&4icelly attribu~ t.odi,inhibitioo ofveslibulospinallrACI. Imore cAudill) ~nd pUCltloe reticulAr formotion IRE) by .-emo'l;n, inhibition of medullary RF (LrD03C!ctlon lit iot.ercollitular le~el. between vestihulllJ" and rlld nuel@i). Overview: abnormlll utenaion in UE and LE. Dctsil: opisthotml!ls (head and trunk exteoded), teeth clenehed. anNI extended , ...uducted lind hyperpronstfd (InternAlly rotated). wrists nexed. fingel"l nued. Loegi ClItendI!d lind ,nternally rotated, feet.plnntarflexed lind Inverted, ton phmUlrnexOO. ETIO LOGIES O F COMA T OXIc/METABOLIC CAUSES OF· COMA I. elHtrolyte imbalance: ""pe<:illliy hypo- or hypematremia, hypen:a.J.,...mia, renal failure with elevated BUN St creatinine. liver r"jlu", with elevated fI/lImonill 2. endocrine: hypOglyccmifl, nOhketotlc hypefOlimolar 8tate, DKA (diabetic Iotl.OacidO$ii , AKA diah<>tiCCOIl,a), myxedema COIllII , AdditotUILIl cn$is (hypoILdrenaliamj 3 . vll!lcula.r: va~ulititi. ore, hyperten&ive encephlllopathy IHtl JICISt 64) 4 . !.oxic;! EtO H, drug oYerdOl«! (including nllra>ties, iotTOfl:eruc polyphannsq', barbi~ tuute.), ln d ioto>(iclltlon, carbon lD(NJox.ide (CO) poisoning. cydoe-porine {CfLIlUI ftn encepha\opetby that.l>owB white--mat~r d,,!.ngH 011 MRlt./Iftti.e often reve rsible with discOUWlufttioo of the drug ) 5. infectiouslinflftmmatory: meningitis, en.cephRll tis, ~~psi. , lupulte rebriti~, Ileumu rc:oidOlli6 lUI /XJgt .',6), toxle-ahock s yndrome 8 ne-opllllltie: leptomeningeal carcinomp~i.t, rupture of Mopl8lticeysl 7 . nutritional: We,." lco's erwepltalopethy. vi' lUIlio Bit deficiency 8. Inherited ro@tabo\icdliOrderl: porphyria, la~ti~ aeidosil 9. ot"!(8n failure: Uremia, hypo" emia. bepat,ic en.,...phalapathy, Reye'& s yndrome , an oxic enc~phalopalhy (e,g. poO t. re8USCillLlion &otlll;l).rdill~ arrest), Co, oaTCQlli$ 10. epileptic: st.atll.ll ('pileptklUl (including non-.(:on'lu\aiv('datWl), poSt...icl;:llat.ate'1s-pecilllly with unob6ervtd !lei~ur~) SrAUCT1JRAL CAUSES OF COMA I. vaS<;LLlar: 2. A. bilateral cortical Or subcortica l jnrarcUI {e.g. with canlioembolism due w S8E, mltrlLl &tell08 li1, A-fib, rnuraltbrombu • .. .l B. 0«Iu810n of venelsuVplying both ce rebral hemiaphare.g (e.g. severe hHate ..... 81 earotid sle n{)lli.) C. bilateral cU"n~phallc In llirrta: wdl des<:ribe<l syndromI'. May be due to oedua ion 0( a thaJamo·perforaUlr&uppl};ng both medial thalamk a",OI or with ·top-o~-the·hlla ila r · O«l u8ion. l n itillJly ret.embles metohDlic coma (in· cluding diffuse I lowing 011 EEGl, patient ev<Inlually arour;e~ with apllthy , m('mo/,), lOll, verticai gau paresi. inrectiQU": ab6enoo wi lh .'jJIliflcan l ''''''''' ~ R"L><!t, ."bd,,~.J e mpy""na, h,,'P"o Aim"lex e ncephalitis 3. neoplutic: primary or ro~ tlL-ilt.atic 4. LrILU'Il I: hcmorrhILgic conl~ion5. e!lemtl, hem9tom9 belo,ul herniation from maM effect: presumably br8in8wm compreuion C.8uses <b'sfuru;tion of relitular activat· ing .yalem or m~S8 in one hemispbere l:IIusing COOI~ pression of the other rnulla in bilateral heroisphen! dysfunctiDo increased intraerso;.l pru..;ure: rcduC<!8 CBF aCute laterA l dhil\ of tm, hrwn : e.8. due he mlLtoma (.ubdur1l! Dr e pldural l (...,~ Table 8.J) (...,~ 5. 6. 7 NEUROSURGERY 8, Com8 Table 8-3 Ettect olla te rshill on level of con scl0ll8nesr a' >S, P SEUDOCOMA Diffe r e ntia l diagn.osis; I. 2. 3. locked-in syndrome: ventral pontine infarction psychiot ric: oOt01OnlO, conversion ",oction neuromu&Culor weiliest: myasthellio IP"lIvia. Guilloin·Bo:rrt 8.2. Approach to the comatose patient The follow;ni covers non t raumatic oomo(see Hood Irauma, paie 632 for thllt topic). Initilll evalulltion: il>(:ludea ITH!O.!IUre:!I to protect brain (by providini CB r , 0.. lind iluoose), assesses upper brllinatem (Cr . N. VII I), and rapidly identifies8urgica.l emergencies. Keep "peeudoooma" os II pol-lJible etiology in b8ck ofmilld. ApPROACH TO COMATOSE" PATIE"I>IT, OUTliNE" 1. cardiova~ulllr stabilizlltio n; establish airway, ched< cil"(:ullltion (heartbea t, BP. cllrotid pulse), CPR ifnece56sry 2. obtain blood for tests A. STAT: eJectrolyte& (espe<:ially Nil, glu<:OSe, BUN). e BC + diff. ABC B. others as IIppropriate: toxicology screen (serum & urine), calcium, ammOnia, IIntiepileptic drug (AEO ) levels (lfpatient is ta king ABOs) 3. IIdminister emergency supportive mediclltians A. gluoose: lit lefUlt 2::' rol ofOll> 1VP. Due to potentillily h arm fuJ e ffect ofglu· OO/Je in global ischemis, ifpoallible check fingerstickgluoo$t! first , ot herwise ilucose i8given without exceplion. Wllesa it is known with cert8inty thllt Be· rum glucose is normal B. 118loxone INarcan®): in case ofnarootie overdose. I limp (0.4 IIIg) IVP C. flumatenil (Romll!ieon®): i.., case ofbenzodiuepine overdose (ue page 36). St.Ilrt with 0.2 mg rv over30 secondR. wait 30~, then give 0.3 mgover 30 sees lit I millute intervals up to a IIIg or until patient llrouge9 D. thiamine: 6()..lOO rng IVP (3'10 ofWemicke'. pre!!<lllt with coma) 4 . COre neuTO exam (aesHS8s midbrllin/upper pons. allows eme rgello!)' rnefUlures to be Instituted rapidly. more thorough evaluation possible Ollce 8\.abilite<ll: - {see Con MUro ~%(Im below) ::.. irhe rniation syndrome or aigns orexpandil'lg p-f088a lesion with brainstem oompression (ue Table 8·4): initillte measures to low&/" ICP (see fCP Irwl"",,,1 ""-'<l' .urn. page 6::'::.), thee get a CT &Clln if patient bt'gins improving. otherwise emergen cy surgery (ue fHllJe 772) . • Do tiQI do LP '" long tract sign$ , i immedillte- B. .,. move ". 6. Coma NEUROSURGERY Ol"gl.t. (LP in thilletting m~)' Iw risky. lee u,mbar puncll<~, p.gto 61 $). seilurel if pn!lenL If sLu l u8epih!pti~", i'."6'-~, trut ... in. d,tlIted on pa¥e 26510b18111 &merg<ln~)' BJ::G If ava.llllbl.) 8 treal metallohe abnorma lit;,. A. reltore acid· ..... b~lllJ\ee 8. reltoN ~lecl rolylA! 1mba\" ' r:e C. m.inl.a;n oody lempulllture 9. ob"' in o. cOll'1plelA! histo.,. ILl! poMible onee ~taobiUud JO. admlnlat.er ~I*ifi~ Ihrlll'i .. 7. t.n1I~III!ll~TB!I,eC CORE NEUno EX~M (FOR COWV A. rel (!i r ll.tory rote hod pa lttm: the moat rommon disorder in impaired ronac:IoUllnltlll 1. C h eyn ...S t oke.: breatbin, gradually CN!IiCendo.ln amplitude a.r>d thlll! ~~ trail~ off. follow.d by lin ,.pirnt.oty L p9U61!.and then the pIIl\.trn repeat.a. ," H~rpne~c phue iJ, ",uIUy. lon~r Che ne-Slokes r,S!li'-'Ory panltln thftn .pnetc. Uliu.lIy Ief!1l with dl~V oopba!lc lesion. Or ...n.teral ~bral henu'pbere d),.ful>elion ('!IIf1 •• ~U;cJ. e.,.. ea.l)' Increased ICP or mt~boho .bnormahly. Rault.l fnlm anllKtea"d vMulltory ' ''I!pon,e toCO:! 2. bypene ottlatlou, usually in reapo"" 1.0 hypou:mia, m~botic !Icidof;i., .,pi... Lion. or pulmonuyede",a. True ef1ntral neur~nic hypo""Mtilal>orr .. raN, and ",u.lly results fromdywfundion withm the poria . [fnoothe. bnunst.m algmare present, mRyaUUe6t pli)'Chialric di5Ol"l!tr 3. du.ter bre.thi ng: penodlOf rapid ilT1!gula. breathio" &epa. ral.e'd by apneic lpellt. WIly IV· pur .imillr to Cheyne-Stoket, UI'\J' merge with pat· tern. of gupin, roespiratloll5. High medulla cor lower pont~­ ,iOl}. Often an 0"';nou5 eign .. . a plleuat;o (rare): e pause It full iD!lpiratlon, Indie.\86 poll' tllle lesion, ~" with b .... il •• ar_ tery O«Iu,ion -I''''' v.nou. , a t .. le (Biot'. bN!athini~ no pattem in rate ""depth of ..... pi_ raliOI\l. 58" With medulla.,. le.ion. UlUlUy pNltarminal Alax"oc .espifaliol"$ * B. ""1.11 (,ioe in mIn) in ambient light. and U! roeacLion to ditftlltnnsens.uallight "'lua) and. reactive pupillindiuole to~i~n-...llIbol;c CII~ WlU! few el<a!pllona lllft ~OU/) (m.y h."", hippua). The light n!f1ex ilr the JIl(If;t uaful tiign in d181inguW1lOll metabolic from IIf\lctum toma A. the2lllx ....J.!>boIic ca,,_ ofrued/dilated pupil: i lutethimlde toxicity. an· ode enCf!pb.Jopalby, I ntldoolinergiat (ind..dilli: .tropi~), _ftiolUllly with botulJlm toun poisom"l 8. narcotiCi cause 1m!>11 pupill(migaWwith I , mall ran~ ofr:onfuiction and . Iulgiab NIW'tion to light lin "~fre oyerdon, the pupil. may be lo.m.ll that a mqniryinr "'Iy be needed to _ runion) 2. unequal (nOt« an aff.... nt pupiUaryde/'ecldON lUll produce InrlOCOria (... Alltrolio". in pllpillo,),dillnteler, pep 582)" Ii liaed Ind dilaWd r,u pll: ,-uilly dUII.OOC:l.llomoto. pal.y. PIluible hemia· lion . NPf'I'iaUy if arce. pl.lpt.I MIOci.ted with 1P'!;I.\.t. al 3rolM!..... e OOM pelsy (eye doeviat:.ed "dowD !>nd ouI"J B. pcnible Homar'. 'rndrome: conlIider ta.ro!.id _It>.ionldiasut lol> 3. bilater.1 pupillbnormalruu Ii pinpoill~ with m;nl.lta. .eec:tilll1 lbucan be det.ec:uod with l>illi'lifyl ng ¥I ...: ponline letion (.ymPl'tMtic inpu~ it 11If1; paru)'UIpllt.het.ics emerp at &d. i"le.·Watphlll nudeu. aDd I~ "nl,lppClSed) 8 . bilateral n~ed and dilated (1 · 10 trim): . ubtoul dllm.~ to medulla or lmmeI. ,1_ NEUROSURGERY 8. Com8 '57 diate post,.anoxi~ Or hypothe rmia (core temperature < SO' F (32.2' C)) midposition (4-6 mm) and fixed: more ex.tens;ve midb".ln lesion , prosumably due to interruption ofsympatheties and pare.sympathetics C. extraocular muscle functi on L deviations of ocular a>:es at re!lt A. bilateral conjugate deviation: 1. fron tal lobe lesion (frontal .::.enter fQrcontralateral gaze): looks toward aide of dea: n.octive lesion (away from hemiparesis). Looks away from side of /leiZllre focus (looks at jerk.ing side), may be statu s epilept icu &. Renex eye movements (ru below ) are norm al 2. p..",tioe leaioo: eyes look ~ from lesion and tooYards he miparesi s; caloriC!! impai red on side of lesion 3. "wrong way gaze": medial thaJamiehemorrhage. Eyes look aw .... y from lesion and towards hemiparosi . (an exceptioo to the axiom that the eyes look ~a destructive $upratentoriallesioo )' 4 . downward deviation: may be associated with unreactive PUpil8 (Parina ud's 8yndrome , oei1 pag~ 86). Etiologies: thalamic Qr mid brain pretecta l lesion s, metabolic coma (esp~iaJly ber bitW"ates), may follow a llelZUro B. unilateral outwa rd deviation On side of Iaeger pupil ([II palsy): uncal hemi· ation C. un ilateral inwa rd deviation: VI (abducens) nerve C. O. !;k~1l!i.2n 1. III Or IV nerve/nucleus lesion infratentorial lesion (frequenUy dorul midbrain) 2. spontaneous eye movements A. 'windshield wiper eYell": random roving conjugate eye movements . Non·l .... calizing. Indicates an intact 1lI nucleu s and medial longitudinal fasciculua B. periodic alternating gaze, AKA · pin&"·pong gaze": eyes deviste side to aide with frequencyd - 3·5 pe r seoond (pa using 2-3 &eC$ in uc h direction). Usu· ally indicates bilateral cerebral dysfunction C. QCulp r bobbing: repetitive rapid vertical deviation downward wiU, slow re~urn to neutral position. Pontine lesion (Ht paIJ' 588) 3. intern uclea r ophthalmoplegia UNO) : due to Ie. ion in medial longitudinal fasciculus (MLF) (fibers Cr0531ng to contraiaterallil nuc\eua are interrupted ). Eye ipsilateral to MLF lesion does not adduct on spontaneous eye movemen~ or in response to reflex maoeuvers (e.g. calories) ( sa P<JCI' 585) 4 . rolle .. e)"l mo\fflments (maneuvers to test brainstem) A. c>cw Qvest ibuln r enel<". AKA Ice water ca lori ea: fi rst rule-out TM perforation , then with HOll at SO', irrig8teoneear with 60-100 ml of ice water. NB: ffl9po<lse is inhibited by neuromuscular block.i ng agents (NMBA) I . a comato"" patient with an ~brai nstem will have tonic conjugate eye deviation to .ide of cold stimulU$ ..... bich may be delayed up to one minuteoT more. There will be 0.0 fast component (nyst.egtOusl (th e cortical component) even if the brainstem is intact (NB: c>culoccpb alic renc,..s (dolJ'8 eyea) providSll similar infennation os oc~lovestibu lar relluc . but poses a greater risk to tbe spinal cord irC-slline not cleared ) 2 . no re!lpoou : symmelrical, could be spe<:iflc toxio (e.g. neuromuscuJar block Or barbiturates), metabolic cause, brain death or pos.aibly mas. ive infratentoriallesion 3. asymme~"c : in fratentorial lesion , es pecially if ro'ponse inconsiJItent 2. (.. A. ""ulov"'. 'ibulor ...,n~" Joliet): tho ...,'icipourl reo""" ... i. commonly "'i . und ~ ....toOd. In • norm.! oW "",ie nt Ib..,., i•• Iow de';. ti.n towordl lhe . id. oflh. <old . timulUI .. i,b ny• ..,." • • (which " n.., eeI ror the ,. p;d. ~i ...1 ph...) '" th. Oppooi<e di,..ct;'n (hen .. ,ho .,nemon;' "COWS" {<o!d-<>ppooile . .... ""...... Nyotap>u . ... m be IIbHnI '" th . ... ",.,.,.. ""tI'nt 8 . oc:u.i"".pb.Uc ren"" {-doU· •• ye'" or "<Iolr. _d" ~ d. ROC porfurm if ,he .. \0 . 01 un"..u;nty .bou t ".mCIII .. pifl . .." bility. In an n:aK ""tio-nl.lho e)"U";1I oitlMo, lD_with the hu d . 0'. if ,h. 1D0",,"'on, if;.low el1O",h and the "" ti.nt lo futatiDg on on ohjo«. tlMo .....ltI be . ontr. ~ .. i"" •• nj ",ot.e.yo .. ov."'~ o\· (c.f. ocul ..... tibuJ .. ,..II~ ~ "'·~ i.~ _ not depend on pII t;. n", 1•••1 or .... ope"'tion ). In . oomo_. ""'ien, with a.n ",tact b,..i n. tem '" <T. ni. l Dorv... 11...... ...,11 . 1.. be oon· ' .......i • • <onjuIOt.e . ye """,.",ent (. poI;ti • • doll'•• ye..... ponst) C. o<ulov ..,ibQIa,. ,..11..... oro o boent but o<ul_ plo oli< Ide ",. iflt.oiaec! . nlywh. a . .. tibular lnpu," . .. int.ern>pted, ~ -i . OlfoOp", ..ycim ",';";ty ofJobyriDth. or M.teral """""ti. ","uram.. ». '" 8. Coma NEUROSURGERY wilh 3rd nerve palay (herniation). UaullJIy OInjntllmed in !.OXic/meta· boUe«>tna 4. 1IJI$l.IIrmul without IOnic deviation (i ....Y" f8ma ;n In primllry lion) virtually di/lll(n08t ic of l'IIychopnlc wIDe c:ontrelatualaye r.u. t.o adduct: [NO (MLF lealonl 6. ~i. B. optoki ne tic ny ltermu, ~oc. atronal, IU!;!;"ta paychOgo nic eon,' D. UlOI.Or: mu aele tone a nd l'1!f1exea, t8lljlOilBe W pAW. Bobinski (no'" a.ymmetries) I. ap propriate: impJi" cortiw.pi nlll trleta lind eort.x ",tact 2.. 8.ymmuric; lupl'lItentoria l lylon (t.one Ulually IRcrenO'd). unlike ly In meUiboJic S. incon, i.tentJv.ri.blt, HilU ~, POIytroBtnc 4. eymmatric: metaholic (""1I811J' decteJIl!f:d). Al tarixil , l!"tmor, n'yoclonu, rnft, tw present in metabolic: coma .. 5. I!yporene;<.ia: ooNide r myud.'lu, «Ima, nPHililly In patient ane '1Taa.uphenoidal 'utte ry 6, pattem. A p r~ ti [\1 wHIl$ _ decort.iute po&tu.rinr; 8nM nex, lell ..,u.end: large co rtieal or ",beu rtlcaJ I&- B. dfetrfl>l'1IU1 """tllnn,: . n . . .nd l.pcst.tnd: brainatem iDjury.t Or Mclow lower ruidbra<n C I~ nexed. lep nac:cid: pontine le(1JIeotum D. Inn.llaccid. lep a ppropriate (·(r\8n·in .(h~bll'T1!l.YIldrom~): a no~i~ iIiju· ry (poor proenCNia) E. cilio5pi ...1 n!'f16"u (J'IIPiUary dil/ltf,upn to o'WO"'- cu t.f>toOUs.~l muJ i): ""!toll inug· rity or lymP'thetic: pethwan J bilaterally preMnt: mottabc>lI~ 2. uailatll"'Uy ptUe1Il: poeible 3rd nerve le.si!>fl (herniati()rl ) iron.Hit orl~'1:er pu pil. Po.aibll p ....ni.Itin! Horner'. qndromf- ifon lide oI'".n>.III< pupil 3. bilateraUy a.IuIenr.: lUIlJ/I Iy nllt h.. lpful 8.3. Herniation syndromes Cla.ic If'Ichinr:: hu been that shiJ\l; in bnlin mue l",r::. QI\I500 by m8He1 or inintmer.nilol prasulll) throuCh rir::id openi",. in thll . kv ll (hemiatiaa) c:omp..... other Itzvcture. oIthe CNS prodlldog theobMrved 8Ylnptoml. Th.. view hal; been challf-nCed'. .. ith the h)'pOthuis lhat hf-mlelion may be an epi phenonllnon that !XCu" lau in the pr_and i. notaetu.lIy thetaUSlloftheomllrvau.",.. Hp~er. Mmia tion moder- al ill H .... e III ~ul.ppro~imation •• ThUf- are many popible hen>i.tion ~dromH. the » vI JI)OIlc..mmon ....: J tentral ltranlt.tn:.orilll) bemlation (_ Pl'B" 160) } .... p ... teotori.l 2. uneal herniation 1_ pG6I161l herniation 3. cinguJatl hf-miation: ci llCUl atll eyru. hernlal.eoll und~ rab (AKA l ubralcine .... mia t.ionJ. U..... lly ....ymptomalicunle.. ACA k.inb and ooduducaul lng bi· ofimpenliina: lTan"III1LOriallworniation frolltRl infardion. UsuaUy 4. upward Of-",beJlar (we bdtN#) } inr.. telltori.1 hf-mintion 6. ton. mar lu.miotion 11ft. t>tlow ) ~ ".roII COMA FROM 5 UPRATEHTOfilAL MASS" CantrllJ and unul hemlll t'or. eoeh ca U_ " differtil t fOND ofroatraJ-eauda l ae' . ";orlltiol1. Cfll tra l htm,at>on , H uh. In Nqlle"ti.1 ra;tu", 01' dian«phalon . midbra in. pon •• medulla (arf fHl6' 160). For ul\C8l herniation , 11ft' pap 161 . ' CllIu ic" l ien' ofin· o;rellSed ICP (HTN, bradyurdia , .1te~ ,,"piralor), patUom ) lUIUlllly MIn with p-fOM. Inionl may blabHn~ 111 alowly d~'optl\( au pflteatoria.! mlti",:tion betWl!tn cl!tl lTal and until hl!rnill ion i. ditTi~ull .. hen dysl\.lncti!>n ruche. Ihf- midhrai n 1,..1 gr below. Predielin. the roeatlGn a rthale4k)1I bAM<! on the m._. hemiat.lon ayndrome ill unreha ble. Clinical c horacteriat iu d ifferentiati"'i u ",c.a l from ctmtrlLl h e rniation dt\:reaH<! «In.c1ousneU«Cllr. early in «nt ... 1.... rnillthn, late in uneal uma! herniation IYIldromll.r.JJaiy giVell riM t.o d-"w:ate poiiturina: NeUROSURCeRY •. c... '" Differential di agnosis of s up-catentori a l etiologies L 2. 3. 4. va8Culu: CVA, intracerebral hemorrhage, SAH innammatory: cerebral abs<:ess,lubdural empyema, herpes simplex encephalitis neoplastic: primary or metastatic traumatic: epidural or subdural hematoma. depressed skull fracture COMA FROM lNFRATENlORIAL MASS NB: it is essential to identify patients with primary posterior fos~ IKions (lee To · bit 8·4, page 156) u they may require emergent surgical intervention (Iff poge 772 ). Etiologies of infratentorial m ase L vascular: brainstem infarction (including basilar artery ocdusion), cerebellar in. farction or hematoma 2. inflammatory: cerebellar absceS$, central pontine myelinolysis, brainstem encephalitis 3. neopl"sm s: primary or metaetatie 4. traumatic: epidural or subdural bematoma HYDROCEPffALUS lnfratentorisl masses can produce oblltructive hydrocephalU$ by campreaSing the Sylvian aqueduct andlor 4th ventricle (Iff page 404). UPWARO CEREBEt1.AR HERNIATION Occasionally lOOn with p-fosla masses, may be exacerbated by ventricul ostomy. Cerebellar vennis ascends above tentorium, c:ompreuing the midbrain, and p<I8J1ibly.,.,.. eluding SCAs - cerebellar infarction. May compress sylv-ian aqueduct - hydrocephalus . TONSlliAR ffERNIATlON Cerebellar tonail s 'cone" through foramen magnum. compressing medulla - respi· ratory arrest. Usually rapidly fatal. Otturs with eitber Supra- or infra·tentorial masses or with elevated 'CPo May be precipitated by LP . in many cases, there may simply be pre$9ure on the brainstem with· out actual herniation', There are also cases witb significant cerebellar herniation through the foramen magnum with the patient remaining alert'. 8.3.1. Central herniation AKA tranatentorial herniaticm AKA tentorial herniation. Usually more chronic than uncal herniation. e.g. due to tu~or. especially offrontal. parietal or occipi(allobe •. The diencephalon is gradually forced through the tentorial incisura. The pituitary stalk may be sheared, ",,"ulting in diabdes insipidus. PCAs may be trapped along the open edge of the incisura. and may occlude producing cortical hjjndness (see BliJ\dnu, from hydrocep/w.11l8, page 202). The brainstem suffers ;"chemia from compre!!5ion and shearing of perforating arteries from basilar srtery - hemorrhages within the brainstem (I)"...,t h .. m" ....h .. g .."') CT or plain x-ray criteria Downward disph.cen'ent of the pineal gland may be demonstrated '", Perimesen. cephalic ei&terns are compressed. DIENCEPHALIC STAGE Early_May be due to diffuse bilateral hemisphere dysfunction (e.g. from decreased blood flow from incN!""ed ICP) or (more likely) from bilateral diencephalic d)'$funtion due to downward displacement. This stage warns of impending (irreve",ible) midbrain damage but ill frequently rever$ible if the cau"" is treated . ". 8. Coma NEUROSURGERY COi'iio.igalf'o:iiligll1fiOMiiOml tIM"'il 'Yen w:,ugaie t!iiiT&aiiStem 11'.l:id. OSU/IRVIiCiSib\ie i OO!..L'S EYES and conjIJgaltl ipSiIalMaj response LO OJI~ w~tGfealctb (CWC~ ImpaJred III)galt! _ to corrcresOOn 01 SlJPllrior coIIiaJ~' lina di8!\Oellha1ic pt(Ite<:Wm (Pariodli Ii)'l'l~romeSllflpa~86) MoIor a-"f"pjjlopOiajilii~~liSelO r.o~6itiIe"""'iirBitiiiiil<j. iiiljiiitiil!ili (paralOnic .. ' iiS!anu). II pltVicmly hemlpar~K:conl!aralelallO lesion: ma'J I'oOfSoefl. h~ mo!lonlessness &.JI!.a5P ,~, Ihen OECOATICA!E (rilia/Iy ~JiIltira.!.!<' ~ n~_caS:!'.5~ l MIDBRAIN - UPPER PONS STAGE Wh&n midbrnin s igns fully d ..... eloped (in adulu), pl"Ojj1\os is is very poor (extnme is cnemia of midbrain). Fewer than 5% ofcase:s will have a rood tf!COvery ifl"'H tm ent Ie successfully IIndertakl'II a t this st8g~ . Aespiii1loiip~ ~ """"""'in panlinll lllmo"noge poIlPQltlI PllPis lQIIItat IIKaus- I'" 1M$0I sy""",l~ C5 ""'_IIIePllr~l­ In n~mill\ron. 1M f'II!I,.yrn~lh.tIcs ... USUAlly 10$1 , too (3nl "'''''''1,*,'11) Ic!I Uf'OllllllS8<l. _<OM LOWER PONS - UPPER MEDULUoRY STAGE ISIOW, Ifii'9Ular r~lti arid deillh: Siijhs/gasps. !Oocasionilly /lype1)lOU I llelOlt!og OoTaleMdityWilh~'" - ============ wl\tl apnea OUTCOME AFTER CENTRAL HERNIATION In a series of 153 patl"nbwith sigNlofe(!nlrai herniation (altered l..... el ofellnlicloU$IInss,ani!!OCoria orf",ed pupHs.aboQrf!Ullmol.or fiodings) 9% had good recovery. 18~ had fun~ional out.come, 10% weI'\!! wverely diubled, Bod 6O'l> died" Facl.ors fls&ociated .... ith II better result wera young age (eapedally age,. 17 YJ"IIJ. anisoeoria with deteriorating Glasgow Coma Score and n<.lnflaccid motor function. Fa",. lOra .... soeiat<>d with poor oukorneo weI'<! bilaterally fixed pupils, Wilh only 3_5% orthf!Se patientl haYing a funct.ional recovery. 8.3.2. Uncal herniation Usually oc<;u,.,. in Olpidly expanding traumati. /oemat.omal. rr"'lue utly in thalateral middle'{08'8lI Or tfimporal lobe pUHhing medioJ unn.S and hippocampal gyrus Over edge of tentorium . 0D trapping tbird nerve and direetJ,y eornpre~Bing mi~brllin . PCA DUly be !>c. duded In with central herniation ). For CT criteria se:B. below. Impaired consciousoes5 ill NOT a reliable ea rly sign. Ea rHut I:OnSi9tolnt sign: llOi· lat.erallydilatinr pupil. How~ver. it is W1likel, Illsta patient uodergoinr e8rly unca l he ... niatioD would be completely neurologie.ally intaet ex~t for anisoc<.>ril (do not dil;mias confusion. agitation. etc..). Onoo b",ir.u;w,o findinga app"ar, deterioration may be rapid (deep coma may OCCUr wlth;U hounot CT criteria" Tentorial incisura surround~ interpeduncular and prC-pOntine cisterns and b!"8 IO' stem. There is gteatinterpersonal variability in the amount ofgpace in the incisura . Impending- uncal or hippocampal bemintion may be indj~ated by en<,:r08~bm~n t on NEUROSURGERY 8. Coma '" lpterala sped ofsupras.allar cIstern - nMterung or normal peuLIJgoIIP I ~ hape. Once herniftt.ion OCCUMI CT Dlay "ho ..... , brail'lStem di'& pl at~ment and natten;n" coroprellSion of tont ralateral eerehral peduncle, midbrain rotatilm with sligh t i~ase of ipsilateral s ubarachnoid spate. Alii<), ¢olltralateral hydl'Ol'ephalus may occur". Oblitern tiol). of par8S1!ll.r a nd interpeduncula r cisre" •• ~rB as uncus and/or hippocompll. are ror~ed th ....ugh hiatus. BrainBtem c,ompres!lion - AI' elongation. Since du ral s tl'\.lcture, enhance ..... ith IV contrllBt. thl~ msy be"SEd to help del ineate tentorial IJ'IsrgiD,S .... bell neC@$sary. EARL Y THIRD NERVE ST.AGE (tj:QI A eRAlHSfEI¥I FINDING, DUE TO 3AO NERVE:: COW'RESSION) LATE THIRD NERVE STAGE Midbrllin dysfunctioo llCCW"S almost imlJ'ledjal..Jy aJt.er symptoms extend beyond th06edue to foc.l cerebral lesion (i.e. mayskipdiencephalicslage. d~ to lateral pressutE on midbrnin), Troatment deJ a}'s may result ill i~versibl e damage. From Ihi~ point ,,"wanl . the unM I synd ran... is indis lingurnru.ble mill untrnl herniation (u<! aoow). 8.4. Hypoxic coma MOllie eneephRlOptlthy rna)' b. pO.) or a.nemic 1I"."tia (following e..'(du. 10 .... 0 • ....,;" auo.i .. (drop MyoIn IIDnguination or canl iac IIrreat). donU! i. commlmly seen. Pat hology: Jesiona pre-dominate in 3rd oortica l loyer (grey ma~r): Ammon'. 110m ~ 1.1110 vulnerable_Whi ta me lter;1 u~uaJ1)' better preserved (due to lower 0 1 requirement) . In tht bani g.nglia (8G ); enollernie anoXil eave",]), affects globus palHdu.; " ""mie ano..u a aITec;ts th e caudate nucleu s and pUI8Ulen. In the eerebeUum. Purkinje «1I~, daniel<! nucl ei. and inferior olivea er& affected '" 8. Coma : '~'~'~.~'~"~~;~~~~~~'~";';'~'~'~'~'='~~~ NEUROSURGERY Mu Ltiyariate analy"s yieLds (XIt· come prognosticator'll shown in Tobie 8·:; &06 Table 8·6. NB: this lI.Oaly. l, ~pp1ies on.1:t to hypo,ao;..ischemie coma'· More r~nl6tudinwnfinn the poor prognosis of ..mrellct;ye pupils and !ack-ormotor ..,sponse loG pain"; if /lither orthese findi np 8M $/len within a rew houllI lI.l'ler cs,rdillO!aTTffl tbfte ;11. 8n 8O'lI ris k ofduth Or permanent vegetative I Ulte, 8nd if present at:1 day. these th'. r8le t(l9f 1(1100%. Clurocortiooids lau-roids) hllY~ ~n ahown tohll.Y81\O bt:neficill ~trKt on ~ urviy.! TaU- or neurolog'iC<lL re<'(IV~<:Y rate al't.i:!r cardiac: al'TV!t!7. Ta ble 8-6 al>b""vlat;o,u,: \Oo?iL .. ... 'lhin no""oJ Il",H••• GCS • GlUt_ Com • .su..101''GCS-<IIO\<I<' nk .. Ie lIN IIIOICT ""..... .J: BOM • ".-craocula< mlUC.!.: 8.5. References t..-loItC.J .. _ R. ... " ...""' .. of ......... PAI' ... _ _, ......... JITXU<o.I-. ,,n..... ~, ":! 11"' , 19"). >. V',_ A B. H"'Y" R Il!C""'V.o;)" ............... .,,'''',,, I/w 1onJd.J";""" p<1IWoI I. 1'I'~roI"'''' ..... ro . . y'l'R K. Wi"",,,,,, J E.on<! Povl"""""l J T.(*") MoCro",!.II;U.N, .. v .... l\I96!pp 1,9- ,. • , , , II",," V l.aw..,C.YonIo<l M J,,,IM. ll00d <0)0. 1,<1 In <M,n. "_ loS ""''''M of 'P' 1:l<mocr" s>Ily ..... ao"' ...... C~11<II " .... S)'>. 4: 'l-'...q).I9U. lI.op!"" " Ii; l.Il.-ru d..,....""'., of II... ."..;" oM 1<.. ' vi COlI"' .......... ,n ~"1<n .. w;lb ....... N hJl J M... ) \ ~ . gH· I.I~ . P-c>ri<tCM· s.... ........ opN!\o\tnelotlcol_ ,;.,. •. J ""'..... No........." . 1'<)<1tio'r) XII )1J·~2. "<"""""...,...." •%, a..."...-uw.2uOS V...l6oolAlltJI ..,in .., .... ",..,po, ...... ,.,.d ,..." .. 46' )6 1·), 1W9 fi",...CM """"1ni.I>&ni,....., .... ........... _. .. pt . s.... N• • rnk>tl' " 0\ 1·11. 198-1 . _f._.JII.Th<d....,...."'''.po<ond <Omo F ... D.t .... P~il .... l,.,i •• l..:J 011,. \OIJO;pp«J. ." •• • AIII<.C M.PI<w EH . " - .... "81~ ...... <hJ · "',..."...., ",,_,. , "'".,Iy",. o;_fl..pd /'I...., M,", Dis 100 n ·n. ...."'.,_.'.J NBul/OSURGERY '" " " " " " ., n J9U. H.... r. c..... yI cr"""..r.. _ _ ndl •• ,,,,,,.. _1,,,,.1Il>0<l. A... J N.."or1>dIi>I6: ...... '. 1~8J. "'odrc"'" B T. PI&> L H' FIoO<1iato>, <K<I.<t}or... "",,",oM! ~"'ion. J'I_fIH}' 19l :!ll.,JI.I'Il1 0<b0n0 ... G: DL,.<>OOi<otda<.""", '..............1 "...,....;0: _by <,..j/llC1".Ilod~ IJJ, ~J-6. I~n 5IOYn., I, o ..<-,i", .......,/11 ..... ,.,...,: FUId" "OII«><" pYldiu<1l...,."".rb, !'Itu'.... dlolor;r 14, 101·f. I!fIT. Me"fo_' W, nf!O< J C. B_ W H. "..s; E.< · .....", ... <N .... r. Otoot", ....... OIl !~,~ _ ....""'" 167·n.I'lfI/). D f ,c..o... 1 I.S' ..... 6 K.m./J l'I«iico<o1 ........... r_..,·p<\I""l\co..nl< COOI"', JAMA 253: L<., 1~1O-6.19t) ~EG I, .II ... RI. S,"".. _C,.." .1. ' S,.,.""'o<,....k"ofeotlJ'pttd~GI __ ""I<""' " ,•.,.,.io>--«<h<",,,,..,.... u..:.. JSl, IlIOS--ll. \991 . ,..". ...... M. ' '',/Io·T,..!! K._ v ..""", p." ..s. O_ialldIlUlmmlClod _ ............ I""inl _ . " iot ...... ,", <.. d,,,,, __ J AMA 2~ ' JoI!1·JO. 1919 8. Coma >OJ · ~ - " - ~.- '. ... I 9.1. Brain death in adults MOS1Uates l<C«pllOO1efonn of "brain death" asa valid detennination of death. The President'a Commiu;on proY'ldes the following guideline5 L: 1. the diagnoBiB ofdeath requires both ceBs8tion offunetloll IUld imlvO!rsibility of ceuotion ofeith<!rca rdiopulmonary 8~tem orfnlin broin (including braiDilteml 2. for Bge < 5 yean. _ cUrtlll in children. pag~ 167 3. with no "eomplicatillg ::onditloDP" listed below. there 8re· ...llo eases orbraill rune· tions returning followmg a 6 hr cessation. dDl'umented by clinical examination and eonfinnal.ory EEcM 4. with cnnditilll18 such 8S massive intrllcerebral tumor with hemiotion Or gun!lhaL wound to the helld , it II possible 1.0 pronounce death sooner with more certainty than. e.g. with pclL5t ""rdiac-urTe$t anoxia Or foUowing B toma " funknown etiology 5. wheo death re8ulLi from criminal ISlIawt. or tbe .... ia the poasibility oflltigatlon l"'I"f!arding the death. extra care must he Liken and legal counMlJ rnay beadvisable before rooking the determination of brain dCllth a""'n BRAiN DEATH CRITERIA lWcommendatlOD sL. ' : 1. !lbsenc&0I DrI_irISIem 'elIeUS A. absen'-"!of brai"8Iem refl ca·e.: A. liud lll4"~ t. lXular eumination: 6 BbsenI comeal relle.(eS A. rlX~d pupila: no ....~Pllnse. to bright light (tau: ion alter reaus, C. absfnI OC\IIOYestIWar ~tle~ citation: H e bflow). usulIlly midD. absenI ~hallc po!Iitiou (4·6 mID) bll ~ may VB"" E. BCseoI gag &. w.; gil IeIlel: 1.0 dilated rlngeB (9 mm) In size 1. B. abJ;ent corneal Taflel"'I!lC 3. no r~ to d\'ep~ pain C. abHnt lXuloc:..phalie (doll's 4, 'oi\I1~ eyes) reflu (coll lrain dicated If C·spine not elesr edj, _ {XlB" A. tori! temp > 32.~' C (90' F) /58 B. SBP '" 90 rrrn t'Ig D. ,b....moc ulovQ tibuJllrren .. '" iccld wewr ca Jo rl ell): it1lltill6(l.. 100 ml iea water into one eaddo not do ifTM perforal.ed ) wiLh HOB at 30' . Brsin death is e~duded ifan), sya moveroent (... ~ IJ06('. r58l. Wailalleut 1 minute for responBII, and::t a min before testing the op~it' side 2. absent oropharynC .. a! ....1'1,:< (gag) to stimulation of pDJIt.erior pharynx S. no rough TeSpOnsa 1.0 bronchial auctloning B. a pnea leat AKA apnea c:w.Uenge: nospontan~ou~ respirations D lifter diSCOM&L:!tion &om ventHaloT (aases_ function or ln.duJla). Sioce elevating f'aC01lncrease.ll tCP whl~h oould prec:lpi tate h<irn.i!ttion !tnd vuomotor ;n5tability. thi~ test ahould be,..... IGrved fa, las~and only uled when the diagnosis of brain death;5 reasonably certain. Guidelines" · 1. PIICO, should be:> 60 mm He wiLhou~ reapiTation$ before apnea can be attributed 10 brain death {ifpatlent d06il Dot breathe by th ill point. they WOn'l brellthe at a ,.!le.o .... ' .I.. no<e: EEG .. J!PI "'.1\11. 10'1..... ...... ,~_ntkd """""', ..... ~ .. . pop 16:1 B. Cl M ... I-rmp. ,heli. p. thw.y. ... r ' ..... in "' ... " C. cornul ... ~.,~. d<lO,nllO ctl:I>O.1 lnaud . ..I1 . IIa"Lul.' .... o .... pi"''''''''' ... dtr",od u abel"",,,,,,,] or <be" ~L<C\UII""" th., po'<IdLKf IhIon r. . ny '1LLoe$"Gn • • ' p'n>moler "'.Y ~ conn"""" 10 II .. potkn,' '" 9. Brain deaLh .<Wq""'" tid.1 vatu",..; If NEUROSURGeRY 2. 3. 4, 6, 6. C. no high". £'aC0 2; lIot valid with aevere COPD or CH F) t.o prevent hypoulIlia durin/: the ~t'w:il.b. tho>.da.ngerQf cardiac- 8l'ThythmI~ or myncardilll ,,,fa rtl;on), p~e th! te!! with 16 minutes f>fwm tilation w ~th 100$ 0, prinr!.Q th .. le!!t, a.;ljual the ventilator W bnng!.hl! PaCO, 1< ~ O mm H~ (to ~hOrWn lh~ teat time and t l!1.L8 reduo;:e th~ n.k of":lypoKemia) during the len. hay., p!l8IIive O2 fi()w IIdmini5!.ered at 6 Umin through either II pediPirie-oxygen cannu\anrll No. H Frencll tracheal suctioncathcter (witb tlleslde portCO\'end with altha.lve tape)p:lped r.o the estimated 1@~1 of the carillll etllrtinl from nOmlOCRpnea , Ule aVeJ'lIge tim" to re8ch PaCO, '" 60 mm Hg is 6 miouteM (cl9S81~ tuelling is IhIIt raC~ rises 3 mm Hglmin, but ill act.uality lJtia nne!! widely, with an average3. 7 2: 2.:1'; or 5.1 mm flr/min ifst.8rting III normocarbia'j, Sometimes allong os 12 minutes 1Il1I)' bee necessary the t.<'1;t aboJrted !»"emlltu",,'y if, the pa.t;en: blllat hu: iOCODlpatiblf! with brain deflW significant hypoterll!ian {)<:Curs If0 2 uturation drOPfi below 80% (on pul!MI a>dmeter) significant cardi"e arrbytlunias IICCUT U' patient doea not breathe, lend ABC at regular intervals and "t tM complet.ion often rl'gardl~u ofre!l.8On far ten;ainatian.lfthe pa tle.:lt doe3 nat breatM for at least 2 minutes!l.lhr II P/ICO. > 60 mlf) Hg is doc:ulI>en:.ed, theo the tnt i8 valid and ill compatible with brain death (irthe patiMt is steble and ABCs resull.!o Ir~ Ilvailll.blewithina few minute8, I.h~... pnea challenge may be IIOI'Itinued whiJewaitin\! for Tl'suJt8;n aase the PaCO. 'i C 60) i fPaCO. atllbilii:es be low 60 wm Hg and tb@pOl rem"in.adequate,tryreducing the plIIS!!ive ~ flow rDte .ligbtly motor function u. ""'~::?;~~~~':'i~J;:~~~:~post uring Of seilure8 afE, intODljl8tiblfl with !hOldi. 2. I . :' 3. o. I. • Ii .1 3. <. ; ; 5. 6. E. I. ; II condition i, a single valid brain 2. NEUROSURGERY 9. SrIOio death '" 3. ifan in-eversibJe condi:ion ;1 well establiJibl'li Md no clinical confll"lllat.ory tntl ...... ..ed: 12 hou", 4. ifdiagnoosU i. ulll'Utain and nO clinic.1 confirmatory ~I.t: 12·24 bour. 5. if anoDe il\lul)' ill Uw! mu~oCb~ain deaLh: 24 hou", (may be . homned if ce.N· tion of CBF ic demonllnted) CLINICAL COtfARMATORY TESTS CEREBIMI.. ANGIOGfY..PH'f Crit.lria: at.ence orinlJ"atrallial now al the level o(the carotid bifurution or eircl. of Willi,'). f"ill.i.al o£lbe supe rior "giual . inu. 0fX\U" in a delayed (a,hlon. lnt.lroblerv<!r validity hIS not Men . welied . NO!. routin.ly used in the diAlIlllllil ortx-ain dn lh, but IJI~ ba emplO)'ed in difficllll . ilu.tio .... IQ.., EEG ell! ~ do,", III bedlitl... R.eoqui... . .,;.nced int.lrpretar Don not del.a(:t brain. • t.lm artivity. and elec\rocerebr.l.il.nce (ECS) d ... not oelude the pouiblUly 01 ..... venibl. coma. ThuI, I I leul a:..bmu:a ~rvillon if, n!()Ommendad in cortiUDc;tlon with ECS, U.iDg RCS . . . cliniu] Ql)nUru'lltory t.I, t . lIould be doni only in pui. nu without drug intoxication, hypoth~ru'li. , nr . hoek. Definition of . leetl'O«lnbral all.nee 011 EEG: no elec:triwltCfiYl t)",. 211V with th e following rtquirelDl!nt.l! reeord inll'r<om ..ealp or ref. rential eh,,: lrod. pair. I 10 au apan 8 1C81p .Iectrodes and eat lobe Alr-renot electrodn int.er-elec;trodt! relilt.a"ce '" 10,000 Q (or impedance <.6.000 0 ) but o.. er JOO 0 ~n.itiv;t)' 012 \,Vlmm time oont\.Mnl.l Il.S.0.4 lee for pan. orrecotditll no rQpOn ... 14 , timuLi :PII;n, noi&e. ligh~) .ec:ord '" 30 mini ri!JM!lt EEG in doubtful ~o_ q".lified t.eo;:hnologi"U. lUld el~troencepbDlor... pher with leu EEG experience telephone lJ"an.miuion not pe.rmiuible TRANSCflANlAl DOPPLER' t. IIn"U peAk , in early iystole withDUt di'itoli, flow 2. fir reterbe.ating now (indica. tiye of tlfnificanllj Inereased ICP) i"iultl "bllence ofdnppler ,ignal. cannot be UIIM U cri!n"1a for brnin d~ath since 10'110 of palIon II do no~hl'" temporal lS()nPtion window! CEREBRAL FVoD/ONUCLIDE .foNGIOGRAM (CRAG) Can b, perfo.medllt the bed"lde with a general PllJ"PO'M! Kio tillatlon camera wIth a low enerl,)' collimator. Ma.\' not det«l minima! blood flow 1.0 thl brain. esped,l]y b.min. l!.em, the ... fo ... i.hwu:J. obsen·lltion in cortiunction with CRAG i. ~ed un.leu there fa • clear etiology of o"erwhehnilll br.in irtiury (11.1. lnIlSlii .. e. helllorrh'g' o.r CSW), May be ll.O~ruJ to conlinn dini;a) brnin death in the foHowinl"u.inp; I . where complicating conditions are pNlSent, e.g. hypotherm ia. h)'pOleJaion (e hoci<). drug intoxication 2 . ..,veN:' racial (numB where ~u lar findlnlllQ.lY bt difficult 01 con~lnl 3. in "",tienll with "'vere COPD or eHF when apnea teating mill"! not ~vRlid " 1.0 s honAtl th~ observation Jl'l'.riod. " pt'Ciolly wheu organ don' lion i," poIIsibUi t)' Technique 1 acintiUation came,. fa poIilioued /iI. lin AP heAd and nKk view 2. i~ 2Q..30 mGi of99",Tc·labeled _rum albumin or perte(:blletlt.e In a .. olum. of 0.6--1.5 mllnto a proxlmlll lV pOrt,ora ~ntr.J Une, f<lllllWed by I SO 101 NS nU lh 3. perforut H ri,l dynawle JlDage. It 2 _1>11 inteJ"Y,I~ for. 60 JieCOnd, 4. then , ooLDJII , talit IUlagas with ~OO,OOO flOunlll ill AP afld Ihll" I.tera] "I..... lit 6, 16 .. SO minute. after lnjection s . ,f a "udy need. 1.0 be ~t.ed beeaUH or. p .."",uI no,,-dla~tJc uudy nr .. previOWI euDl inoomplltibll. with brain death, a period of 12 houn should I.P'I~ '" 9 Brlin death NeUROSURGERY Findings No uptake ill brain pllni!oohyms 1I<lUow $kulJ phenomenon- (_ FilllJ.~ 9Termination ofcarolid circulation lit the skull bass, lind lack ofupt.ake in the ACA and MCA dislrlbution5 lab:lent ·oan· ""labrs efTect"), There may be delayed or faint visua!i~ation of dural venous ,;nuIIlS even with brain desthIJdufl to oonn""tions betwf!f!n thfle~tnocr8nia l circulMtlon arid the vanou s system . E n SSEPs BilAteral abseocaorN20,P22 re· sponse with median "'Il'\'a stimulation, ATROPINE In bra in death, an amp ofatrop,n8 ( \ Oli) sbould not sITed. the hellr! rllte due w the absence of "a gal t,;mel it normally in· crease the heert rate). Although atropine in usual dOM!! doolll>Ot ""use pupilllll")' dililtation'''u, iti, prudent to '!)Carnine the pupils first toeliminatl! uncertainty, 9.2. Figure 9-1 "Hollow-.kull" algn on CRAG ISLOIIc: AP _ W<enl~ .....".. .~.er IrIjecdon) Brain death in children Criteria for death : ;:'ravarsibla loss ofcardiopnlmonary or enUre b""in fUnction 18f1 in adult), but the (clinically unproven) auumption that (I child'S" brain it mor<! resilient lllSul!. in ",ore difficult determination ofb",in death , The foll.,.... ;ng guidalin.s U1! propo6ed for Pflt;enlll -< 5 yra age'" thesa re<:olllmendat;onB are not applicable for the prelllilture.lnfant determination of proximate cause ofllOfIla Mould be made to ~lUIur. abRonte of ~medip.ble conditions: especially toxic and metabolic disordert, sedatives, para· Iytics, hypotharmia, hypotension (for age), and su!Vically tNlltable conditions criteria, A, com" and ap nea must couist: includini complete loss of ron!lciousnau, vo· UliUllion aod volitional ael,ivity S. absence of brainstem function 1. midp<l8ition or fuUydijllled pupils, UMeIIl"",si"" to light (RIO drug ~f· fect.!l ) 2. EOM: ab8efl~ ofsponUln80IUI, doll's eyt!8 and calorie DlQYell'H!nts of .,~ absence of buLbar mU8Cui.aUlte movement: including oropharyngeal lind facial rnu~cll'll; absence of corneal, gag, \lOugh , $uck, lind r!lOting reflex 4. llhoien"" of ro~pi ... tor:v movem0at (usually tl!;lted alter other erilens met) 5. flacci d tone aod ahoieoceof5pont.aneoua or induced movemenUi (spinal myoclonus and spinal \lOrd I.llOvemenu, e.g. renex withdrawlare not included) 6. examination r""ulb should remll;n clllU"leZl~with brain death t.hrllughout observation periOd observation period~ according to age, A. in nawborns born at or art.er term (:> 38 wks): 7 days B , age 7 days · 2 m(llS: 2 l!Jl3mination.s and 2 EEGtl48 hn apll.r! {repeat ualn unnOOl!5Sary ifcerehrnl rlldionuclide IIngiDgl"Bm (C RAG) (ai .. to y;suali ZOl cerebralllI'tl!riesJ C. ai" 2·12 nlll~: 2 ua..rninatiofUI and 2 EEGs 24 hn apart lr"peatexam unlJ<'<. essary if CRAG negatiw) O. ai"" 12 mO$: if irre"ersiblt \lOndit;",n ~~iBt~, labora\.Ory tesling is nnt nee· 3, NEUROSURGERY 9. Brain death '" usary, and 12 ~n observat iOfl is sufficient (undesr conditions, especially hypoxic· i&chemic encephalopathy, are difficult to assess, and 24 hra obser· vat ion is suggested unless electroce.-.ebral s ilence Ofl EOO or a negative CRAG confirm dillgllosis) confinnatory test3: A. EEG: standard .-.equin:'ment for 10cn, electrode distance<SU!X'llt 16n may be decreased in proportion to site of bead B. CRAG: applicability to patient" 2 mos age unproven 9.3. Organ and tissue donation State and federal laws require families of individuals satisfying criteria for brain deatb to be approacbed a bout the po$sibility of organ donation. ~'acts that may be con· veyed to family in order to help their understanding about orglln procurement: 1. any Or allauitable oTgaJl.S may be individually specified for donation or t.o be ududed from consideration for donation 2. organ procurement may be done in such a way as not to interfere with an open casket funeral (Le. disfigurement can be avoided) 3. families tan receive infonnation lUi t.o tha ultimate use of any recovered orgaJlll 9.3.1. Criteria for qualification for organ donation Ge n era l el:(l lusio n ary criteria for organ donation (modified") l. infection A. un~ated septicemia B. the following infectiona or oonditiOfla: AIDS. viral hepatitis. viral encepha· litis. Guillain ·Bam ayndrome C. current rv drug abuse D. activeTB 2. malignancy: brain tumors represent JlOS8ible exceptioJl.S ('ff ~kIw) 3. relativeexelusions: chronlcuntreated HTN, hypotension (desired SBP> 100 with normal CVP) 4 . dise_ of the organs coosidered for dOJ)ation 5. anencephalic newbom~ : recent consensus is that the functioning brainstem in these inf8J1tJ; (e.g. spontaneous respirations) di9qualilie~ them froro the diagnosis orbrain death (furthennora, few such organs would likely oonefit others)" G uidelines for inclus ion (some recommendations from refe rence" included) These guidelines are constantly being revised . in part due to '".proved results with the use of cyclosporin in recipients. In general. consultation with. a transplant coordina· wr ia recommended to determine appropriateness of donation . 1. brain death in a prev ,ously healthy individu~1 2. organs: A. kidneys, age> 6 roO! (because oftize). Normal blood pressure, BllN.serum creatinine & UlA. No S I..E (because ofposllible lupus nephritis) 8. heart and beartlluolr. ageideaily" 40 years for males and "45 for females (above these ages. a cardiac catb i8 usually performed) but up to 60 yrs may be used depending on condition of heart and potential recipienta). Euro by cardiologist ind ,eating 00 heart disease (cardiomyopathy, valve defect. reo duced ejection ('-""tion. severe ASHD. SIP CASG). No roDM C. liver: age > I ".os. Nonnal hepatic fuTlCtion (nonnal Or acceptable AST, ALT.I..DH, bilirubin (direct , indirect & total) 8J1d nonnal dotting studiea) wit~ no history of liver disease D. pan cre as: age 15 - 40 yrs . No history of disbetes. Nonnal serum glucose and oroylase 3. tissues : A . J:lI.m9!: age" 1 yr. Neither cancer oor sepsis di5Qu"lifiea (rabiea and CreutzfeJdWakob disease are contraindications) B. Din: "ge 15-65 yrs. E~c1uded if cancer C. il®l::; age 15·65 yrs . E~duded if cllncer D. bone marr!lw: age ~ 50 yrs '" 9. Braindeath NEUROSURGERY E. hgart valves: age" 55 YI"II 9.3.2. Organ donation in patients with brain lumors Asnong patients with a hrai,n tumor: 1. those that al1llll!t tandidnIQ fOT O'l[1Ul donotlon : A, meta"talk tumol'll to the b ra in B. brain tumcr~ rnat hllve been manipulated (biop.sied Or I!:lcised ) C, p/ltienl..$ with br/lin tumor" who hlV(' been 6h..."ted 2. tholle thAt m;ghtbe candida~, but eonlide.eII higl,..",k donora'" indude p,;p"IDtitd: A. glioblaslOtnIl rtlultifonne B. a naplastic astrocytoma C meduUnblBllOmp 3, unmlln;pulpted tumors that might not be considered high nsk A , henlsngiobiastnma B, meningioma u.nma:. Optimally, ifno mela!l!.ll.seSOI1l seen on CT,chest, abdomM lind pelvie) And no meu are found /It tune oforlClin procurem~nt, a brllin bioP"Y would beperfo,m"" II..fl&t Lhe 01" gan , aTil procured li t the same anesthetic bnd the organs would not be ~ele3Sed' until the biopsy prove... which of the 1I1x we o:IIU!gonl!.!l applle.s , 9.3.3. Management after brain death for organ donation Note: OnCe b""i n dea th 0«Un. cardiovBlIC ular instability aventll.lly ensu e., genef'/Illy within 3·5 dayo, and management with preSSOI"ll; 8 u"ually requinod. Fl uid and elKtrolyte imballlnces from 10M of hYJIothalamk regulation mun be non:r"dl ~ed.ln eQme instanrtlS a beating·beart cadaYH can be maintbined for months". 1. ~osent: mustbeobUlined from donor'. legal guardian. NB: mUlltala<) be obtaoin<!d from nu:dical examiner'or coroner's office foraiJ cases under their jurisdktion (in n'IOI! t 5tPU!S. death llISulting from accident, within 24 hI"! or hospitalization , ec.t'. ) 2. ~iQ:ned noU! in chart filatingd3t.e And tim .. patient pronounOO<i bTlin deBd 3 , oontact traru;ph'f]tcoon!inator 3t earHe&t pn6Iible time 4, ween from yasoJll1!BIOTI ir possible, Control hypot.enail)(l t.l)cough yolum. upan· Irion whenever I""uibl" (after brain dealh, A1)H p.oducliof] ""a",," , pl"D!;luclng di· abetes ;Mlpiduft with high urine oulput, thU! ~pious tlilid ad.nunist.ratIOtl i6 BntidpaU!d (,. 25().500 mUbr 1$ common). MOAt cenU!rs [,refer AVO IDING l!lI:oge- 5. nouo ADH (vasopreain (P;lreMin®J) if J1OSs1ble . ;nett th~ ri8k of renal s hutdown increase!. i n brain·death A. start with(:r)'l l alloid (05 V4 NS + 20 mEq KCIIL is gtntrally a good choke a ln ce. it repl~teS frO!t' water}, replace urine t'C for « plu. 100 cdhr mainlA>.nance B. un c>olloid IFrP, a lbumin .,,) if unabla to rnalnlem BP by replacement C. UIIe V"Opruso ", if 8tiU hypotensive. Start with low dl'lSll dopmrn;ne, h~ c.... a~e u p to - 10 l'gikg/min, add dobutamine ,(still hypot.enS;VD at this d!l!le O. If UO;s still,. 300 mUhr afte r above lIleaSUri!$, U!iC ADH anlliog ' aqUfOUli v8llo prea:l i~ (Pitretl>in®J i. prefem!d over DOA VP to a void ren8J. hutdovm ) thyroslobulin given TV convertl50me cent from anaerobic to ,,~robic rneta\lolillm which rnay h elp .. tav~ oll'CIlrdiDY3i1Ctlla. collapse LABORATORY EVALUATION U Gel)er a l iDitiallabll I. 2, 3. serology: VORL ~r RPR, H8&\(, HIV, CMV,ABO blood group, HLA tiS8ue Lype dtellli,t.ry. eleclrolytes. gJUCOOle, BUN , ( reatilline, cal(iulII, phOllphate, liv~r f..."I:' t ion t.ests, U/A ( unn~ D.nD!y~i$) hematology: c ac , PTIP1"r to" A, h,fb ·rlok ."...ns ".1 b< OOlI.id<rtd For I,,·., IntUIpl&l1\O in p" i.nt • .,ho .ro "''1 t_ "" the U.ndul l.o "ii ... h<'P.I«t\l~I.r 'M~' NEUROSURGERY 9, Brain deaLh ". 4. microbiology: blood, urine II l1d sputum cul t ures; sputum Gram stain Kid ney donor l. 2. in addition to general labs (s« (Zbo~). check BUN & creati nine ~ q day check electrolytes ~ q 12 hrs (m!l(liry as appropriate ) Li ver do no r l. in adwtion to gene ral labs ("'eabo~), check LDH, AST, ALT. bilirubin (di rect. indirect, and tota l) Heart don or 1. aU require an echooardiagram prior to don alioo 9.4. References ""......... Comm,..'" roo III< s..~1 of !;lll i<ooj , ,. .. ,. _ " " 10 M«I"I ..: C"jdoh ... rOt'~ "1r>1II;' ~.\6; 118H•. 1981 . Qualroy S~. 5"1><"",,"",_ or <h< .. """"'''' ...,.ooI< .. y of N<"tokIcY: 1'\W;1ic<~ .. I", de. '....,; ...1 tIftIm"""" ,~0<I0 1.. (•• mm..,. ...... "",,,,). N< ... %c 'J: lOll". 19I1S. Wodr<h E F": 0dem>i0I~ 110>.. _ .. ""'11 •. N...""",," 45: lool-II. I99S. a.~ .. I EC.O .... CO. _ "l A. ,,0/ ' Tho "I'nul<>ll""he .. ' ........ ionolln'n<le;nl>. J s .... ......... 71: 191". 1939 a._I EC.Mu.l\bltmJ !'.CotHa:! $ ... <>1" .. pne. .... ,.. I", III< _ " " , .... orl:l<>in ",.,h. .!. """,. ,/icd """"""'.J N"''''''"'I 76: 1:»9·)1. 1m . I... 1.1': Sp;1I.I1 ..11<><. ill ~ ""-"h. 'V 1): 6,.;).2. 197). T""""I.!.. Ro'''.!.. Boj_ ".ki '" ..... Sp;n.of ...... • f .. , <Io<1..-., i"" of 110>," dealh . ~'-''11'''' 21: m·)(lI.I99I . L. V«kioJ' J. I. " GI' l.ual'll$ "In and .... """ 0 Ini ....... d J S.u ...... " 71 : ... ~ .,1. 1989«_ "pori). II.,.",.,. '" H. 1)..... 01 ...,........, ... ""'.......... br> .. __ pou,ru, . s. ... oIoc- H' 108\1·91. 1984. J.. ' ........ I M S. Pow"" D. S..,.-d" I." ~t" Sponu· """". ol<><."bu .. ""''''''''' '' <10<1... ,,,,,, 01 h. N"",,",u,,.,,. 19. 4-;'9·80. 199 1 (Iel· fIMioo 01 .... ... . J"'M .. t>r.,. "".. GI-o<""., "",'"rio, .. po'"'''' .fIe, ",' '" 9 . Brain death Tit.""" .. ofh,..,.....",.. • . M", ........ , 36: 116-7. ,~ " .. RI .... ,.. t-l . o.p"'" 0 E.M""n.,.lC: S"",i.a! . I· .. ' "",Ioo&«! h1p¢O~nni • • N El>aIJ 101«1 HO: 119. " Goc>dm>." J M.1l«1; Ll. M<:><m B o ,conr""",.,. 011n;,.0..1I1 wIlh 1IOf" '" _ .., """,,",' " ..... wof2G4_"',"" ....... N.. """..." 16: '91·7,19U 0"",,"" J .l'nud I. Comparison .1 .... 0l."Il111 <1". lecliOI"""";"_J!)'<"Of)'mof ... .. ill1 ''''' IV",. ""<lion . . . .. H, J .!. ....... b Sl: I80-S. 19tI . Oo"u ine M O. Cntu ..... E: Sy""m .. """""'" 011",i.""" ... "",inl <onl,,,,, ....... ""'"' nco r,,«f.,.., dil.,«1 pop;Is ... nB Emo<a M«I 10: '.1-7. 1991. Tasl Felt« foo ... olB";n O<><h i. Q,;1cI ... • G"idol .... roo.he dtt<",,;,u._ oft><H> d<>,h 'ft <~ ,IcI .. " . ArdI N.... 01 ..: ,n·l. 1987 . D..-b)o 1 M.S .. ,. K.c.."Yil; .!..<loI""ppn>o<hlO maoa,. ... '" or tho: h<&r\btI,,,,! 0l/na ...... . otpa " " """'<-of. •• He,.."' " " " " " ". ,~ <I.,.. 0.""""'''''''" cIcroOt. J........... 261 :n21 ·8 . 19~9 . She..-""", I) .!..Co""", A M .fU<o<~ "" 1.<lGt. The ..... f .... "'"'l""taIi< ",r."I," A <ri'iqu< .J"M" 161. mHlI.I'lS ~. a.m ... ;n I M. W..."" M. Sl ......... C 1.4 . <101.: M....... I "',n "".'" ....r "",I""tod r.al ..",; • • 1. Qb" .. GJ _oI7~ : 4l4-7. '919 "'p. _«u' NEUROSURGERY 10.1. General information ~Mbrospi.nal 0 ... ;<1 (CS F) aUm;lUIlda Lhe brain lind _pinal 001<1, and !lilly functi,,m liS II shock 9bsorber ror the CNS. ll may 11150 storYe 9n lmmunoklgical fundion BllalQious to !..he lymphattcsYlltem'. i lcircula.tes within the subarachnoid space. between tlleanch· noid lind the pial membranes. CSIi' is normally" d ..... coloillfflfl fluid wit.IL ~ 7.33-7.35. Production 80%ofCSF ;8 for-9S~ (>fCSF produ~ in the .... -- s"""ific gr"y,ty of 1.007 lind II pH of Table 10-1 Normal CSF production yolumea and prBB8Ure prod"ted by the choroid plel(uSi!$, 10catA!d in both Jat.e raJ ventriclee (acoount.& 1\ P"",,,, IO\aI voIUIII! ( ICl(lT1;IIion ral'! ....... I 5 25nWd ." • ,.,,' H OYTl ISO (50"1. inlritcta<llal, 50% sp8laI) _ 0.3.(.3.5 mVmin (_ 'W-150 mVd] mean: 10 BdIIIt: i·' 5 (". 18 YSUaIy abrIcN!NIQ roormaI:. 15 young ~uII: . 18-20 choroid plnu""s) (em o/nlid) lind in thl! 4th ven· tricle. Most ofth as me .... JI.a I" tl>lllumbir .,..OQf.ch_ opac9 ...ttII1h. 111"01 ,. I . ~.a In t~. rest of intrllcrania 1 "'leIal GeoJbolus posiTio(I production O«UrBin the in t.e rst.itial SPl>Ce'. A $l!IaU III[IOunt lI\ay also be produced by the e pendyma l lioing oflhe ventrieles. [n the spine, itis produood primarily in the dura orthe nerve root $leeve$, T,,(Jle JO-1 show.. properties o{CSF production, volumes Ilnd PTeiSureS. Produdion rate:: In the adult, CSF is produced (It" rote orabou~O.3 mllmin (Re Table /o.J). In tenus thMared lnicollyrelevlUlt, this lipproximate54SQ mlt.!4hn, which mU M that in an adult, thJ, CSF i. ·~umed over' _ 3 times every day. The rate of fonnation is inthf"lnd~"t orthe inlrac ranial pressure!{except in the limitinK ~ when lep beeomu sg high that ce rebral hlood now is reduced'). Absorpt ion CSF is ~bsorbed primarily by ~rachnoid vi lli (granulations) u,alext..nd Into the duo ral venous linuses . Other s ites o[absorption include the-choroid plellUSf:. and lymphat.iC!;. The-rat.. of Bb50rpt;on is pr8S$ure dependent". 10.2. CSF constituents The cornpoiiition ofCSF differs lli,htly in the ventricles wb~re the produced compared to the lurnbar5uooruhnoid spare. rnajori~ of it ;.; CELLULAR COMPONENT In norm al adult CSF, there are 0-5)ymphocyus or mononuclear cell5 per mrn~, Bnd polys (PMNs)or RBCs. ln the absenceofRBC., S· 10 WBCs pttr mm' is sUspicious,lInd .,. ~O WBes per mrn 3 is definitel)' abnoTmal , 110 NEUROSURGERY 10. CerebrospinalOuid HI CSF CONSTITUENTS Tab" 10-2 CSF .01111•• II, ,.." , _ T_ _ _ "...,.5(0) 0111 ""'" T_ s., 01 "Ce_oo.p;n.l Flulclln 0iIN_ oil"" N _ Syatem' "" ~ A. F l - . M.O, 11orCEA.AfP.&~CG . CI'*. w. 8.~Co., I'IIiItM:IeIpI'~.P""u_w;",~ -- _tiIoIpIa<mo NoIe: CSfPfOl_ II ........ , in~ 1ILoicI,1wI1n....-..--. _"""CSF_ns.s . , ~_,...oI.In ... _ Ttbl.1004 ., hble 1~4 CSF IIndlngs In varlOUII pathologIc conditions (ad ult vllu_)" (comlnued) _,_iono OP . _~ ~ : Ine C6F!irlclir9t1ll n __ IMI tJaciII .. _ I ... . _ . I . - . , , ; t ...... _ : ~. ~nItr ... """9a'" CSF ...a......*olI _ ••pIIl~_IIWr_U/ 1II~2!h1OlIo_. 1O~_Ir1_IICI~1tom SAt1, eIto_ ~ SAH __ ".......,.,'IA _ 173 t "" ....... ~""\IIICSf' .. Io!S. _rMf1I51 TRAUMATIC r AP D itre r e DtialillS' SAlI ITom traum Ati c tap For typi~.l findmg5 in SAM. JU ~ 784. Some f'''l!.l m W I from 'IT lire f howo in 7b~ 10-6. NB: ""- candl!i<>r\s.CIaI' _ b~lpful in difrerentiatiol! oWI\fIoCIwomil Differentioting tr1l e le ukocytollill l'rom tTlio umatie ta p When many RaC. a nd WBC •• "" preo.en t In t he CSF d ue 1.0 a t raumatic lap ('rn, It may be important to eell if' lhll wa C. ar. elev.~ or 'fthey are prl..,nt in the ...... OItio 81 in ~he penphenll hlood. In non-anemic patieDia. Ihlll'1l shou ld be - 1·2 (01' every 1000 RBC. (alII. tonec:uon'" '''': l ubt' lIct 1 wac for livery 100 RBCIf .. '>II), In the presence of .neroi. or n Opbltal l.ukDeylolllli......1 f'i.hmlLQ'. fCN'Olul. lI • ''',oo''n in Bq IV. I toUtrmaUolhe origi nal WBC eountlo the CSF ~the TT. wee. I . ~BCC:UOIUG/I...L . WklC ar - NEUROSURGERY WIICB!.OOD" R8CCSI' - - I!q t e. t RHC,t.OOO m where wnCCSf'O~ICI"AL K wnc lXIun~ in ~heCSF befall!-U\e 'IT, WTJCcs., &; RaCcst''' WIIC & RBCcounts mellllured in theCSF, Dnd WBC8I.OOI)& RBC8l..OOO" WBC & RIIC ~r mm1 in the peripheml blood , Estimat ing tru e Lota l CSF protei n CO l:ltel:lt with a traumati c tap If the hemogram lind peripheral protein are. normal. then hllve ~he c~11 count alld pro\.e.in content run an th,urne Lube, and the IXIlTection is'I.""': • 8ubtract 1 mg per 100 ml ofpro!ein far evel")'.1000 RBC per mm' 10.3. Artificial CSF II numberof famlulfttiOll8 ar "artificin l" CSF have hean Pl'1)posed OVer the yell1"8 in (lrder to mon dOlely mImic the pH. ~l1lolarlty. COt, and membr."e a~tiv" ion roncen· tration ofCSF . In many instance$, normal B8\.iDe (NS) 118.0 he~n used in brnin Burgary. probably without ronijequlmre. How<!ver. renewed inwrut in the su~tofanmdal CSF haa bHn brough t about by the use of neuroendoaropy, with poeIIible reaction . to non· phy>liologlc ",,\utioo8 when large vQlume8 Qf n uid lire exchanged . 8B <>CCIII'II during 80me Qr th~e procedLlres . An actu'" reliction t<I NS. however. has never been prQven. In uddition t<I.irnlllatinr the eon s tituents DfCSF. it lIIIIy alao be wen to in sllre u physiologic temp_t .....e c>fth~.oIl1lJon". E Uio tt's solution AKA Solution a or ElIiCK: lin d Jasper"· II. lin used in the pRIlL 10.4. eJaborli~ formulillion that WAS widely CSF fistula AKA CSF leak. Two major J;uogrOllp.l: 1. ijPQO~DeoLl$: rare \,rE~tow) 2. post- procedura or poettrau.ma tie (mare I.'Ol1lmon): 67·17\\1 orcases. Including ~I.­ transaphftnoidol sUlgery snl,! poet skull b8ge s urgeI")'. Subgroups, A. immediate B. delayed CSF fistula should be BLlSpected in patient1! with otorrhea or rbmorrhea Bf\u head trsum8. orin p~tient.C wfth recurrent menillgitis . Possible routes of egress o f CS F I. 2. 3. 4. 5 Ii. 1. 8. 9. 10 mastoid ait ~elll \u!'e<'ia llyaf\e. p-lOesa 8Urgery.e.g. forac:oustic neuroma (ANI . '"' PDlJt 435 ) s phenoid air cells (""perisHy po!I(..u1.n9Bphenoidal sU'l!el")') crlbrifornl plate/ethmoidal roof(Ooor of frontal fOSS.ll) frontal air cells hemialion into <!lIlpty sella and then into sphenoid liir a inu. Rlong path or mtema! earlltid artery Roae:nmOUer'a rONa: [OClltcdjllSl JnferiQr to CQverooLl • • inll' . IMY be I"'~ by drilling off anterior clinoid_ t.o allow 3ccesa to ophthalmic lir'tery 3Jleu1)'sms lito or the openiog oI'lhe tran,ieD~ latpral craniopharyngeal canal percut8<U1OuBly through a ilurgical Or traumatic wound j>1'trou~ ridge I). intenl.al auditory .,.,..al, fLlnowing tc'mporal bone fractUle or acoustic neuroma ,"rgery (,u pag~ 435). 'Then either : A. rbino .... bea: throllgh middle &Dr - e ust.achian l.ubli - nasopharynx a . o to .... b e a: via perforawd tympanic mertlhran. - ellLernal auditory ean&! T RAUMATIC FIST\l LA Occur in 2-3'l> of all p8tienl.! with bead ;'I.1UI")'. 6O'lb <>ccur within days oftrallmli. 95% within 3 n,onthBU, 70% (of CIl$e;I oI'CSF rhjnOlTheo It.op withIn I wk, and uSLlally within 6 mOl in the N5t . Non·traLlmatic fQeS cease apontlllleoualy L'I only 33%. Adut~child tati" il 10;1. 1':Ilrf! beroN ago, 2 yn. AnO!lmJ.a is.eommon in trallmatic leaks '" 10. Carebrospinal Ouid NEUROSURGERY (78~), TIIN!;n sponLln.., ... " . Moet (8Q.85%) CS F otorrhu ceases in 5-10 days_ CSP liltull oecurred in 8.9% of 101 easel of pe netrating trauma, and intreases the infection rat. over those penetrating injuries without fistu la (50% vs. 4 .6~)". It i$ reported to occur flO't·op in up to 30'l0 of eases of .kull·ban surge.,,". SPONTANEOUS CSF FISTULA Nontraumatic leaks primarily occur in adul", > 30 y .... Often inald iou5. May be mil_ ""ken for allergic rhinitia. Unlike traumatic leaks. these tend to be intermittent. the ...... of 1mell i. ulu.lly prtHrved, an d pneumocephalus ia Wlcommon". Sometimu lMOCilted wit h the following" 1. Igenesi. of the noor of the anterior faua (eribrifonn plate) or middle f _ 2. empty leila . yndrome: prima." or poSt tranAphenoidal ,urp." (He poet 454) S. increased ICP andlor hydrocepbalus 4. infection of the p8ranU81.intUles 5 . tumor: including pi t ui""ry adenomas (He p4fe 438), meningioma. 6. I pe ... il tent rtmna nt of th crlniopharyngeal ClInal" 7. AVM" 8 . dehiscenteofthe footplaLl of the ."'pes(a congenital Ibnonnality) which can produce CS F rhinorrh.. via the 11lItachian tube" P08terior fossa 1. 2. pediatric: usually preaents with either meningitl. or hearinc lou A. preserved labyrinthine function (hearing and b.lanee): these ulually prtsenl with meningitil. 3 ulull rolIteaofr.. tula: 1. facial ~llJlal: oan fistulize into middle ear 2. petromastoid canru: along path of arteriallupply to 111lI<:0II8 0( Olutoid air sinuses 3. 11yr1I's f1.-Uft! (AKA tymp.nomenillpal f15l ure): Hnka p-fous to hy. potympanum B. Inom alies oflab,.-ri nth (hearing IcMt ): ona of ..vera I typea of Mundini dy._ plllSillS, usually pru'!'nting with rounded. labyrintw-:hlea ~hat per mi'" CSF to erode through ova l or round willdow into auditory eIInll adul t: u~ually pn'senbl wit h conductive hearing loe5 with sera... err.... ion, OleningiUI rolW n follo";ng an epi.sode ofotilis media ), OTOIIreb1ll1 aba<:esa . Occurs most commonly through middle fOll&8. May be due to arachnoid granulationl erodi ng into lir linus compartment Spinal Olkn pruenta with postura l headache associated with ned .tirrnea and Io!ndem e5S" (He pogf /78). MENI NGITIS IN CSF FISTULA InciderlC$ with !»'ttraumltic CSF leak: 5--1~, i~ ulealr. peniata > 7 da)'L Menln,giti.1t more common with aponl-aneoul fistula_ Ri$k may be highe r in poiSt- neurolurg'icil CSF fistula than in porit-traumaticdue toelevatad ICP comJllOn in la ller( fon:es CSF outward). If.ile ofl",k uoidentir.ed prior 10 a t loompted .urgical treaunen ~ 3O'lodevelop. ~rftnt leak !»'l-oJI, wilh 5--154 ofth ..... .re.eloping meningit il! bero", leak is stopped". Meningi til may promolo! in1lammatorychangH at the l ite of the leak. with a r ... "I1.alit oeuation ofthelealL Pneymoc;og:al menIngitis;' the IDOIt common pathogen (83'1> Of Cll$eS1O), mortali ty 1,lower than in pn.eumoo;oc:cal meningitil without unde rlying fistula « l~ VI. 50%). poaibly becauH thelatlo!r il frequently leen in elde rly debili""ted patients. Prognosis in children il WOrM". EVALUATION Dete rmining It rbinorTh ea o r otvrThe a i . due to a CSF fia tul a 1. ~h.racteriltka orthe nuid luggesting the preeence ofCSF A. nuid illII dear al Wiler (Wlleulnfected Or admixed with blood) B. fluid don not ~I"'H eltcoriat ion within or outllide the nose NEUROSURGERY 10. C.rebTOllpioal nuid C. pati,nte with r~inorrhea describe the t.R'U as l aity D. collect nuid and obl.llin qUBntiLa ti"8,' u<:oee (urine rlueoM detection I trip:t may be positive even with exceu mue ... ). Teat the n" Hi abortly .ner collection to roinillliu ferme nulion. Norma! CS F' IJluc_ 30 m&"lo ( .. I ... lly lower with meningiti l) wlMreaa lacrimal "cretions and muc ... are ul "ally < 5 m~. A negative test i. ~ he lpful , ince it ruin out CSf" (ncept in hypoel,.:orrhacbi a), but the .. il ' 4S· 16~ chance of r.IN poaitivet". ,.-, E. BrtrllUlafe ITln: pr,..nl in C$ f', but at..enl in t ...... u llvB. nu,,1 exudatu and IUUrn (except for newborns and patientl with liver diNu,)" ,", The only othe r !IOun;e i. the ,,;t ffl(lU I nu id of the eye. Dfttec~ by p. atein elec- i.,. t.rophores;I, . 0..5 ml needll.o be pl.~ in aluri le conla inu, packed in dry ie., V1d .hip~ to a lab that can p4!rlorm thilstudy F. "ri ng ' ign": when' CSF leak i. I Ulpe<:ttd but tho nuid i, blood tinged, allow the nuid to drip onto linen (Iheet or pillowcue). A ring of b]ood with. I.rrercooeentric rina of dear nuid (-.;I CII lled "double rint' or haloaign) luaant. the PftSenH ofCSF. As! old. but unn!1iab]", sign 2.. r.diographic ,igne of"pneumocephalul on CT or akull ~·ray 3. cinemogram; intrathecal inJectiQl"l ofradionuc:lido trlcer followed by lein tigram or il1jection of radiopt.que cont.rasl followed by CT lean (... ~ Mlowl 4 . atl(ll mia i, pre.enl in ~ $'lo ofCS F leaka 5. followina l kull ·baM "'1lI:ery (especially involving greate r l u;>erficial p<!t.rOllal Mrve) there may be • p8eUdo-CS F rhlnorrbea pouibly due to na8l1 hyperse· cretioo from imbalanc:ed aUl.<)nomic regulat ion of the n" al muc:osa" i""ilaterall.<) the , u1ll:..-y. Often accompan ied by n ..alstuffiness and ,beent ipsilaterallacrimatiQl"l, and occasionally by facial flushing TO LOCALIZE SITE OF CSF FISTIJI.A ~ of the time, localiu tion doe. not require water·aoluble co ntrast CT cistemogr'phy (WS-CTC) (_ bel(HD) I. CT: to RIO hydl"O<'ephah.. and obstnH:tive n""plums. Indud" thin ~ cu ta IIlrough anterior fOMS all the way back to the tella tu",iea A. non-contrl5t (optional), to demonstrate bony anal.<)my 8. with lV o:ontrar.: l~alr. aite is usually associated with abnormal enha"",,· ment of aoljacent brain parenchyma (possibly from inflammation) 2. ""ater-aoluble contrut CT ciitemogT1lphy (procedure of choice); _ below 3. pla in skullll·ray (hel pful in only 21 '!&) 4. older tests (abandoned in favor of above): A. plu.rldire<;tional tomography: S3'!& yield. better in traumatic leau 8 . radionuclide et,teroograpby (RNC): may be uaefu! in ]eau too alow or amall to MOW up on WS-CTC. Various radioactive a~nta have been uRd, including: ndiaiod inate<l human terum albumin (RlHSA}I-'-", and 500 (.ICi Indium'" DP'I'A. Cotton p]edaeta a~ packed inttlnually lanterior naul roof, posterior nan ] roof, sphenoethmoida] reee.a. ",iddle m ~atu,. and p0sterior floor of the nOli) and arw roarked 10 that their location ia known . Ra· diotrao!! r il then iJ:Ue<:te<I int .... the.:ally Ul ually by lumbar puncture. Scans are performed in lal.e.al, AP and posterior view . A pl"'OtOCOl .... inaln'" DTPA is to obtain a SCIn ahortly afUr il\iec:tion. At 4 noun! post ·i l\iection, th~ SCIOn il re~ted. and 0.5 ml of blood is drawn (to raeNure llrum activity), and Ill" pl~d&"ta are removed. The p]edaets ani then individually placed in a welkou nl.er and a ratio;' calculated (or pledget radioactivity ..dativ. to ",rum. A ratio " 1.3 ia nonna] , and a rat io > 1.3 ,ulI"ta leak . If no le~k , the no. can be repacked and the study repea:.ed the following mom ,na· Leak. into fron tal sinul will ampt.y into nllOpharyu anterior I.<) the middle contha , unlike leak. throuah cribrirorm plate. RN C identifies the .ita in only 5O'A-. May be milleading" with pouible contamination afU r M veral OOUnl (rom ablorption o( rad ioilOtope into the bloodstream and accwm,l ,. tion in the muOOP] /danda ofthe turbinatot. Patient ~itionina mly ~ COQtaroinate other pled~ta C. intrathe<;l] (.. i" ble) dye I tudin, some luoeIII witb indiao aormine or Ouoreacein (1ft PfJII' 699) witb little or no complicatlons (II methyLene blue il neu rol.<)";c and should not IN used, _ PQlt 599) 5. MRl : ha. litt.le to offer in Jocalilation of"CSF fi. tula 00 below) '" 10. Cerebroepina] fluid NEUROSURGERY WATER-SOLUBLE CONTRAST CT CISTERNOGRAPHY nu. te$~ i. perfQrmNl lf: no l ite. identlfied j:1n pla in CT (with coronals) when patient is leakinlC clinically (the. aite 15 only 5Qmetim .... identified in the absence of an active leakl 3. when m\l.ltiple bony d,,(ecu art! ident;(ied. and it i. enential to determine which site is actively leakine 4. if a bony defect SlOen on pla;n CT does not have associa~ chan~ ofahnormal enhaocement_o( adJacent brain parench)'IQa Prot~u .... ofrhol~. L 2. Tecbnique"" Use iohe~ol lue pu.je 127, which hill! geoerally replaced metriuom ide S. 7 mt or 190220 mp] ) [njerted iOl<llumbar 8uoorechnoid space via 22 K8uKe ,piruol n~le ( or 5 ml via CI-2 punc~u",). Patienl positioned in -70" 'l'rendelenburg _ 3 min prone with nee). gently n""ed. in CT t.hey .rekept p[lme with head hypereKtended wi~h I> mmcoronal cuts with 3 mm overlap (U6" 1.0 IOIJl CUtii if necessary). May n...ed provocative. maneuvers (coron al llCIII"\8 prone {brow up) or in position o(lellk, iotratilecall8l inei.n.fu.sion (requirea Harvard pump)'·" .) Look for aCC\Jm ll l~tiQn ofconLrast in air sinuses. Apparentdi5conLinuity ofbone on CT without extraV8$S8tbn of contrast ;. probably not the ~ite of leakpge (boRe_diseootinuities may be mimicked by partial Yolume ll'·f.r~ging on CT). MRI MRJ pro..-ides little additional informa!'!on for IOC/Ili:wtion , but it CStn RIO I>"fo""l1 mo:;.s , tumor, and elllpty3e1!~ bo!tter than CT. Both CT and MRl C"IIn RIO hydrocephalll6. TREATMENT AcutA!ly a~r traum8. ObuNation ia jWltilied as IIIos1 fa ....8 ceo"'losp"[ltatll!Oualy. Propbylactic anti bioti C8: Con tro~ersial . There w;;u no differencc io !.he incidenfe Or n)Orbidlty ofllleningltia between trtlMed o.nd untreat«! patients"', Furthermore, the ,;~k of8~lectiug reaistaolst.ra ins sppeal"l real" and i3 thoenrorflll8ulllJy avoided . FOR PERSISTErff POS17RAUW.rJC OR POST·OP LEAKS NOll -s urgi ca l trea tllle llt. I. rnellsures t.o low~r ICP; 2. A. bed retlt ; although recumtMtncy may am eliorllte SYrQptom l, !.here i~ no other benefit froro bed rest'"' B. avoid atrair,ing(stoolsof\enel"l) and avoirl blowing nOlle. C. aeet.a:u>laIOlde (260 mg PO QrD) t.o /"l!dUCf! CSF pN>dudioll D. modest nu;d A$tridion (eaution po<It-tr;msaphenoidal becau8<!- of pouible DI ('~l pag~ 16); 1500 mllday in odultli, 75% of rn>rintA!nRnwday in peds If leak ptr8istli (c)ution: firs t RIO obstructiv~ hydrotephlllus with CT or MRl ) A. LP : q d to eJ'D Oower prt!$Sun! to nUr atm.osphen c or until HlA) OR 3. B. continuous JumblU" drn..in.age (C LOt via percutaneous catheter. Ke-ep HOB el""al.<:d 10-15" ,."d drip ch8lllber "l shoulder le"",1 (,;4ju8t down if leak pil .... iatli). RequIres leu mouitoring. Irpatient oeUlrioratQ with dr"in in place: illlmedi awJy st(Jpdrainage. place patien~llat in bed ~or !light fun· ~lenburg), st.art 100% 0 •. ge~ CT or bedsideCTOEsH lible .kull x-ray\to RIO tension poeumocephalu8 due. to drawing in orait) lurgkal treatment in persistent cases (...-e below ) SURGICAL mEATMENT ind ica tions ro r 8lU"gh~al 1. CSF leak 2. leaks 3. inte rve n tion h P e trou a bone May ptellent 1111 otorrhea or 8S rhi noIThea (via the Imstachilm tube ). NEUROSURGERY measures !U r gety: UIIU_ po,., 1. following poat.erior {()$.'ja ~u r g1!ry: IIf'e 435 for treatmen t following aco.>ustic neuroma eurgery 2. following mastoid fractures: may be approached via extensi,·" mastoidectomy" Leaks thr ough c ribrifo nro pla t~/ethmoi da1 roof Extradura l fl pproacb: Gi! neralJy preferred by ENTlurge0n3"' . lfa frontal craoiotomy is being performed. an intnadural approach should be used ,ince problems may M$e In dissecting the dura olfofthe floor oftbe frontal fossa, wherein the dura almost slwllY~ tea", and then it is dilTtcult to know if an identified tear is the cause of the leak or ifit is iatrogenic. Fluorescein dye m;"ed with CSF injected intrathecally may helpdemomtrate the leak intraoper8tivelyICAIITION: must be diluted to red uce risk ofsei.ures, see pog~ 599). Intradural approach: Generally the procedure of choice". If the fistula site is uniden· tified preoperatively. use II bifrontal bone nap. General techniques of intradural approach : Post op: lumbar drain after craniotomy is eontrove"'ial. Some reel CSF preuurt may help enhance the seal". Ifuserl, place the drip chamber a t the level of shoulde r for 3·5 days (for precautions. $ff COOtie). Conside r shunt (LP Or VP) if elevated ICP Or hydrO)a'!phaiua is demonstrated. Leak s io to s pbe noid ,;null (incl uding post-tranllllp be noidai a urgery leak) I. 2. 3. LP BID or C!..D, as long as pressure" ISO mm H~O or CSF ¥anthochromie A. ifleak persist$ " 3 days: repack sphenoid sinus pnd pterygoid recesses with fat. muscle. cartilage Mdfor fascia lata (must reconstruct floor of sella, packing alone i$ inadequate). Some recommend against muscle sin.::e it putrelles lind shrinks. Continue LP or CLO as above for 3·5 days post-op Il if leak persists ,. 5 days: lumboperitoneal shunt (first RIO obstructive hydrocephlllus) mOte difficult surgical approach: intracranial {intradu rall approach to medial fI9peet of middle cranial fossa consider transnaspl..,llar injection of fibrin glue under local anesthl!$ia" 10.5. Spontaneous intracranial hypotension The syndrome of spont aneous intracranial hypotension is cha racterized by the fol· lowing in the a.brwlg; of antecedent trauma or LP (or epidural injection ... "': 1. orthosta t ic headache 2. low CSF pressure 3. diffuse pachymeningeal eohancement on cerebral MRI In most cases, the underlying etiology is thought to be II sponlan eousCSF leak from a spinal meningeal diverticulum or dural tea r". Clinical features Most patients have orthostatic hel>dache. Atypical patients bave been described withcu.t lilA , or HlA tbat i$ !)On_pOiIitional, without pa.;hymeninll:e.. l enhancement on MRl", with dinicalaigns of encephalopathy, cervical myelopathy, Or parkinsonism". Sinti! some plltients roay have normal intracranial preuuTe. the term ·CSF hYJlD"olemia" has beeo suggested'". MRI evidence of brain df!S<'enl oceurred in 36%"'. and reyenl!ible pi tu itary enla rgem~nt with a eonvu superior margin" may also be . een . Subdural bematomas may occur as a result. Radioisotope ciste.oography was abnonDal io 90%, and showed 8 leak in 40%". Treatment l'reatment includes: 1. bed rest 2. analgesics 3. hydration 4. epidural blood ""t.ch (EDP) for appropriate cases:"" poge 46 Outcome Complete resolution ofHlA was pchieYed in 70%, and was higher in patients ,""ceiy. ing EBP, and W illi lower in patients with multiple .ites ofCSF leak". '"~ ]0. Cerebrospioal fluid NEUROSURGERY 10.6. ,. ,. , References , _01_.,.._CSI'~ . _ I t T: CSF_I..;u, . .. pIIo>i< .. ~ 10 ...... ~ _ eo>iI, .... ....,n.... _ no .... Ur n.-t J l ' ·191·'. I991. E>. ... ~ _ _ '" - s-O.II< .... JEA ~"" Iloid. '''''N<", ' 9 U~$. 1961 .... \..cnoI ... A \I . . . . I. r; . ~(l\l . hJ.o """"'" _ _ _. bo1_ft~n.", ....-;,,-~""""'.,....... '<nO. , ). " ...1ri........ CT c~, J J<i... __ • • "u . 679-91, IknII&EA.S.... O' H~· c-F· .. b· '. _ .... _ ~ 01-,....."" ,~ Grilf.~ 118. 1...".,.... ... 8: no. .... _ol<lMiII· -lIy4oo<tpNIIII", ......". ,................. ..... ""'r..... ~""'- .... fIoiol porlu1... N.......... tt 4, 9S<IOO.I990. • u.. .. ,. Ft.,........, I. J 1910. •• •• 00. " ". ". " " .. " " ". W. I , S_.I'II;'",,"IfIIIIt.. '1lC 1(; """"," lnII ................. n.", .....,... ..... KM.W.."'_.... Jl II~ ,I"• • Oh K. Y_ _ M.!<IoooIUT . . . . _ n.. ...,..r~ CIIOC< d ... ,r"Io' .... -,;011 0."' .. perf..... I .... ' - O . .u,,..-,.l'I<u..........., ll: 1ll-6. ,.... Ell ... K "'C , J..I'O' H II. PII.!.iDIop<OI .. II ..... • ,i... r", ... 01 • • .....,: 51""ia of 10<" pH _";" ..... 1"'><Iic!M I9l1ooff<rood ....... burr...... itooorI .. ......i.... J N• • •_ •• 6: I.oG-Sl. 1,.9 1...0"" MC. E'I;", K ... C: a .......... of .. ... if!· <i.ol ",,_p"'! nul6. J N....", ••• 1: ~. 19$0. 51"'.1<' MF.b_llI! 1 M: ! n•• d r...ull.Ca.u ... ~ N...........: 1·1. 1986. M....n. C.C.ll<rin P. Sabol D, II .t.' Of mi_ · .....: f._".01 ..... .,1", ....,;-<;"• ...,....""'. AJNM1 15-.10. 19111 Mo .... .,.,y A M.C. ....... W F. !'>oltonJ D• .,al.: O F n"ul •• <ompl;'OI i", ",,, •• 1< w ...... of ,Ire broi. , J N.u' ....... S4: """.191 1 C¥."".""M D.S<AIo.a, I. N. ~ .. ""I (1uOI.ho_. J N............. 80. 1994 C ........... TCC#Tt~._ . I.()oo. ...,.....,aov.Ero&lilllG M./... .).I.ipp;...,.,.R....,. PI!;Io<k.,..... 1991. YoI. 1, Ooopr .. )1: PI' 1·7. l'I.. k;....!<: . .... o.Ft<>D R. K-'" R 1. .. ", _ Ce~ _11'Iui<j rIIl-nocI .. . _""'.,. 01 pi<l>....,. _ 1"<00...........,6: 191-1.1980. _ W_H: C-....,...I "',...... -=Tlo<_y or_UK _ of ...... aIron .... _ f........ _ publiobed .i_ rood. ...... OIoItoryq<lllS: 1m. 1926. SdW ...... W I. Mol'<' F B....... _ I 1. 0 ...." Spa-. .piMI~ noi<! ~ ....s;".. ..........11o)"'*"""".J I ' I _.. "':~. Cue....,..... u-», ""1«0 ....... ,~. _ ... T P.-...CJ. Pftoo: ... _Io<.I".. NEUROSURGERY 1..$_'''' ~M<wrioI 1.. M_ 7l.Uf.1~ . 1 91(1 W;!Mn ~ H. .......NIr)' u.(e6\,J:_ .......,.. McGoow·HiU. Ne_ v..... ItlS. ",,_ItO ...... 1)·.... G._H41: .~t) .... u.tf-.. oI .. _ _ _ .. II>t_oI,... twoop. J~ " - . r.s...... c IJooI. n... •..,.C. .. ... Hjply ..... "; ~""""""" ot ...... l~ .. _ " __ ... -..roo-.-.-.. • • ...... CIIo ~ 'CSF) ....... AcUN.. _I09: .... IO I. I99I . OI:Io.-. : R........,.. ~.o(_ . 1'1"' ..... 1( ... ,C.m'..pI .... n"", 11>_01 r ...... <l_~ H. . '" ....71Ul·".991. ","" ...... ...,...'.. _ "ju" .. w(do;n 'M"""br" ..... ,..,Ie>.JNno, ..... lIl: I@4J. U111.-.. _ n. ~ . aioI41. 1f-l', ' '1n. ",_1. WoW to! H.$<&III II D,''''' " E.......... oICSF.,.;_ ..,..n..-cr'...._ fill) N~ I6:S4-60. I "' . 1: ........., I.Sodt.... "' .II<i/Iooy<J: A~ Pf' OP'I,Iu,," "'*"""" "'_ A_ bI...! >Il0l,. 50 ... No."oI" I II .... 1m. pIII01a .... n. .-._Clftf.....- AIIt.C.CiIauooo P•.,.._C lleiloeu; ... _ _ ".ul......r..1 ......... .... l..-m lS4: , 229-)). ,999. • Cok-.. TC E.H.ruioI_ol....-."... N. Low;"W : ~fIoId_"<_ " D~ - . . . . . " .. 0001 "" _ ". U. RIMMI~ joJ..n... II J ~ 11: 1·1I. 19S0 . TF.Geotco ED' SortrbI _ _ _ ",,,,,· _<"'~jhJJ/i_ . I. ~ .. _ """"'rpcall«.h....... s.r:_tHH_S_W H.ledo.). W.8. I'Io<1I<I<lp!lol .1"' ... .. 199'.Yoll: ppI Jl·ll Fujii T. Mi ...... S.Onod.I K... III" SioRpIo ....... MO" ofCSF , . " , _ oft.. JO"'''"'Y ""J<r)'. 50.. Ntu. oI 16: :WS·I.I986. f;_RA.o;lI.. wP.O""I _ _ s......... ",.. brol displ>«m<m""""" .. iona_ 1oJ_ _ . Nt.roIoK) 4). 110'1-1 1. 1991. Sr:Io ..""'.W l.T_.it J: - ....... ")'J'<IICMiooo .. ~ ""'" _.q ..I - . , .... ....,...., '""" . , _ ;"", • •• ,. j Nt"'-'I 91: (1'·1, XIOO " ". ""'" n. 19. 101-16• «_ Clouo'SJ.)(imIS ..... M C: Sy_or-.brol .p;n.1nu'" ~JPI>"O-' : Cli . ...1_ i","- r..• ou_. I'1 ... ......,. ss: In l.1. :IOOO. MoO.rI l : Spero ........ , .... t>n:oopiool r..1d 1<&1< •• f,.,,,, io ........ ;aI ~, por..,.;.,., ...... bfoopI ... nulll .I!,,>,'Ol<mil' F._o!w.. o r .~ . M. ro 0 • 1'>0< 10: Illl_ll . 111'99 • ... I...... tint" I. J. lkrI...·t.- J... ~" Pi"",,,,, .111 ......... ;" ,..1..,...."" ......... i.ol N... ,oioU S,: It9S·7. '"ta ..... -. Ei<"_ ". Itl_"'_"_ 10. Cf:rebl"Ol'pinal nuid ,,, ., · .,. ~ . - , .. ~ ,..' EPIDEMIOLOGY E$tlmat.ed pre~aleMe' l -l .5'l!t. Incidence of congenit.lll hyd rouphalus ;._ 0.9-LB/lOOO birth. (re ported range from 0.2 \.113.511000 birth.'), FUNCTION.t.L CLASSIFICATION Two main tunc tional s ubdivi llioDsorbydrocepbalulI (Hep) I. ob~trud;ve (AKA lIon-conlmunicating): block prol<imol \.II the arachnoid gTIUlUlatlonil (AGJ. On CT Or MRI : enlargement or~entridell ptoltlffiSl \.II block (e.,. ob. truction ofaquwuct ofSylviua _ lateraland 3rd vMtric:ullU"enlargeme lltoutof proportion to the 4th V61tride, ~metimetl referred to al triventocular hydrocephalUs) 2. eomm unit::"tlng IAKA non-obatruct.;vel: CSF cireulation blocked:)1 level of AO SPECI.t.L FORMS OF HI'DROCEPH.t.LUS 1. tollditions that are n;)t actually !;rue hydrocephalus .t.. h ydroeeph lllua e" vacuo: enlargement orthe ventricles due \.111085 ofce-rebral t.I~ue \cer<!brsl Btr"Ophyl, ... , ... aUy IS a funct ion ;)fnonnalaging, but accelerated or !\ccentuated by olutain disease prOce&llU (e.g. Ahheimet's disease. CreutzfeldWllkob) 8. otitic hyd~phah>s: obsolete tenu u!i«l to describe the Increll!led intraocronial pressuNi stell in patients with otitis media (see seeJdiopoli,.ic inlraen:a ' nkll "Y{lfnell~ion, pace 493) C. external hydroc~phal .... :,.,.. poll" 181 O. hydranlmcephaly: lei! b<./aw 2. normp) preSllure hydr ouphalu8" (NPH): $ft ~ 199 3. entrapped fourth ""ntride: sn pa~ 182 4. arrested hydrtlCl'phaiu8' 1ft PrIfJ' 181 HYDFlANEN(;EPHAL Y A pt>.Sl·ne urulation deffO:t isuptlge. 112). Total or ne...·\<It.al ab.'lence orthe C('rebrulu (small band.!:r of cerebrum may be consi$\.I'nt wilh the diBgnosi$'), with intatt cranial vault end men;nlleS, the intracranial cavity beinll rill.,d with CSF. 'I'l,.,r., ill. usually p ...... gr-essive matfWl"a nia , but head site may be normp! (especinlly At birth ), and, occllllional· ty , microcephaly may oc~ur. Facial d,...morphlSm i8 TIl,"",. MllY be due \.II II variety of causes, tbe most commonly cited is billlteral ICA infarcts (which rfault";,, .boen"" ,,(brain ti8_ supplied hy th. anterior and middl .. "" ....1>....1 .. r· teries with prnerv&tiollln the distribution orthe PCA). May also be due to infection (congenital Or neonatal herpe&, to""pllt8mllilis, equine viro8). Lesa affected infants may. appe8f nonual at birth. butllJ""ll oAen hyperirritable and retain primiti~e ~nex"" (Moto, grasp, and ste pping ",flex) beyond 6 mo. They rarely prolfl"t!!ls beyon d spon taneo.. vowel produdion and social ~ miling. Sei~W"e!I arecomrnon . Progr<!uive e nlargem ent "rCSF apace' mil,)' oecu' which tan milllie HVere ("maxi· mal") hydto.;ephelu, (HC P j. l tiacrilica.l todifT.,rentist<! the two aince tnlt! HCP may be treated by ahunting which may product! .orne re-t!1<J)Msion of the cortical mlln~le.. Many mean8 to di li tingui.'lh hydrnnencephaly lind HCPhave been descnbo>d , and j"dude: 1. E£G , $ho w.! no ~'1I1iC1llactivity ,n hydraneneephaly lmuima] HCP typically produces lin abnormal EEG, but background activity wUl bE presenl throughout the. brain'l) and i. one of the be!;t way . to diffe .... ntiate the lwo 2 (;T). ~, MRJ Or ull1"UOund: mojo";ty of mtrlloranial space i8 occupied by CSF. U5ually do not see front al lobE ... o. rmn~l horns of lllteral vl'ntricleB (there may be remn.nts oftempcTII I. DCc ipiUlI Or lubfmnw corte..l. A , (nJcl ... re ton,istl ng of '" II Hyd""'ephalu, NEUROSURGERY bra iD$tem aodule (r(lundd thalamic roas$es. hypothalamu s) and medial ocelpitallobes sittingc)O the tentorium oeeupie. & midline position . urrounded byCSF. Posterior f\lS5a structures are grossly intact. The falx is usually intact (unlike alobar hoioprosencephaly), and is not thickened, but may he. displa~ laterslly. In Hep, some cort~aJ mantle i, usually identifiable 3. trilDsillumln a li o D of the skull: Ii hydroc<lpha[jc bead ordinarily does not IranaiJluminate unless the patient is < 9 mos old Bnd thfl cortical mantle under the light source is < 1 em thick " ' ''~' or ifflllid displace!! the oortex inward (e.g. subdUTaI effusions). Too nOllspecific to be very helpful 4. angiOIP'''phy: in "claS$;c· cases resulting from bilate~J l eA D<:<:iusion , no flow through supraclinoid carotids and a normal posterior circulati<.1n i, expected Tre atment Shunting may be pen'mne<! to control head size. but unlike the C8!;e with hydnxeph alU8, there is no restitution of the o;:erebral mantle , m""im~l E XTERNAL HYDROCEPHALUS (AKA BENIGN EXTERNAL HYDROCEPHALUS) T Key features • enla~ed subar8chnoid spaces over th front.al poles in the first year orlife • ventncles are normal Or lI1inimally enlarged , • may It.. distingui$hed froOl subdural hematoma by tbe~cortical vein sign" • usuaUy resolves spontaneously hy 2 yealO of age Enlarged Dubarachnoid space (usually Over the cortical sulci of the frontal poles) seen in infancy (primarily in the first year of life) usually aOX<lmpa nied by abnormally in· crelllling head cirrumference with n01'1lUl1 or OIildly dil ated ventricles' . There are ollen enlarged basal eis terns and widening of the anterior interhemispheric fissure . No other symptoms or signs should be pre:rent (a lthough there OIay be sight del ay only in motor milestones due to the large head). Etiology is unclear, hut a defeet in CSF resorption is postulated. External hydrocephalus (EHJ may be a variant of communicating hydrocephalus'. No predisposing factor may be found in some cases, although EH lI1ay he associated with SOme craniosynostoses' (especially plagiocephaly) Or it may follow in. traventricular hemorrhage Or superior vena cava obstruction. Diffe r e nti al diagnosis; EH is prohahlydistinct from benirn ,"bdural co!!«tiqns(or ex· tra.axial flu id ) ofin(ancy ( Xt past 678). EH must be distinguished from symptomatic chronic extra.axial fluid collections (or chronic subdu ral hematoma). which may be DC, complltlied by seitures, vomi t ing. head~cht ... (sw pas~ 678) and may be th e result of child abuse. With EH. MRI orCT may demonstrate cortical veins extending from the sur· faceofthe brain to the inner table ofthe.ku!! counoingthrough the fluid collllCtion ("C(lr · tical ve in sign"), whereas th e oolle.o-tion. in suhdural hematomas compress the s ubarachnoid space which apposes the veins to the urlace to the hrai"" ". * Trea tmen t: EH usuallycompen$llte$ by 12· 18 mM agewithouuhunting". Recommend: follow serial ultrasound and/or CT to rule Out abnormal wmtricular enlargemenL Em_ phashe to parents that :his does Il21 represent cortical atrophy . Due to increased ris k for positional molding. parents may nBOO to reposition the head w/tjle the child is Bleeping". A shunt may rarely It.. indicated when the collections are hloo<ly (consider the pos. sibility ofcltild abuse) or for «<metic reasons for severe macro::rania or frontsl h.o$Sing. "ARRESTEO HYOROC£PHAlU5~ The exact definition orthis term is not generally agreed upon, and some use the ter m comperuoated bydrocepbalus interehangeably. M()/It clinici ans Ul!e these tenns to refer to a situation where there is no progression or deleterious sequelae due to hydroo;:epbalus that wouJd req uire the p""",nce ora CSF shunt. Pati~nts and families should he advised to 8~k medical attention if they develop symptoms of intracranial hyperten . sion (decompensation): headaches. vomiting, 9t.a><ia or visual symptoms". Arrested hydrocephalus sat isfies the following criteria in the absence ofa CSF shunt: 1. near nonnal ventricular size 2. normal bead gr<lwth ClIrva 3. continued P6ycbDmotor development Shunt independence The concept of becoming independent ofa shunt i$ not universally accepted" . Some feel that shunt independence occurs mOre commonly when the HCP is due to a block at the level ofth e arachnoid granulations (communicat ing hydrocephalu s)" , but otherR NEUROSURGERY II. Hydnxephalus '" hlVe l hown Ihat ;1 Qln occur rq:a rdleuoftha elio10gy". These p, ti""'- must be followed dOHly .. there ar .. reporta of dellth u late .. 5 years al\.er app..en t shunt independence, somet;me.. without warning". Wh en to remOve a di sco nn ec ted or n on-fu nctioning s bunt? Noc..: a dia<:onne<:ted , hullt may con t ioue to fu nction by CSt' l10w t h ro ugh a l Ube ... · t.aneouilibroul traCI . Reeornmendationl on whether Or not to repai r "". remove I d iKon· ntete-<! or non·ruMtion;n, . h unt : 1. when in lIoubt. I hunt 2. lndiutionl for shunt re pai r (VI. removal) A. marginally functioning . hWlu B. the prese Dce of IIny .ign. Or .ymptOm, ofin~r.a.ed lCP (Yomil;ng, uPiale palsy, IIOmet i.mel lilA .10ne ..... ) C. change. in eogn,tive fu~ljon, I atteotion span, or emoUon. 1 thanl" O. patle nta with. aqueducullf.enOli. or .pioa binda: mosta rt! Ihuntdependent 3. beca U.!oi! of rlab al!lOC:iaud with , hWlt removal, IU'1e ". for thi. pu..-pote alone shou ld be perfo nned only in the . ituation or. ,hu nt inft-Ction" 4. patients with a nonfun~tionin, . hunt I hould be followed dOHly with ten,1 CT•• and possibly with lienal neuropsychologiQlI eVlllualion. ENTRAPPED FOURTH VEWTRICL E AKA isolated fourth ventricle, al the name implies, i. a 4th ven!.riele that neither oommunica\es with t he 3rd venlriele (through lhe Iylvian aqueduct) nor with the ~.. l cisterns (th rough the foramina of l.u&chka or Ma~ndie ). UlJ\lally ~ with chronic shunting of th e latera l v~ntricles, especially with poIt.-in ftel iou, hydrocephalul (especiaily funga nor in those with repeated shu nt inf«tiona. POQ ibly .. a relu)t of&dhesion. forming frOID prolonged apposition of the ependymal lining ohne aqueduct due to the divers,,,!) "rCSF th ...... ugh the ih'~n t. The choroid plexu. of the 4th vemride tOntin ..... to produce CSF which enlarges the ventnele when there il 4th ventricul ar outlet obItrueti on Or obstruction at Ihe level ortne 8r&Chnoid gran ulatioN!. Present.ation may include: 1. heada che 2. lower ~rania l nerve palsi es: swallowing difficulties 3. ataxia 4. reduced le ... el oftOnsciousness 5. nauselilvomiting 6. may a lllO be aD incidental findi nl (NB : some "atypical" fwding', auch as reduced at!entiOI) l pan , may be .... Ia ted) T rea.tment Motl.urteONI advOCllte shunting the vent ricle ei lher with a separate VP shunt, or li n king into an existing .hunl. PotenUal complia t ionl ;nc:lude delayed injury UI the brainltem by thl catheter Up " t he bra'NI!em moves in Ul i~ norma l position with.drainage ofl ha 4th ventridl. Thilln8y be avoided by bringing lhe CIIItheter inlo the 4th ven· tricle 81 a .Iight aogle through t he cerebella r hemisphere. A Tork.ildsell ahunt (ve ntricu lociste roal th unt ) i. an option for obstructive hyd ..... cephall.. if,t i. certain that the ar achnoid granulationa are functional (\dua lly not the CMe with hydrocephal .... of infantile onMI). All LP . hunt may be considered WhM the 4th ventride outleta an patent. CTfM RI CRrrERtA OF HYOROCEPH ALUS N uroerolll methodl h,,,. been deviMd UI attempt UI q uantitatively defilM hydrocephalus (HCP) (mo.! date back to the N rly CT experieoce). Some ... prt!!ented here for COOlplel<!oeu. For tldioloei~ featu ..... of chronic HCP,I« f1lJ#f 184. HydrostatiC b ydrocep hal us Hydrottatic HCP i •• ugguted when eilher": A. the I oU of both tempOral born. (TIt) i.", 2 mm in width tift Fi/llOre 11· 1) (i n t he abMn", of HC P. the tempo ral homl .hould be berely vi,ible). and the Iy lvian'\ interhemi. pherie fi"url' Ind cef"flbral uk; are 001 vilible OR '" 11. Hydrocephal us NEUROSURGERY ~ 2 mm , IruI the ratio ~~ > 0.:1 (",hel'll PH i. the lalllest ",idth of the 6 . botll TH ar. frontal horlU, and ID ~ tll. l1Ilemal diameter fr1>m l.n ner· Ubl. to j"neNlble at thi. level ) (_ r-r /1 . 1) Other foatu,," IUlge,t,ve ofb.xd..Gt~ hydroceph· F" . 1111&: I. t..lloonilLS of fronu l homs orrete •• 1 ventri· de. (" Mickay Mouse" Hntric]es]lrld 3n1 V~n· triela :l. pfriventricuLar J.o.N deMit,)' on CT, or periyentrkuLar high lnt@n~Lt,..ign .. l em T2Wl Oil MRI eUi!ftUIIlS trIInlepeodym,J IIb.... rpLioo Or milP'lIt;OIl orcs!" 3. II&ed along, tht ratio 'H!<~O% iD 4. S. _I boiok,lioc: hydroctphalul Evan'. retio: ratio 0( PH to rnllJtimAl biparieul di~meter > 30$ tllgittal ~ml ml YI ho'" upward bowinG Qflha c:orpua ",Ua.um 40·50% > :10"10 $~Uesl.l ET10LOGIES OF HYDR OC EPHALU S HCP i. either due to luboormal CSF "'lb· sorption. Or rarely to CSf' overproduction ia.o Tabl.11-1 HCP In 170 ..vith wme choroid pie."" papilionlU; .... en here, reablorption i. probabl)' defec:tive in 80me &5 IlOrnUll individuals ~ould probably 1001"II\e thuliglrtly el eYlted CSF production 1'lI\e oftheMl tUIllOI'5). The etiolOjliN in onesenel of pediatric patienls lI5hltWn in Ttlbk 11. / congenital !t, Chlan Type 2 malformltioo and/or myelOmeningocele ( MM ) {ulually "'cur together) B. C hiari Type 1 malformation: HCP mIIY occur witb 4th ¥i!ntricle out.letobI truction C. pnma.,. aqueduclal . teno."" tUlullily p ........ t.o io infancy. taJ'l!ly;n adult- hood ) D. uc<md ...,. Iqueduclalpiosia: due t tl ,ntrlulotrirw infec:tioo or ge,,,utU\! m~· Mmorrhage" E. DaDdy· Wall..,r mal formation: alrellia orfonlmina or Lughll .. &. Mar~nd. it 1_ PflIl //01. The incidence orth~ in patient! with HCP 112.4% P. ,..'" X·linked inhentH disorder Kqui red A. intKtiouI(the .....' common (3~ OrConHDlllliutinr HCP) I . pCIoIt-lI'IfninsitiA (upec:iaUy pllt\l~nl and basal, Inc)udingTB) tn.,. 2. t)'AWmI6LI 8 . JIO'" .... mcnharic (2nd IDlIISt common CIIUIW! ofcorn munic:aLinG HCP) I pINIt·SAJ-l lMc~783) :l. poIt-in~.v.ntticular hemBnhage ( IVB ], man)' ",ill develop laI.Il4iln\ JlCI' 2().SO" olJ'l'tienlir with la'lle IVlf d""elop perma nent Hel' C. HCOndary to II"IIMH I . non neilplastic: e.l, v.nuJa. malfbnnation 2. lleilpJllltic; mosl prodUCI oMlructive HCP by blockinr CS ~' palh",1IY1<, upedaUy twoonl around aqueduct, e.l. medllJ!olllal!IOrna. A coJ!oid ()'IIte- n block CSP Ilolw It ~ (onome n ot Monro. Pituitary tumor: iU' pl'Jltellar e~U!ruion of lumo. or upan.ion from pituitary apopleJ<y D. pott·op: ~ ofped'atric pat.ient.o d~veJop perma nent hydrocephalUl (ra-qu iring I hunl) (ollu"'illl p-f05lle tulUO' removnl. May II<! delayed up to I yr NEUROSURGERY 11. Uydroc:aphhw )" E. r>eu rosar<:(lidosis: see fJ08~ 56 F. 'const itutional ~entriculomegaly": asymptomatic. Need! no trutment O. associated with spinal tumo ..... DIFFERENTIAL DIAGNOSIS OF HYDROCEPHALUS For etiologie. of HCP. sefabo~. Conditions that may mimic HCP but are not due to inadequate CSF absorption include: I. atrophy: IIOmet im"" refef'!'fld to u "hydrOCf'phalu$ ex vacuo". Ooet not represent altered CSF hydrodynamics, but is rather loss of brain tis.aue (set page 180) 2. bydraneru:ephaly: ~u page 180 3. developmental anomalies where the ~eotricle s appur enlarged: A. agenesis of the corpus callosum: see page 114 (may occa~ionaJJy be associat.ed with HCP. but more often merely represents expansion of the third ven' tricle and separation of the late ral ventricles) B. . epto-optic dysplasia: ,~ P08~ 122 SIGNS AND SYMPTOM S OF ~ HCP in young c hildren 1. cranium enlarges at a rate> facial growth 2. irrilability, poor head control, NN 3. fontaoelle full and bulging 4 . enlargement and engorgement ofs~alp ve i",,: due to reversal of now from intra_ cerebral sinuses due to inc ",,"sed intracranial pr""",ure" S. Ma cew en's s ign: cracked potlOund on percussing over dilated ventricles 6. 6tb nerve (abduce ns) palsy: the long intucranial course is p08tulated to render this nerve very sensitive 10 pressure 7. "aettjngaun sign" (upward gaze palsy): P arina ud'a syndr ome from pressure On region of supra pineal recess 8. hype ractive renexes 9. irregular respirations with a pneic spells 10. splaying of cranial sutures (seen on plain skull ~-ray) 10 older childrenlad uJt.s with rigid c ranial v a ult Symptomsofincreased ICP. including: papilledema. lilA. NN,gait changes. upgaze and/or abducen s palsy. Slowly enla rging ventricles may initially be asymptomatic. CHAONIC HCP Features indicative of ~h.onic hydrocephalus (sa opposed 10 acute hydrocephalus): I. beaten copper cranium (some refer to beaten silver sppurance) On plain ! kult ~_ ray". By itsel f, does not correlate with increased ICP, however wilen auociated with ' 3 and U below, does suggest I ICP. May be seen in cranioayTlO$t08is (..... pnge 101 fordeacription) 2. 3rd ventricle herniati ng into &ella \Been On CT or MRIJ 3. erOllion of sen a turcica (Illay he due 10.2 above) which &101eti.lnes produ""s an em pty ""lis, ond erosion .,(the do ..."", ..,11" 4. the temporal horna may be less proll"lillent 0\) CT than in acute RCP -5. maerocrania , by C(ln~ention. OFC greal<'r than 96th percentile.. '...... 6. atrophy of ool'J)Us CStl 06um; best appreciated on sagittal MRI 7. in infaOI$ A. sutural dillBus;s B. delayed closure of fontanelles C. failure to tllnve or devetopmenl.81 delay OCCIPITAL-FRONTAL CIRCUMFERENCE Tbe oc:cipi(al _fwnlal Circumference (OFC) shou ld be followed in every growing cllild (as partofa "wen-baby" check-up, snd especiatly in infants with doc:umented or suspected bydrocephalus (HCP)). ~ s rul e ofthU(llb, the OFC of a nonnal infant should equal tile distance from Crown to rump .. '.... ·- . Sf!<l pog~ 9 19 for the differential diagnosis of macroceph aly. '" 11. Hydrocephalu8 NEUROSURGERY Normal head (Towth: parallel. nonnal curve.a a. seen on lhe graphs on the in side front COlVer , Or in Fi,,,re 11·2 a.nd Fill"'"' 11-3 for preemie.. Any of the followirtg may . ig· niIY tnoatab!e conditioflt ",ch as active HCP, aubdu rt.1hematoma. or l ubdural elfulionl, and sho... ld prom pt an evaluation of tile intracranial contenta (e .g. CT, head UIS .. J: 1. ... pwa rd deviatiollS (croQ ingc ... rvu) 2. contin ... ed llead (TOw th or more than 1.25 emlwk s . orc approaclling 2 atandard deviatIon. (SO) above normal 4. llead g rcum ferllnce out of prOpOrtion to body length or weigllt, even if willi in nor· mallimita for al:'8 <- FiB"'"' " ·31"' ~ I ~ I ~ • » V /' u "» k' PERCENTILE i-- , -- H 1""1" H V j,,~ " V I H 1"'1" ~ /f 25'!- " I I I / I '~ ~ n ~ H I " " H 11_2 H JO 31 32 XI , . ~ :J& 31 .... e e KS OF a e S l AlIO .. • ~ , H ~ , ." Theseconditions may al&o beseen in llie-cateh·up pll8Ml"ofbrain (TOwtll in premature infants aller Uley reCOlVer from thlli r acute medica] iIIn......., . . Colclo ·"p p",,"" 0( /lmin 8rowth page 864). Devia l iona below the c ... ,.... or ne..d growth in the prematUnI infanl in the neonatal period oflesa Ulan O.Scmlwk (excludIng lhe fint few weeka ofli re) may indicate rnicrooephely (,« pagt 113). T"",hn;qu,"c m~ ... ," eircumr.... nce arou nd rordtttad and ,,"ipul (ucludinj: ea.,) tllree consecutive timn, and use the Ia.r:n4l. value. orc i. then plol.ted on . gra pll oraverage values as a functi:Hl or age- and followed for each individual patient. Use the graplls on the in$id .. front cover for most cllildren and adolt!K<l' Dta. The .... ph in flBurt 11-2 11101011 the ore for premature infanta .. a fwK:tion or ee-ta tionalap up to term. Th .. grBpli in FiB"'" 11·3 aliowl the n lationltt.ipo(lIead circum(trflnce, weillllland length for v.riou. gestat ional agea. 11.1. Treatment of hydrocephalus MEDICAL HCP nlm.in s .. lurgicaJly Lreated condition. ~tnol.mide m.y be helpful !"or temporizing <1ft btlow). NEUROSURGERY '" .. " " -l • • _I • •» • '"., • " ,.", "u ..••, , ~ 1/ b#J J '1.0 ' ~- 11 .0 f-7 r -~ CL ~ - 7 , ;7 ~ -,=- .. - , U ~ 7" . -. - - -- - ."" - -~ . -212130J2:Ull5 001 ' " poe ~ - = ~ ~ <0 U , , .1"> ,,- /c , 7' /'" ~ "7 7' - ,, ~ ~ /' -- = = - • • ., ~- ~o. .. 2!)0. -.~ {WIlMs ~ .- - - (/IIotII"" parium) .2 '" ~ t I •~ Flgwe 11-3 Head Qlcumklrera, ~1gN and length (_ _ I!om Journal 01 _.,11<8, ~ Go""", to< .... Cheal ~ at 1nIanI. 01 Varying 0 ... _Age·, IIIIIleo:wISG. _ G l, ...... ""eI5 , wiIII~' .........) Di~li c the rapy Ma, be lri~ in pI'MllI lun! infan\.!! wilh bloocty CSP (.. long" the.re i, no ~vide~ of&etw. hyd....,.,phalLl5) ",h ile waiting to lee it lhere will be resumption ofnOtmBI csr .l>3olll';OIl. H_ev~r. M be" Ih i. .hould only "" colllid"red u lin ~djund to definitive trealment or a.s 8 temporizing I'IlflaluN. Seli5fact.wy con trol or Aep '"'11$ reported in _ ~ ofpatienu ofare <: 1 yeer who had . .... bl" v;1;61 s;rn-, IlOrmal renal function.nd no symptoms of"l.... tood ICP (apnea , Ielhllf'D'. V1Imitincl u!!ina" ~ foll_i,.,...: .eel.~ol .mide (a ce!"bo.uc anhydrase inhibitor): 25 mgl'kWday PO divid~d TID • II 1 day, inCrell!le 25 mgI'kNday -n day \1ntil 100 mlJl'lWday i. r1!6ched ,;multanew5ly ftort tul'ON.lnide: 1 .Wday PO divideod TID to oaunterltC;l acid..;. tridtrl~ (Polyctr4) 4 mlil<,dly di ..idtd QIO (.ldI rr.l it iquiul... l W 2 mEq ofbicarboalle, snd conlai ... I mEq K' .nd I II:IEq N,,') • mtlu ure MorialtledrolYIU. and adjult dONp 10 mli " t.sin &en"n HC03 ,18 mEqfL • chlnge to Poiydlrll·KII(2 mEq K' per ml, no "'I') ifMnlm poUiaium" cornu low. Or to iOdium bicarbonlte: ifHTU ra aodi um beoc.Gmellow Witch fo. O!JM'l rfll)'tl imbJ,J&IlCI and Ic:fItll.Ollmid • .ul1I.rr_.... IlIlhll'2)', t&chypM I, dia"hea. perislheilu (.... tincline in It>. tincenipe) perform weekly UIS or CT tean and Wart ".nllieul,r shunt i t progr",i... ""PI\riC\.llomeca!yoccu,..,Otherw.lt, ""inlain therapy fo. aSmo:o1h tn.I , th.n la per dOSllIl" ovllr 2-4 _ h. Ruuma 3·4 "'(110 of t reat mtlnl .f~ye HCP occur. • . , NEURQSURG8RY SPINAL TAPS HCP after intraventricular hemoTTh age Illay be only tranaient Serial ups (ventricular or Lf"O) may ~."porize u.otil resorptioll resumes bu pogf 864) but!.Ps can only be pe rformed for communicatini HCP. Hrea bsotption does not resulM wilen tile pro~in (on tent of theCSF is < 100 mgldl, then it i. unlikely that sponta neous resorption will oc· cu. (i.e. a sh unt will u~uany be necessary). SURGICAL Goals of therapy: Nonnal sized ventricles is not the goal of therapy. GoaJs are optimum neurologic function and a good COIIroetic result. Options include: 1. choroid plex\!ct(ltlly: OOBCriOO<\ by Dandy ill 1918 fOf communicating lIydroeephalus". May reduce the Tate but does not totally halt CSF production (only a portion ofCSF is secreted by the choroid plexus, other souroes include the ependymal lining of the ventricles and the durolsleeves ofapinal nerve roots). Open surgery Wa! associated with a high mortality rate (possibly due to repla".,. ment o(CSF by air). EndOllCopic choroid ple~us coagulation was originally de· scribed in 1910 and was recently T€SUTTected" 2. eliminating the obstruction: e.g. opening 1\ stenosed sylvian aqueduct. Often high· er morbidity and lower success rate than .iro ple CSF diversion with shunts, ex· cept perhaps in the case of tumor 3. third ventriculo~tomy : (sec b<Jlowl 4. shunting: various shunts are described below - ventriculoperitoneal, ventriculo· atria l, ventricuic>pleural. lumboperitoneal ... T hird ventric ulost omy There hu been a resurgence of inteT€St in third ventriculClStomy (TV ) with the recent incl'(!aeed use of ventriculO$copic surgery ($et! pas.. 622 for technique). Ind icatiolla: TV may be used in p!ltients with obstructive HCP. May be an optioo In managing shwlt infection (as a tIlean' to remOve al! hordware without subjectIng the pa· tient to in<:Teased ICP). TV has also been propoeed 88 an optioll for patients who devel . oped sobdoral hematomas aner shunting (the shunt is removed befoN! the TV is perfonned). TV .,,8Y alao be indicated for slit ventricle syndrome (see fXJiIe 197). COlltr aindiclltion.,: C<>mm"nicati"8 hydrocephalus is considered a oontraindlcation to TV. Relative contralndication8 to TV would be the presence of any of the oondltiolls asso· ci"ted with a low succo''IlI rat(> (su ~Iow ). Complication s: 1. hypothalamic uuury 2. t ransient 3rd and 6th nerve palsies 3. uooootrollable bleeding cardiac aTTest" 5. traumatic ha,ilar artery aneurysm": pO$.9ibly related to thennal injury from U911 of lase. in performing TV Succe$8 r ate: OveralllucceJ;;S rat(> is _ 56%(rangeof6l).94% for nontumoralaqueductal stenO$is" (AqS)). Higheat maintained patency rate i5 with pnviously untreated Il(:qu i~ AqS. SUC<:e&o ,"te in inrllnt.a "",y Le po<>r beu. .. "., they mill' not hllve " n ormlllly developed subarachnoid spllee. There is a low success rote (only _ 20%ofTVs WIll remsin patent) if there is pre.eristing pathology including: 1. tumor 2. previous shunt 3. previou. SAH 4. previous whole brain radiation (succes.'lwith focalstere<ta<:tic radiosurgery is not known) 5. s ignificant adheSIons v'sible when perfornting through the floor of the third ventricle at the time ofperfonnance of TV 4. 11.1.1. See Shunts V~nlric!d<>r shunls NEUROSURGERY on page 620 for surgical insertion pointers. 11. Hydrocephalus '" TYPES OF SHUNTS SHUNT TVPE 8Y CATEGORY L v~n lriculopentonta l 2, vlntricu!o-atri, 1(\IA) "hunt {'~ lilkuIAr .hunn: (VP ) ' )Hun: A. 1II00t commonly IIStd I hllnt In mod~rn IN! B. Ii tt rA! vtnt.ride IS t h. l.IIuol prOllimplloca tion A. s hunu vI"triclel throughJugular vlin to,up"nor ~In~ CiV., 1O-C.1Ifl1 "ventneule-.tri.l" I hunt b6ctUlI it , hWlu the N",bral Wlilnc/~. to !.he vaKultr .Yitem with thl eath~ter t ip in thl ,-.gion of the rilhtC4J"d1oe gtrlllm) B. tr~ .. lmMnl of chOice w)"ln $bt!om;1UI1 SbnortIlAlit iH ... pr_nt (Utfnllvl IIbdomlnallUl"(f!r")', pentonlli" morbid obesity, in preemw who hsW! had NEe snd 'My nol t.>lenw VP .hun t .. .) C, I horter ll1ngth of tubing ""ulla in lowe. d;'tal PT"@UUNllnd leu tJphon Irfect Ihln VP IhUlll 3. Torki ldGAA . huIII: A, shun t...eo.lricle tIJ ciaw,nal,par:e B, rarely used C. ~ffertJ~, only In .equired ob.lrocUvt HCP. II petlenl.l with eotllenital HCP frequently do 001 do:\velop nonoallu!)srtc:hnoid CSF pe.thwa)'J 4. m;"ceUanl!Ou,: vlriou. distal prajectilHl' u,ed hiltorie.lly 01" in Pl'tienlawho l.. vI had l ignifiesn! problem. with tradiUonal I hunt 10000lioni (e-l. pllritonlti. with VP shuot, SBE with vascular . hun1.l): A. pleursl spIlee tventricu] o pleura l l hunt): not I r.rstchoiCII, buill ';shkr altemsLlve if the pe-r;tol>l!um is not sVliltble'S. Riak of ;r;ympt.>nllllic h,.. drothorax nece8IIitallnlf relocating d istal end . Recom~ only fM peuent.s" 7 yn.1t'! a, gall bladder C. ureter orbladder: CIIU",", electrolyte imbala_due!.O 10..... throuch urin .. 5. Lumboperitonea' (LP) ,hunt; A. only ror communie.rtinll HCP: pnmariiy pr;eudolulDOl' teTl!bri or r1.&lu)s". lhIeru l in lIi tullionl with IImall " .. ntricles B. o"er ale 2)""S. perculaJl~ul iDliertiot\ with Tvoby ne.IJe ia pre~~ 6 tyIIlor llubdursl,hunt: from 1IJ1Ielwoid CYlt Or 50bdural hygram. ClIvi!)" ususlly \0 ptriwne ul1l csr Djl!adyantages/con;r pi icationa of varioul ahunts I thOMlthat m.y occu r with lillY 1hunt: A. ot..truction: the UlOIIt common cau'" or,hunt malrunction • proximal: v~ntrieullr CIItheter flhe mott tommon "i~ 1 • valve ml!'Cllanilm • distal : reported incidfflClof 12-3-4","". ~ in petito"'!a] cathel.er in VP Ihunt 411ft below). ln atrilll CIItheter in VA . hu."1t B. diKOnnection lit ajunr:cion, 01" break at IIny poIn t C. u.feclion O. hardw ..... ef"OlJlon thl'OUlh sk in, usually only in debilitated plltienlt (espedally preemies with Inlllrpd herodJ; and thin SCII lp rro m chronic " CP, who lay on OfIe aide of head due to elonll"lt.ed cr.nium). Mil,)' a lso indicate .ilicolHI allergy (_ belOUl) E. KWi1U (venlricula • • hunl.lonly}: (hue il - 5.Kriskol",ri~ul"f.in the first year aft.er pl_1Mn1 01. ,hunl which drops to - 1.1" ancr Ihe 3rd y ...... INa; this d_ nO{ IIINn th at the I hUll! 101" the caulII! or.1I of th_llri,urM) Sei~ure ritll ItqustlolUlbly hia:herwith ,","1.11 CIIth.,tertthan with parieto-lI«i piW F. Itt nl conduit fo.ntnlniuraJ mfllMlUftofCflrUln tu monr (e.1o medullo- bI •• toml ) Thi, i. probably I relativlly low n&k rr G. "licone .Ue..,... rsrelifitOtt\lrt.1 1m. May 1'fIM00bIe .h uM InfKtion WIt h ,ki n breakdown and fllnptill(lI'.nulomsl. CSF i. in,tially Iterile bu~lster infection, mil,)' oc~u r. May requi rl f.tobrication of a ClJllOm $iJicone·free d .. viCII.(e.lf. poI)'urethane) 1. VP lhuDt; A. ,7'" ino;:idO!I>re inguinll hernf. {",Iny IIhuntl are il1Mrtad while pnlCIIIL~UII "I" nali, is patenU"" B. need t.>lengthtn artMI.fI" WIth ,",wth: I1Ily bt obviltAro:! by usin, 10111 peri. 08' NBUROSURGBRY too"ol catheter (IOU page 621) obstnJctio;>n of peritoneal catheter: • may be more likely with distal ~lit openings ("alit valves") due to occlusion by omentum or by trapping debris (rom the ahuntsystem" • by peritonelill cyst (or p8IIudoc)'!lt:r"': ""usHy lL$$OCiated with infection, may alllo be due to reaction to talc from aurgical g loves. It may rarely be necessary to differentiate a CSF collection from B urine collection in patlen!..! with overdistended blpo:idel"$ that have I"\Jptl1J"ed (e.g. seeondary to neurogenic bladder). Fluid Can be aspirated percutaneously and analyud for BUN and creatillille {which should beabsent in CS FI • severe peritoneal adhesions: reduce surface area for CSF resorptiOIl • malpo.'lition of catheter tip: at time of surgery: e.g. ;n preperitoneal fat tubillg may pull out of peritoneal cavity with growlh D. peritoniti s from shunt iofe<:lion E. hydrocele F. CSF a..:ites G. tip migratioo • inlo acrot um" • perforatioll of a viecua": stomach", bladder ... More common w;lh older spring- reinforced (Raimondi ) shunt tubillg • through the diaphragm" H. intestinal obstruction (as oppo.iled to perforation): rare I. volvulus" J. intestinal strangulation : occurred only in patients in whom attempt was made to remove peritoneal tubing using traction on the catheter applied at the cephalad incision with subsequent breakage of the lubing leaving a residual intraabdomi.nal aegment (immediate peritoneal exploration," re<.:ommended under these circumstances:r'" K.. ov.. rehunting: more likely thao with VA shunt. Some recommend LP shunt forcommu>licati>lg hydrocephalus (su pagt 196) 3. VA shunt: A_ requires repeated lengtherling in growing child B. higher risk afinfe<.:tion, oepticemia C. pOssible retrograd .. Dow of blood illto ventricles i(valve malful)Clions (rare) D. s huntembolUll E. v8.I!Cular complicatiOM; perforation , thrombophlebiti s, pulmonary mie...,.. emboli may cause pulmonary hypertension" (i ncidence _ 0.3%) 4 . LP ahunt; A. if at all possible. should not be used in growing child unless ventricular aeceSli is unavai lable (e.g. due to slit ventricles) because of: • laminectomy in children ~auses !>COli,,"," in 14%" • risk of progo-essive c.. rebensr tonsillar hemiation (Chiari I malfonna. tion)" in up to 70% "fcase..... " B. overshunling harder to control wh .. n it occurs (a special horironlsl-v.. rtical (H -V) valve increa8e:! res;"lance when upright,..,~ ",,-I()W) C. difficult access to prox.imsl .. nd fer r.-visienorassessment efpatency (ueLP shunl eIJaiualion, page 622) D. lumbar nerve root iniUltion (radiculopathy) E. leakage orCSF around catheter F. preuure regulatiol) i. difficult G. bilateral 6th and even 7th cranial nerve dysfunction from overshunting H. high incidence ofarachnoiditi. and adhe\lioJUI c. MISC ELLANEOUS SHUNT HARDWARE L tumer filter, used to pr.-vent peritoneal Or vflS<:ular S<'ediog in lumor. that may metastasize through CSF (e.g. medulloblastoma". PNETs, ependymoma); may eventually be<:ome oco::luded by tumor cells I!lIId need replacemenl; may be able to radiate tumor filter to "sterili,e" it. The rak of "shunt meta" appeaJ"ll to be 10...... 2. antisiphon device: prevents siphoning effect wh .." patient ill er"i!<:t 3. "horizontal_vertical valve" (H-V valve) Ulied with LPshunts to increase th .. valve resistsnce when the patient is vertical to prevent overshunting (He page 193) 4. e>clemaUy programmable variable pressure valv"" NEUROSURGERY 11_ Hydrocephalus '" 5. on·orrde .. k.; uad w open or oa:lud•• hun t '~8t(l\Jl tinn of . hunt (I.g. Portlloy device) b~ ",;ng utom.l m. nipul.· SHUNT T'l"PE BY MANUFACTUR ER Nu.oe .........hunt . ylte.o. .... on the lIllI.ket. The fQllow;ngdeKribes the M.1ie flt fea · ture. or lOme commonly ulled .hunt.. Di'gr.rna Ire not 1(I1I:.le. X·RAY "P~AAANCE OF SOME Sf/UNTS fbe followIng figure depictt idu.linlI. x· ray appearan~1 of IOnia <:<I)",,,nn th""u.. Agurfll 1 ... X..... y appelllince 01 common SIIunI. P$ MECNC/tUMEDTRONIC ","'"." 125 C.tlrnona Dr. (lop view) GoIttIa, CA 93117 USA (800) 826-5603 ':I:":f!'W.1!!!d!'0!!1£,9O!D Stand..rd co ntoured valve A li n, l. one'''' IY Dl<!:m· brane "II... de.ign. The. ra· dio-opaljue l/TOWhead point. in the di.-.d.ion ornow lI« Figurt J J·41. Pumping tbe .... I..e To pump Ule Ihunt in the "forward" diNld..on. r;Tlt occlud e the in18t pori. (1ft Figurt J l.ff) ,.,ith p,"*ure from IIlIe fi nger on the '"i nlet occludet'" {pn!~entt bao:k. .. , _ !low !low (lode Yiew) FIg"" I 1-$ PS Medio;aI-.cIatd -....:I "I~ NEUROSURGERY nnw into the \il'ntridl! du ring the .)\,,,t step). The n whlle main:ainin& t his Pre5!lutll. (II!'ptell5 the ruervoirdome with 118/!(X)nd fin,ar. Ro!lel\se both finGers, and repea t .1'1lE! One- way vllive reguJate8l'ihunt pfeMu re and p.... vl'nlll reflux of CSF during normal during the rel<!lll$<l ph8~e of shunt pumping. w;e and X'rpy c ba r acter iiticii The lhree ava il able valve pressuret an indicllt.ed by rndio-opaque dou. on th~ .,,,,lve (allow5 x-ray identification Qr"alve preuure), one dot :. low prell!lur~, two dots z medium. thfSle (lotll .. high r;.~:r~~~~::~~M~EP~,~:t::~,.. _.. ..... STB> 1 FIgura 1HI Pu"lf'lng!~ cl!tprllSS poolp ctIamber PS MedIcal vaIYe Strata® program m able valve The Medtronic Strata valve is aD utemll.llya!(jUlltable "alve thllt i. pro8Tllmmed (Ulling II magnUjtooneoffi"e perfof[oaoCill evel I"P/L- ) setting!! (Filllire J J-7). Bi!cause tile YDlve mil)' be inad_ venently reprogrammed by external magnet.a, the patient must be in formed to have the \/lI]ve setti llg thecked aFter an MRI performed rOT IIny reaSOn . SOPHYSA USA Sophvsa USA, Inc;, 760 WEtSI 161h 51.61dg. N. Costa Mesa , CA 92627 USA (949) 546·6484 www.sophysa.cgm P o l" n .. p ....gy...... m .. bl .. vw" .. The Polaris"V ... I,,", ial'" H lernally programma· ble valve thai \ISe!I two attracting Sarnor iUlDCobal ll1lagne.t8 to loel< the pressureaet\ingllod to ,.,.ilJl. inadvertent reprogramming by e.",i. ronDlent.ally encountered magnetssl.lch at MR! 5el!onen>, oelt phon"_ headphon es .. Available in 4 rnooels (dim-rent preasure ranges. ea~h identified by II unique nllrn· ber ofradio-opaque dotal, each wit h 5 extemally adjustable posit ionL The ~-ray appeara nce and correBponding pr\l.'!SU'1!S lire .hown in Figu.re 11..8. NEUROSURGERY II. Hydroo:ephalU5 '" NEUROCARE Oisl<ibuted in U.S. by; NeuroCare Graup 8401 1020d Sireel Suite 200 PIBasanl Prairie , WI 53 158 (800) 997·4868 Heye ....SChu tte The t.PV nlye i, shoWn in Figun! //-9. To pump the sh unt, o.;d u<il'o inlet port wiLb eM fiel:er. -Figure I I,; Heyer..sct\ulle LPV® (IGw.prollle) ya"-'e (sideYlewl then depl'(" ~ reservoir with anelber linger (as for the PS Medical "alye, "'~ 000 ... ). This "alYe ma,y ~ il\iected in either djr~tjon by depres.ilW tl1e appropriate occluder while il\iecting Into ttle re!Arvoir. ,"","::",",,,;:;;:;:;,,,,,,,,,,,,,,,;;:;:;:;;;;;:;-::;;;;;;;;;:::1."" HAK!MSHUNT Dlslribuled by: Inlegra N6U(OSC'Bno;es In lhe U.S. ~ 311 Enterprise Drive PlalnsbalO. NJ 08536 (800) 654·2873 tl.!!P :I~_i!lt'9ra-ls corn A dual ball·Yal"e Flgu.e 11 -10 Hakim StaJl(lard M6ehsnosm To pump shunt. depress the indi · CIted portion of tl1" "IIYe. NS, Wuwt. tap be ... , liS the sHirone elastomer bousing is not .-.elf-scaling. The ant.eehambe. Is provided for this type of 1~88. mechlni~m . '" It Hydrocephalus NEUROSURGERY INTEGRA HORIZONTAl-VERTICAL LUMBAR VALVE May be u!led in lumboperitoneal shunt to increue the transmiS9ion pres· sure ",hen the patient i~ upright 1.0 pre· "ent o"ershunting. Markings used to orient the de"ice during implantation: I. an arrow On the inlet side of the unit indicates direction of now 2. inlet tubing i. clear 3. inlet tubing has s ma lle r diameter than outlet tubing 4. ou t let tubing is white 5. before position ing t he valve and fastening it to the fO.6Cia with per· Ulanent suture. t he valve shou ld beconnected to both the subarach. noid catheter (iD let) and the peri· toneal catheter (outlet). The arrow on the inlet valve should poiDt tQ. wards the patient's feet ... /esistance Figure "-'1 Inlegra H-V "a"'a HOLTER VALVE' Distributed by: Cadman & Shur1leN Randolph. MA 02368 (6 17) 961-2300 A dual .lit valve mechanism (set Figur-e , I · 12). Usually used in COmbination with a Rickham orSa lmon-Rickham reser· Wli. (_ FiJluNI 11.13). To pump the . hun:, simply depress the indicated portion or t ~ valve. X-ray charac te r istics The sil astic tube bet ween the two one-way valves;$ radiolucent 1_ Figun 11.4, page 190). SALMON-RICKHIIM RESERVOIR Simi lar to standard Rickbam ruervoi . 8)l'cept for low· er profile lou FiJlun 11· 13). "·'3 FIgure SaIIl'lOl'l-Rick· Mm-.. 11.2. Shunt problems Neurosurgical eva luation i5 usually requested for patients with a CSF $hunt with variety ofsympWms. Shunt ·problema" usually involve one or more of the followi ng: 1. ~nde~hunting ($u belowl } accounts tormostOJllVTlOO!.hunt problems 2. ",factIon (su pa~ 214) 3. overshunting: slit ventricle syndrome. subdural hematoma~ .. _(ue page 196) 4. seizures: 8U POll~ 188 5. problems ~l ated w the dilltal catheter A. peritoneal: IIt:~ pag~ 188 B. atrial: IIt:t page 189 6. skin breakdown Over hardware: inrection Or silicone alle rgy (ue pagt 188) NEUROSURGERY 11. Hydrocephalus '" TAPPING A SHUNT indicllti(ms to Ulp a shunt or ..entricular ac~s.s device (e.g. Ommays reservoir) indude: 1. to obtain CSF' specimen A. to evaluate ror shunt infedion B. for cytology: e.g. in PNET to look for malignant cells in CSF C. to remove blood: e.g. in intraventrioular henlorrhage 2. to evaluate shunt funotion A. measuring pressu res B. contrast studies: I. proximal injl"'tion ofenntrast (iodinated or radio·labeled) 2. distal il\jection of enntrast 3. a8 8 tempori~ing measClre to aUow function ofa distally occlClded shunt"", .. 4 . to inject medication A. antibiotics: for shunt infl"'tion or ventriculitis B. chemotherapeutic (antineoplastic) agents 6 . for oathetel"!l placed wi t hin tumor o)'>lt (not a true shunt): A. periodic withdra ... al of accumulated fluid B. for injection of radioactive liquid (usually phospilorous) for ablation TECHNIQUE (For LP shunt. see LP shun' ~!JfJ1ualion. page 622). There is a risk ofintrodudng infection with every entry into the .hunt system. With care, this may be kept to II minimum. I. ~h a ve area 2. povidone iodine solution prep _ 5 minutes 3. use 25 gauge butterily r>eedle or smaller (ideally a !>Oneoring ne<ldle should be used); for routine taps, tile need le should only be introduced into shunt compo. r>entll specifically designed to be tapped To measure pressures Steps are outlined in TaMe 11·2. Table 11·2 a s hunt neous IIow into btmertly tubing; S-i.J.e in manometer IN STRUCTIONS TO PATtENTS All patients and families ofpatienta with hydrocephalus should be instTUoted reo garding the followjng: 1. signs and symptoms of ahunt malfunction Or infection 2. not to pump the shunt unleu instructed to do SO for a specific purpo:se 3. prophylactic antibiotiC!!: for the following si t uations (mandatory in vascular shunl.!i. somet imes recommended in other shu.ota) A . denUlt procedures B. instrumentation of the bladder: cy~l.O!!copy, CMG. etc. '" II . Hydrocephal\l.!l NEUROSURGERY 4. in 0 growing child: th~ need for periGdicevaluation, including asses&mentofdi.r;tal shunt length UNDERSHUNTlNG The sbunt malfunction rate is _ 17% during the finlt yea r of placement in the pediatric population. May be due til one or a numbe r of the following: 1. blockage (occlusion ) A. possible causes of occlusion: 1. obstruction by choroid plexus 2. buildup of prot.e.inaceQus accretions 3. blood 4. cells (inflammotllry Or tumor) 5. secondary to infeclian B. site of blockage I. bloek.sgeofven tricularend (lTI(Istcommon ): UBuall,y by cbaroid ple"u", may also be due to glialadhesioru;. intraventricular blood 2. blockage ofint.ennediate harowan! (valves. connectora, etc., tumor fil. ters lIlay become obstru~ by tumor cells, antis ipoon devi~ may dose due to variable overlying subcutaneoU8 tissue pressun!~) 3. blocked diltal end (U<I page 189 for VP sbunt) C. diSC(lnnec:t:on, kinking or bn!akage of system at any point with age, silicone elastllmera used in ca theters calcify and break down. and become man! rigid and fragile whicb may promote subcutaneous att.chment'". Barium im· pregnation may accelerate this process. Tube fractures often OCCur near the davide, pn!9UJl"1ably due to tbe incn!osed motion there Signs and ayruptom s of undersbunting SiIWS and symptoms a~ th08e of active hydrocephalus. and include: 1. acute axDlJ>12m~ of incn!ased intracranial pre$l!ure A. HiA B. NN C. diplopia O. lethargy E. ataxia F. infants: apnea and/or bradycardia; irritability C. sei~ure8: new onset, increase in frequency, Or diffICulty in control 2. acute ainI of inCn!8.'Ied int racranial pressure A. upward gaze palsy ("setting sun sign", see Por;mwd', r:t"drorM, page 86) B. abducen. palsy: false localizing ,ign C. field cut, o~ blindne8g (lee RIi>ld~ss from hydroctpho/u.r. page 202) D. papilledema (rare before age 2 yt$) E. infants: bulging fontanelle , prominenlscaip veiD~ 3. swelling around ShUDt lubing: caused by CSF dissect.ing along shll!lt tract 4. chronic chongu: before sutures close. OFC, crossing curves EVAl.UATION OF SHUNT FOR UNDERSHUNTING I. history and physical directed a l det.ennining pres ... n"" of above signs and symp- tom9, al,o ascertain: A. reasOn for initial insertion of shunt (MM, post· meningitis, etc.) B. date of last revision and reuon for revision C. Pn!sence of accessory hndware in system (e.g. 8Jltisiphon device. etc.) D. for child ren: OFC. Plot on graph ofoormal curve!! (use existing cbart for that potient ifavai lablel E. fontsnelle tension (if open ): a soft pulsating fontanelle varying with n!spi· rations is norllU'll, a tense bulging fontanelle suggests o~t ruct.ion , a sun ken fontanelle may be normal Or may n!presenlovenhunting F. abi lity ofanunl to pump and refiU 1. tautian: maye~ac<lrbat.eobstruct.ion, upeci,ll,y if shunt is occluded by ependyma due to overshunting: controvenli.1 2. difficult to deprf!u: suggests distal occlusion NEUROSURGERY 11. Hyd rocephalus '" 3. slow to refill (genua!]y. any valve should refill in 15-30 &eCS): liuggellt8 proximal (vent ricular) occlusion G. evidence ofCSP disse<:Ling a]oniliract outside "r,hunt tubing H. in children pffsenting only with vomiting, espe<:ially those with cerebral palsy and feeding gDslrOllt(lmy tubes, rule-out gastroesophageal cellwc radiographic evaluation A. "shunt leries" (plain x-rays to visualize entire shUnt' ror vP ahunt, AP & lateral skull + "low· eXR and/or abdominal ,,-rayl I . RIO diSCOI\l1«tion or migrat;"'l of lip by x·rays 10 visualize entire shunt; note; a disconnected .hunt may eontinue to function by CSF now through a fibrous USC\.; the ("l1owj"8 hardware may be radiol u. cent and Ca n mimic disconMCtion: 8. the central silastic pan. of II Holter style valve b. conn~tors IT & 1'" as well as straigtlt) c. antisiphon devices 2. d. (uroot filters ohu.l" most recent ,,·ra)'ll available 14 compaN! for b~ak, (essential for "complicated" shunts involving multiple veutrkular or cyst end~ or a«essory hardw~) 8. in patients with open fontanelles, ultrasound is optimal method of evalua· tion (especially if previous UIS available) requi red if fontanelles dMed. may be desirable in complicated shunt C. systems (e.g. cyst shunt.s) D. M.Rl: too <:(I9tly and I tow for routine shunt evaluation, shunt hardware is difficult to see, However. may be inva luabl,! in complicated cases (may show t r ansepe Ddy ma l a bso."t ioD ofCSF,loculation l ... ) E. ·s hunt..,·gram" ifit is still undear ifshunt ill functioDinG I. radionuclide: see tH.low 2. x·ray: using iodinated co"tra~t..: lI"~ tH.low 3_ shunt tap: indica tions vary, generally performed if surgical exploration is consid. ered or if infection is Itrongly auspected (see T"ppilliJ" sh unt, page 194) 4 . shWlt exploration: sometimes even aner lhorough evaluation lhe only means to definitively prove or disprove the functioning of various s hunt components is to operate Dnd isolate and Lest each part of the system independently. Even ""hen infection is not suspected, CSF" and any removed hardware should be cul t ured . 2. cr "Sb un t-o-gram " Procedure: ahave hairov'!r N!servoir& pN!pwith Betadine. With patientaupine tap the shunt by iru;ertinK a 25 Kauge butterfly needle into the reservOir. Measure tJle pN!Ssure with a manometer . Patien ta with multiJlle ventricul8Tcathetera need to have each injE-c:ted to verify its patency. Rad i()Duclid .. "shunt-o·gram" AKA radionudide shuntogTaphy>': after tapping the shunt, drain 2·3 roJ ofCSF and seml l rnl erCSF fo r C&S. l'1,iect radio-;sotoJle (e.g. for VP shunt in an adult, use I roC; of-1'c (techne<;ium) pertechnetoU! (usabla !"\lnge: 0.5 to 3 mC il in l« ofOuid) while occluding distal now (by cornpressinK valve o. occlud· ing portsl. Flush in Isotope with remaining CSF. JJO.O\ediately iroage t.he abdomen with the gamma <:amera to .ule out direct injection mwdistol tubing. Image the cranium to verify now intoventridea (proximal paU!ncy). If spontaneous now into abdomen is not seen after 10 minutes t.he patient is sat up and rescalUled. Ifllow is not seen after to minuU!$, then t.he shunt is pumped. LooII: fer diffusion of the isol4pe withill the abdemen to role out llII\!udotyst formation aroWld catheter. X-ray "s bunl·o-gram": aner tappilllf the shunt. drain ~ I ml ofCSF and send for C&S. Ir;je<:t e.g. iohexol (Omnipaque 180) (see palft 121) while octludinK distal lIow (by <:(Imp.easing valve or occluding portal. S HUNT INF ECTION See Shun' inr~clion on pOKe 214 fo r evaluBtion and treat.menL " O VERSHUNTIN O" POSSIBLE COMPLICATIONS OF OVERSHUNTING INCLUDE"-" l. '" $Iit ventrides: including slit ventricle syndrome (:ret! II. Hydrocephalus ~fcu,) NEUROSURGERY intrat.anial hypotension: fU bIIloUl subdural hematomas:"" pag~ 198 erSniO$ynoel.oeis and microxephaly; <ontrovl!l"$ial (fU pngt 199) stl!noeis or occlusion of sylvian aqueduct 10-12... of long-term ventricular ahunt patieots wi!! develop one of the above problem ..... ithin 6.~)'l"8 of in itial I hunt ina"'. Some nperta feel that probleml relaud too"ers hllnt;na cowd be m\lIted hy IItilizina Lp , hllnl.l for communieating hy~phalll', .... d r"erv;na ventrieular . hl,lfl!.ll foroburuetive HCP". VP s hun ts may allo be more likely to overd rain than VA Ihll nts beelllie of the longer tllbing- INaler s iphoning e(fett. 2. 3. 4. 5. I NTRACRANIAL HYPOTENSION AKA low ICP . yndrome . Very rare . Symptoms limila r to thOM oflpinal HlA (poa. turll in n.tu.e. u.l.ified by mumOOncy). Althouah uSllally not .ssociated with the fol, IoWLnglymptoml", the" m.y occu ....; NN, lethlrgy. or neW"Ologic 8ian8 (e.g. diplopi •• UPflIU! palay). $oml!timel the Iymptoml resemble thOll! of high ICP ncept that t hey are relie'lfil wheo pron.ate. Mllte effects that m.y occu. indllde": tachycardia, lollS of oon.,now ......, other br. in atem deficits dlle to a roatral.hift ofth.. intracranial cont.:m ts or to low [CPo Etiology i, I.iphoa ina .ff«t due to thl! column ofCS P in the ShW1t tube when the patient iI erect-. Ventricles m.y be llit·li lte (u in alit "entricle syndroml! (SVS))or may be norm.1 in appearance. So~timel it i. OI!OI'IIIU)' todocum.."t a drop in [CP wh en iIG' ing from .upine to ert'Ct III diagnoH thil condition. ThI!8l! patients may alro dt'Velop Ihlln t occluaion .... d ~ the distinction from SVS bill" (..... bt-Iow). With _hon-term Iy mpto ...... n ASO is the treatment ofclwice. However, patients ... ith Iong .. tanding over!lhunting may not IlIleratl! I!fforti to retllm intT.ventriclIlar pres· lllre. to norm.l It'Vel ....... SLIT VENTRICLES 1. uymptomatio:: A. . Iit "I!ntrides (totally collapsed l.tera! ventricles) may be seen on CT in 3· 8O'J:of patients .ne. ahunting"'-". most.re a.symptou>atit B. these patienta m.y occ.as.ionaUy present with l)'Dl ptoJUlllnrelated to the . hllnt, e.g. troe migraine 2, 51it ventriclel)'lldrome (SVS): _n in < l~ ohll shunted patil!ntl. Subtypea: A. intennittl!nt shunt occl usion: ovel"$hllQtinglead. to ventricular c:ollap$f (Ilit ventricles) which caulles the ependymal tioing to occlu de the inJet porta of the vlntriclll.. catheter (by l:OIIpt.ation) prodllCing s hunt obIItrllCtion . With ti...." many oftheH patientl develop low ventricular oompliance"'. where t'Veo minimal dilatation results in high p","ure which prodUCl!ll Iympt.oml. Expanaion then f'lentu.lly reopell8 the inlet porta.Uowing resumption of drainage (Mil« the intermittent Iymptoms), Symptom. may rnembleahun t malfunction: intermittent .... ad.d..!s I,lfIrelated to pMtu.e, onen withNN, drowsiness. irritability .nd impaired menuUon. Signa may include6tb cranill nerve palsy. Incidence in Ihunud patientl! 2·~""""_ CT or MRI .can. may aJao .how t'Vidl!nce oft ...... epeodym.t .bilorption o(CSF B. totll,hWlt maUimttion (AKA nonnal volume hyd.oc:eph.lu"'): lilly occur Ind yet ventricles remain Ili t-like if the ventricl .... c.nnot expand betau. oI" l ubependymllgliol;'l, 0. due to the law o(Leplaee {whidlltatH th.t the praIIU", required llIeapand .I.a.,.e container .. 1(....... thIn the pre"u'l! reo quired to expand. Im.U container) C. VInoU' hypertension with norm.llhWlt funttloo: may result from paTti,1 veoo ... ocdlliioo that 0«11" io 110m. conditionl (e.J..t the lev.1 of th,jug_ IIlar foramen in CrouUln', Iyndrome)_ U'lIllIy sub.idea by adllithood 3. ....... patients with IdioPfotbic intracrani.1 hyputention (ptI!udOtllrno' ce.ebri. _ PfJIll 493) ha", .1it·Jika ventridu with COf\Iillantly ,l,vated ICP 4. intraCTInil1 bypotl!n.lon: .ymptom. onen relieved by recumbency (_ llbotoor) EVAlUAnoN OF SLIT VENTRIClES Th e ,hllnt v.lve fill ' .Iowly ifpUJllped whl!n thl! ventrides Ire ooll_pHd. Monitoring CSF preesllre: eitheT via illmbsr dr.in . or with. hllttl!rOy in ... rted into the ,hllnt re ... rvoir(wltil thil method , preU llrecan be followed during poItll.al chan ges NEUROSURGERY ", to look for MKali~ prn, untt when upright; possibly higher risk of infection with thi~) . The.. patientl Ire . 110 monJtored fo r pr.U unlt spi kes, especiany dunng ,leep. Alternatively, th eM patiwu may be evaluated by "shunt-o ·gtam" (Ht aboutl. TREATMENT In Iru tinr II pa tient with . Iit ventridell in imaging studies . iti, Impo rtant to aacer· tain int.o which of the " e&tegories (8ft .. bow) th e patient fal1a. [fthe pati ent can be catego:lrited, then the '!!<ki ne treU ment li sted below should be employed. Otherwiee, it if probably most common to initially treat the patient empirically as intracran;al hypotens ion , and then to move on 1.(1 Other method . for treatment failu reti. Asymptom a ti c , l it ve n tr icles Prophylactic upgrading 1.0. high er preH ure valve or ;nMrtion o( a n an!iaiphon d~ vice hul_llIel}' been abandoned . However, thia may be appropriate at the !i llM! of.hunt revis ion wilen done for otller realOna" . In trac r a nial h ypote n s i on Postural lilA due to In tracrani. lllypowMion (tN tovtrslluntingl it u. ua IlYHlflim. ited, IIoweve r, iflym pto~ PI! ... iet af't.er _ 3 da)'ll of bed . rU I ar>d an.!&uica and a trial witll. tigllt abdomi nal binder. \.he valve should be cllecked for Jlf'OPI!r elMing pr ... u .... Ifit ift low, ",pl.Cf! with. higt.erpreu url valve . lf il i. not low, an .nthdp ho n device (ASD) (wllich. by itself. al$O increases Ihe ru;ll.II nce of the Iyawm) .Ione or logether with" higher preuu re va lve may be needed" . S li t ventricle syndro m e Patients wi l h aympto ml ofSVS Ire actually .ulTerin, from inwrmllwnllti61t praaure.lftotaJ ,hunt malfunet i(m iI the ea ... se, then I h ... nl revilion;1 ,,,diQlted. For inter· mittent 0«1","00, treatmeM oplions include: 1. if sy mptom. 0C<:Ur early alter , h ... m inaertion Or revi.io", in;li.1 expecta nt ntln· .gement may be indicated "noe aym ptoml wllllpontalltomJy relOlve in I1).IIny 2. revi sion of the pro:timal.hu nl. TIIift m.y be difficult d...e to lhe Imall.;ze oflhe ventricl es. One c.n sttempt to follow t.be e:tilting tract and '..-rl' Ioneer or sborter length oft ... bing based on the pre-op imaging at<>dies. Some adVOC"llte the placeme lll of. seoond ·,entrieular catheter, leavillg Ihe fintone in place 3. patienuo maY"relIipond" to either of the fonowing interveMio ... bec:.... ae the . Iighl ventricular enl.rgement elev.tea tbe ependynlll off oflhe inlet portll: A. val ve upgrade"o r B. ASO insertio n"."': the procedu re ofchoice in $Orne opinio ...... Fint de· ""ribed in 1973*' 4 . l ublemporal decompression""" sometimes with dural lncisior.... Thia re.... lts in dilal.lllion orthe wmporal hol"TU (evidence forelevated press ... re);n 1nOJIt, but not .1l'" cll5" 5. third ventrie ... IMtorny": 1ft ~ un P r oble o •• u o r e la ted t o s h u n tin g For lilA ""MiSleIl! with migraine th. t are not pollural , . trial with migraine-epecifle medicationl ;. warranted ( riorina~ ... " rottre.tment ofidiopat;,ic intracran ial hypertension (pselldol ... mor cerebri ). _ ~ 497. S UBDURAl. HEMATOMAS M.y be d ue t.<>collapH ofbnin with leari", ofbridging vei .... ln me pre-C'T era, the incidenc:e of , ... bd" r.l hem. to"'. (S DH) ronnation rollowlo, , bllnt ;naertion WIl5 probably ","de. . limated 11 _ I .~ However , more recent eatima t.es are 4·23'lo in adlllts, 2.85.4~ in children,.nd i' /ugher wi th lIOm>al pres.ure h)"d rocepb.l ul <:20-46'1» than wilh "hyperte",;ve hydrocephaills" (O.4-MI» ...... The ri.k of SDH i, higher ;n the selti"ll of lotlg.etandinC hydrooeph.l .... with I 1.1"1'1 hNd and little brain parenchyma (crani~re­ bral di'proportion) with . th ill cerebralONlntle,'s .... lIally occunl in childretl with maeroceph.ly and I'TilI ventridef on ioLtial eval .... tion. The.. patieota h"ve an "ext remely deliCIOIe baI.nce be tween .u b\hJr.llnd intrlvelitriaJ.l' r pre,,"re'"". SOH c;an . Iso follow . huntinc in elokr ly p'tienll who have levere bra in atrophy, The development of SOH mly _1&0 be f.c.litated by n . tive preM ..... io the ve-ntriclea.,. relllil or .iphoningn . ". There i•• 1&0 a low ril k of epid ..... l hemalofn. following CSF ahunting" . Ch . raelen , t i". o r lbe n uid : The colleclionl ONly be on t he . ame .,de .. the , h"nt in 32\(" on the opposite .ide in 2 1 ~,. nd bilateral in 47i1t ... ". 11. Hyd roceph.l .... NEUROSURCERY At the ~iltle of dillCOYery. ~he SOfu.~ u. ually . u bacute to d'ITonit. and the p~vi . <>WIly large velltricle . ..e "" u.lly eol1apud. Only 1 of 19 c.. ~ 6howed colorl eM nuld " . In all caSH tated. protein ...... elev.ted compared to CS F. TREUMEWT In dicatio n . fo r t reatn:l.en t S mall « 1·2 Cm thick) asym ptom. tic eol lect ion. in patien t.ll with elated cra nial au· lurn may be follo .... ed .... ith Kria l imaging. SOH wel1l Iymptoroa~ic in ~ 4 ~ of caSf!S Clymptoml ofieo Tfl$flm ble thoee of , hunt m. lfunction). . nd the~ ~uil1l treMment. 'J'natmeotofSDH in t ll ildren .... ith open lutura h .. been ad vocated" to prevent later sym ptom • • ndlor fU,ve lcpme nt of macTOCrania . Many . uthors .-.t(Immflnd not t rta ting a.ymptomatic I"iolll reprd leM of 'ppu ranca'" ", wher1'as others vary their recom' mendation. b.aed on di~flI"H criteria includinc . i:u!. appeaTllnte (chronic. acute. ralxed ... ). ek. Trea t.m e nt tec h niqu ee A numberoftechniqut. lIave been detcribed . M(lft involve evacua tion of tile S DHs by .ny of the ul ual methodt (e.g. burr hole. for ehronic ool1ections, craniotomy fOT acute eol1ect iOOl) lOfIether with : 1. reducing thao.P""" or .hunting Ci.• . tontabli.1I alower pr1'ssur1' in the 8ubdu ral Ip"<e th.n io the intravenlrirul. r Ipace. toUUSf! the ventricles to ra·upand and to prevl!llt ra.a:umulation oI"thl SOH) A. in shun t dependent c._ 1. repjaci nC the ~.Ive with a bia-ller prl!llure unit (upgrading the \/IIlve) 2. inc:~ing the prl!Uure on a prognommable pl'flSllu re valve"''' 3. uling a Ponnoy device that can be turned ofT and on externally. Be l ure that ure pTO>'ldeTl U n reliabl y open the device in an emergency B. in non·ahu nt dependent c. _ 1. .ny of the methods outlined sbove for sh unt dependent cases, or 2. temporari ly tying 01T the.hunt" C. inse rtion or an antj-aiphon device"' 2. draio.gl or the subdur.l 6pe<e to A. the ci!~",a magn.'" 8. to the peritoneum with a low presllure valve (or novalve"). Some authon have the Ure-gLver rrequently pump the su bdur ..: valve The goal iA to acb~ve a deli ... te balll...,., bet~n undershunti"ll" (producing symptoms of active hydrocep/lalua) .nd overshunting (promoting the nl.um of the SOH>. Fol_ Lowing lurw"ry the patient should be lI)()bili:u!d slowLy to p~ent recurrence of the SO H. CRA NIOSYNOSTOSIS, MICFlOCEPHA LY & SKULL DEFORMITlES Also see Cronwl)'tWntotir. page 99. A number of skull chan," hav, bHo deacribed in infants after shun ting. indudin,",,: thickening and inw ard growth of tile bone oftbe skull base snd crani.l .... ult. decrease;n li:u! or the sell. turcica. reduction in lile of the cranial foramina . and cnmio. ynostosis. The moat common. . kull del"o.lII ity wal dolicl!ooeph.ly from llllgittalsyno.to&is" . Microcephaly lICOOunted for ~ 6""of skul1 derormi· ties after shunt,nc {.bou t haJfofthese had IRlgi Llal 1)'I"I05\ol1i.). Som, ofthoete ch. nget werl reversibl e (eue pt .... hen complete I)'1IOIIlO5il WII present) ifiO\.raCl"ln iai lIypert..n · lion recurred. 11 .3. Normal pressure hydrocephalus . I 1 Key feature s c1.ssic triad : dementia. Ca it disturbllnce. uriMry ineontinence • eommu nicating hydroceph alul on CT or MRI • DOrmat prell$ ure on r~ndom LP • symptoms remed i.bl, with CSF . hunting Flnt d~bed io 1966". nonnll l prenure hydrocephilu l (NPI{), AKA H.kim·Adsm. syndrome. ~ originally deacnbed. the hydrocephalul ofNFH Wit considered to be jdiAAllthk. NEUROSURGERY 11. Hydroeephlllu. ". However. in some ca~ an etiology can be identified: 1. poat.-SAH 2. pOIt-traumatic 3. post-meningitic •. following pntIterior fos!a .urgery ~. tumors. including carcinomatous meningiti s 6. also seen in ~ l~$ ofpatienUl with Alzheimer's d isease (AD) 7. denciency of the arachnoid granulations 8. aqueductal stenosis may be an overlooked cause C LI NI CAL Age usually> 60 yrs . Slig-ht male preponderance. C linical tri ad" T'liad is not pathognomonic, aod may al so be seen in vascular dementia" , I . gait disturbance: usually precedes other symptom$. Wide based with short, shufmng step!! and ullSteadiuess on turning. Patien~ of\en fool like they are "glued to the noor- (so-caUed "magnetic gait-) and may have difficulty initiatingsteP8 or turns. Absence of appendicular ataxia 2 . dementis: primarily memory impairment with brndyphrenia ':slowness of thought) and bradykinesia 3. urinary incontinence: usually un witting (NB: a patient demell led for any rell80n Or with mnbili ty impa.i~ment may have in.:.;,ntinence) DIAGNOSTIC PROCEDURE S There is ill:I test nor radiographic imaging thst is pathognomonic (or NPH. Numerous diagnOllticmteria have been proposed for NPII to determille which pat ients are like· ly to respond to a shunt procedu.re in order to avoid poteotial complications (1ft below) and Wlnecesaary surgery without denyinl surgery to those who might possibly benefit. None has proven to be of adequate reHabi ity. Some are presellted here for complete"':''''. LuMBAR PUNCTURE (LP) Normal LP opening prt'u ure (OP) should be < 180 mm H,O. The response to a single LI* (withdrawing 1~-ll0 ml CSF. or taking the OP down by ~ OM third) OT to serial LPs may be of90me pred.ictivto value. Consider ambulatory lumbar d,.s.inage b~ below) fOT patients who fail to improveaft.er a s ingle LP. CSF should besent for rnutine labs(_ page 616). Patients with an initiol OP > 100 mm H 20 have a higher respon~e rate to shunting. CONTINUOUS CSF PRESSURE MONITORING Some patient,., with a normal OPon LPdemon$trnte pressure pealul > 270 mOl H20 Or recurrent B-waves". These patient/l also tend to have a higher response rate to$bunting. AMBULATORY LUMBAR ORAI/JA GE" Lumbar sub8 radmoid drain is pLaced with Tuohy needle. connected lhrough a drip chambe r to a dosed drainage ayst.em. The drip chamber is placed at the level "fthe pa_ ti ent', ear when recumben t , or at the level of the shoulder when sitting or ambulating. A properly functioning drain should pul out _ 300 mI ofCSF per day. If symptoms of nerve root irritation develop during the drainage, the ca theter should be withdrawn several millimeters. Daily s urveillance CSF cell COWlta: aDd cultures fihould be performed (NB: a pleocytosis of ~ 100 cel1111mm 3 is expected just with the presence of the drain ). A ~ day trial is recommended (mean time to improvemen t: 11 daya). CT ANDMRI FeatUCil8 Qn CT"" and MRI" I . prerequisite: communicating hydrocephalus 2. features that correlate with favorable rt'sponse to shunt (thes e featUrES sugge..c. that the hydrocephalu, ia1lll.i due to atrophy al"ne"): 11. Hydrocephalus NEUROSURGERY peri~ntri~ula r low denaity on CT or I'Iigtl inteluity on '{'2WI MRI: may rep!"eRnt tran.ependymal ahllorption orCSf'. May re!lolve wittl . tlunting B. oompresaiCtn of<:On~";ty l ulei (foca/.ulea l di lation may sometimes be,eea and may represent atypical ruervoi ... of CS f' wtl ,ctl may diminish a~r , hunting and should not be OOfUIidered IIlItrophyt') C. rouodiog of the frontal hom, A. Nthough some PIltienu improve wittl nottlan~ in ven t rides". el ioiu l improve· ment mOlt onen aecomPllnies reduction o(ventricula r lile. RAoIONtJCLIOE CISTERNOGRAPHY Usefu lnes, remain& eontroveni,1. One , tudy found that the dltemogrllLll does not increase the diarnOlt ic accu racy cl clinical and CT criteria"', T ec hn ique: Lumhllr auh Nlchnoid iQjec:tion orradio-i$OtOpe ('g. 2.7 mCi of"""c-IYJ'PA diluted 1.0 I cc .... ith IIII line). Cilternorrarnll are obtailltd by planar adntigra phy at 3. 6. and 24 tin after injlC~n ( iOl~ may be obtained at 48 hn if intnventric:ular activity i.still_n.t 24 hn, tlowever . an i.otope other than-rc-DTPA mUlt be used for , uch del,yed Uw.ges). Con ventio nal crit eria fo r a ~ atudy: Radioactivity i, .y~trieaUy di,tribut· td over the COGyex.ity 24 hn .~r il\jeetion. with no intraventricular activity at any poin t. However . up I.D 4 1'-' ofnormal, will demon, trate trllNli .. nt (up to 24 !tn. but not longer) activity in the yentricl.... Findings that may indicat e a bette r ch ance. fo r respon se to I hU"li"if. Of the fol· lowing. on1Y' 2 i, a reliable marur for NPH. I. el1ly acan ('·61lts ,fter il\ilCtion~ activity in ventrides (presumed retlUJI from obac.n.u:ted outRow). May al.o occur in DOnJIal. (_ "buw) for < 24 hn 2. I'te acan (48·72 h n ): peni'tence ofventrieular activity. Pat ient.. with this fi nd· ing are mott likely 10 impmve with , hunting !_ 759l. ctlanee) 3. ~tained activity over ronvexity: these plltienta are Je.1ikeJy to improve 4 . quantitative c:iater rlO(Taphy A. pIItlenta who dear oYer 5O'il>0fl.l!Yl. intracranial radioactivity within 24 tin , re OOfUIidertd to .... ve an adequateove,.lI abo\orptlon rate, and are unlikely to improve wittlltlunting. However others have bund no conelation of clearan~ to shunt rt!Spon5e S . one l tudy found thn If the ratio ofventrieuta r to t.otal intracranial actiyity (Vfr) at 2~ tlOUrll il > 32%, there would be a responae lO ahuoting. wherea, Vfr < 32% did DOt exclude th .. possibi lity of impmvement" M ISCELlANEOUS Cerebra l blood now lC BF ) measuremen t.a: Although some Iludin indiea~ other· wile. CSF measu remenlS show no lpeel"c "ndings in NPH, and are not helpful io predicting who will respolld to shunting. However . inlnNed C 8F a~r ,tlunting ~Iates wit h cl inieal improvement". EEG; No specific findir.g. O<l EEC in NPH. TREATMENT Be(ore undertaking a surgical procedu re. , dementia workup ,hould be t:Ompleted. VP sh unt il the procedure of choice. Lumba ,.. peri l.oneallhunta have been used. but they tend to overahunt. In general, ule a mediym prwYrf valve" (clneing pTelllure M· 90 mm H20) to minimiu the risk of subdural hematotn"(_ ~DU!), althougtl re1Iponte rate may be tligtler with a low·pre.. ure valve", C .. du,lIy ,I t patient up over . period 0( l eve r. ] daya; proceed more .Iowly in patienu who develop Iow-presaure headachM. FoI· low patientll clinically and with CT for - 6· 12 monttll. Pat ienlll .... tlo do not improve and w~ ventricln do not eblngl . houJd be eval u· ated for shWlt malfunctioll. rfnot obatructed. a lower preuure valve mou ld be tried . A. .1., (h¥<I.-ph. ,u, .. ~ ... uo).•,In ooBdiUo"" ,1O<h .. h1lhoi""'r'.d;... ... ,.....,. "'" tha_ of. but doH ........... Iud., rt:l:""dinc WI. ""unl (ooJ1l<.I.<n>phy io . OOID,,*, rind;"';" 1>0011.11, 1 I'1d,~idu.l. of.d•• ntt<! .... ) NEUROSURGERY 11. Hydrocephalus '" PoTENTIAL COMPLICA f /ONS OF SHUNnNG Com plitoti"n ra~~ may ~ III high a~ ~ 35% {due to the froWlity Ilrthe elderly brain~' 'M. Potentl .. 1 M1npiicotions indudalO': L subdu ral hem~tomlls Ill" hygroma (also _ ~e 198): higher rif,k with 1_ press ure va l ~ and old.e . patieots wbll to'nd to have ",,",bra l Dtropl'ly. Usually acco01panied by h..OOo[h ... m.... t re.solv",pontanl"QOJslyorrenlllin stabl ... Appr,,~imBlely 0 ..... thl"td ",quite evacuo tion and tying ofl" orshunt (teml"'rllrily "r permanently), Risk may he mlucW by gradual mObUiJation pll5H'P 2. s hunt in fection 3. inLropan'nchymal hemorrhage in the brain 4_ J;l"i~urell : IN pagf 188 5. delayed INlmplkatioo& H.dude: Bhu nt ob$truction or disconnection O UTCOME li kely symptom to 'mllrove with shunting is inconLioe~ then gait dl$and )/lsUy dementia Slack et ai ," 81"'" th e following mark~rs for gOOd and,· dates for improvement with shun ting: clinical i presence of thO' cla6l!ic triad" (II" PClIJ6 2(0). Al ... 77... of patienta wilh gai t di stu rbance liS thl" prim ary sympwm imprllVed w.thsbunting. Patients with dementia and lUI gait dilitur bllnce rarel)' respond to .u.untin g LP: OP > 100 IIUJl H.o iSlltope eis lemOi,.,.,.m: t,ypical NPH pattern. The n,i>:ed nr normal pat~rn has no INlrrelation ..... ith responlle to ahunti ng C'(\nti llU OIl$ CSF presl un recording: ,""sure> ISO mm H.,o or frequent Lund berg B wa~ea (_ pagtt 653 ) CT Or MRI: large vl!ntrides with f)auened $ulci /little atrophy l Re!ponae is better whenlymptoms have been pruent (IIr a shllrter time. NB: patients with suspe<'ted eo'existing Alzheim<!r'$di5ello!Sl'. (AD I mlly Ilill improve with VJ' lhWlt.s, thUII AD ihnuld not e"elude theM! pa tien ts from shu:ltin g.... _ Smne ",sl'ondel"ll may s ubsequen t ly det.\lriorale. Shunt mstruILd;on and subdu r81 oolledioni must be ruled out before ascribing th is to the nAtural OOUr5eOflha ronditJon . The tu rba"~e, 11 .4. m05~ Blindness from hydrocephalus A rare complication of hydrocephalus and/or shunt m.lfu n~t io n. Possible ca uses include: I . o«lusinn ofpost.eriorc. rebral ar(.eriH (p e A) CAused bydoWll",.rd IJ"Dnste ntori.1 herni ation 2. chro",[ pspill edemu causing inj ury to optic oerve at the nptic diK 3. di latation of the 3Td Yl'J'ltriele with tt1 mpn!MiOIl of optic w iasm Orular motility Or visual field defects are ",ore common with sh'JILt malfunction than is blindn~ l"'''. On"""'nes found 34 repMU!d c.se\l lIfpermsuenLb)iodne.s.ll in children attri but.ed to shunt malfunction with Mncomilant increased ICf»f' (thu e au thors w"re baM<I;n. "'(" ...... 1cente r farri8u" lIy tm pa.i .... dchadren. t hua incid .." "" not ulim~t.­ ed ). Another ....ries t>f 100 pa t ienl$ with tentori al herniation (mos t from acut.. EOH lind/or SOH) proven by CT; 48 patients opel'lloted: only 19 of 100 surv ived> 1 month \,U were in operated group): 9 of LOOdeveloped occipita llDbe infarct (2 d,ed, 3 vegetotin stat.., remaining 4 moderate to severe di8~bilityl'· TYPe s OF VISUAL OlSruRBAloICE 9 ofH had pre~c:ulll~ (IIJIt..ri Dl" vil;ull path ... ay ) bJindneo.s w,th markO!1i optic nerve atrophy {earlyl, 8nd reduced pupillary light rene~e •. S of 14 had postgeoic ul ate (cortical) hlindneu with nonnal Light reBponMI and minimal or nO opti~ nerve at'mphy (Dr atrophy late). 11 few pllti entl; had evideote of dam age in bolh s ite• . Cortical hliodnelll: due Lo leti 'ol\.S po.9t.erio r to lateral gerucu)8t.. bodiea (L e B), may also he """'" with hyV"'Oc illjuriea or trauma''', ()eao,sinnalty 8590ciated with AnIoD'Sllyndrome (denial ofYi!ual defidt) and with Ridoch'8 phenomenon (appreciation ofmllVing obj«UI wi thout jltin:eption of stlilion.ry u.imuli). '" It. !1yd rocephBl us NEUROSURGERY PATHOPHYSIOLOGY In patie nts wit h occipital lobe infarctio n Ocdpitallobe infantioos (Q Ll) in PCA distribution areseen either hilaterally, Or if unilateral are associated with other injuries to optic pathways poIIterior to LGe. The mOl;t often cited me.:hanism is compreS!lion ofPCA .-esulting from brain herniating downward. Alternatively. upward ce.-eheUar herniation (e .g. from ventricular puncture in face of a p·fO$$a ma5'l ) may i,mpinge on PCA or branch"" with !,he !;arne re$ultll"'. OLb are mOre likely with a rapid riseio ICP (doesn't allow compensatory shifUI and collateral circulation to develop)' ''. Macular sparing is common. Reported ca uses ofOLI include: post traumatic edema, tumor, aba~, SDH, unshunted hydrocepba lU5, and shunt malfunction"" " ' . The occipital poles are also particularly vulnerable to diffuse hypoicia''': attested to by case.a of conical blindneM aner cardiac arrest"'. Hyp>tension s uperimposed on compromi$ed PCA circulatioo (from berniation Or elevated ICP) may thus increase the risk of postgeniculate blindn e"",'''''' "'. Both coup and contre<:<>up tral110a may produee OLI. Unlike a PCAocclusion infarct, macu.lar sparing is not expected in traumatic occipital lobe injury'''. In pa tien ts witb prege nic ula te blindness Elevated ICP transmitll pressu re to retioa - blood now st.asis, as well as me.:hanical trauma to optic chiasm from enlarging third ventricle (latter more commonly thought.-esponsible for bitemporal hemianopia''', but could, ifunche.:ke<i, progress to complete visual 10&8). Also, if hypotension and anemia were present. consider the possibility of i$Chemlc optic neuropathy" ""'. PRESENTATION These deficits a.-e frequency unsuspected (altered mental state and the youth of many ofther;e patients'" makes detection difficult): an examiner mun persevere to detect homonymous hemianopsias in an obtuoded patient' ''. Pregenitulate blindness is less often associated with depressed senaorium than is postgeniculate (where di reet compres.sioo and vascu lar compromise of midbrain are more likely'·'). PRooNOSIS Conical blindness after diffuse 9noxia frequently improve~ (O<::<:88ionally to normal): usu9lJy s lowly(we-eks to years quoted; several mos usually sdequate)"·. Many reports of blindness after shunt malfunction....., pre·CT era, thus the presence or extent of occipital lobe infarction not ascertained. Some optimistic outcomes reparted' ",. however. permanent blindness or severe visual handicap are also de8Cribed" ~ "; no reliable predictor hss been identified. AB with infarcts elsewhere, youager patieata fare better"', but extenSive calcarine infarcts on CT are probably incompatible with signific8Ilt visu al rElcov· .ry. 11.5. Hydrocephalus and pregnancy Patiellts with CSF ,hunt.$ may become pregnant, and there are st least 4 case reports ofpatientll developing hydrocephalus during pregnancy requiring s hunting') '. With VP 6hunl'l, distal Rhunt problem s may be higher in pregnancy. The followillg a.-e managernent $ugge~tioll$ modified from WiJloIJ etal." ' . Precon ceptio n manage m e n t of patients witb s bunts I. 2. evaluation, ind~ding : A. evaluation of shunt function: p.-econceptiQn baselme MRI or CT. Further evalua tion ofsbunt pateocy ifany suspicion of malfunction . Patients with slit ventricles may have reduced compliance and may become symptomatic with very small changes in voll11Oe 6. assessment of medications. especiaUy allticonvul! ants counselling, includiog: A. genetic co~n8elling: if the HCP is due to a neural tube defect (N'I'D), then tbere i, a 2-3~ cbance that the baby will have a NTD 6. other recommendations include early admini$tration of p.-enatal vitamins, NEUROSURGERY 1 \. Hydrorephalus '" and Ivoidinlleratorenie drup and exce"'''e heat (e.g. hot-tube): """ N£urtlllu~ de{«II, Ri,lt. {aclo,.. on pare 113. Gravid mllnage m l nl I . dOH obMT'Y&\ion fo r sim. of increased l e p: h•• daclle, NN,le:hargy. ataxia, Mi· utre •... C.... tion: these sim' may mim ie pre·edam!»;. (w hich mUltalllO be ruled out). 58~ ofpatienta exhibi t . iil\1 of; nerea~ [cr, ... !lith may be due to: A. detom~n .. lion cf pa n ial.hunl malfunction B. shunt mllfumt;!)" C. lOme .now .ignt ofincreltHd Ie? in ' pite ofadequ.t.e .hu M funttion, may be due 1.0 inereal ed cerebral hydration and venous en,o~ment D. anl. Tiemant of tumor durin, prernancy E. cerebral "tlMU' tnromboa;': including dural sin .... thrombosis &. cortical venou, th rombo.i. 2. F. enceph olopathy reJa~ to di.o«ler«l aut.oregulation 1_1K>8t 64) patient. developing symptoms of increased Ie? Ihould hve CT Or MRI A. ifnoehlng.. from pr_n.:..ption ttudy, pu rw:turt ,hunt 10 meu .... ICP and (UILUre CSF. Coruider radioilJOtope .hunt ...·cram B. if aU studies are aegalive. then phy.iologie chaagN may be reapollaible. Treatment is bed rest , nu(d .... trietioa, iltId in ....ere eua . teroi.u ... dfoT diuret i"'l. l f symptoms do notabate, then early delivery it recommended a. soon u fetallunK maturity ean be doeumented (aive prophylactie antibioties for 48 h .. bef~re d..!iv.. ry) C. ifv .. ntricl ... have enla'lled and/or ahunt mal function I, d tmon.tI'a~ on testin,. shunt revision is poI'rforO'led I . in first two t rimute .. : VP shunt is prefen-ed (do not 11M poI'ritoneal tl'ocar O'Ietho:)d afte r Ilrst trimester ) and i. tolerated well 2. in third trimester. VA Or venLl'ieulop]eural .hunt i. u8ed toavoid utero ine tl'auma Or induction ofl,bor lnt r aparlum manageme nt prophylacticantibiotico af .. recommtDded dUMKlabor and o..livery ton!lluoe the indden.:.. orshunt infection. Since coliform. are the most common patnog..n in L&D. Wisoff et al . recommend aO'l picilli n 2 gm IV II 6 hrs, and xentamicin 1.5 mgl'kg rv II 8 hrs in labor a nd a 48 hrs post pa rtum'" 2. in pa tien~ without symptoms: a vagina l deliver)' is performed ifobst.etrieaUy . ible (lower risk of forminX adhes ions or inf«tion of distal shunt). A shortened second stage i, pre fe n"N since the inerease in CSF pressure in this Btage i, probably greater than duri", other valsaJvl maneuve.. '" 3. in tbe patien t wbo bea:omes symptomatic near term or durinKlaoor, after stabi· li ~i.ng the patient. C-oteCtion under &:enera] anesthesia (epidurals arecontraindi· cated wi th elevated ICP) is performed with careful nuid moni~"II (LK. PA ca theter) and, in ..,vere cases. steroids and diuretiet 1. re,- 11.6. ,. , • , '" References bo-""f"". ~",iIo" I· _ol .. J,uu,15,,"," 62,19" $ootIoo L N • . . - D A.S<ftoI L H~J "'. ,,11101 ~~ , _ <1..... <ol.lwiIICt_. --.,...,. 6, ] l ••• 1910. Uob1;aA B. F.."", B N' ~ c .........Il10. '_""~oocq:fIal7·"'_ oI1 J .....I..... ~ ,it ................. "" .......... ~ ....1oIoU 1)7 11 ·91 . 1910 ... ,,_ 0 I), Ntto,~ of 101-,- """ doiId· _ .1........a..",..C~... 5prio:JI"..1oI. 1969 ......... L .. . I-Io) ..IJ . Sfu_S ~ ......... ...s"J"""'phoI.., N_oJ.....,._ .. .bo<oI •• 77. 901 · 7. 1M6 _ C F- CSF dr-MI'''' '" hydOUpIooI<ft . ...III <pot'" _ .............1 Do.6. 119-17 . 19101. ao-t w M.a . - t J I , ,,,,,," FA n.. ...... _ .... •• .. ......., »'167·7 1. 1992 ~,II;W.y...u.J IW . _""J W. S - .I..,........ _ ..... .............. _ ......., ... MII _ •."'. A,/NR 11; , J»,9. 'M. h}'droccplootu. _J_ _ _ K.... I B.Goodonoo M. Dirra. .....,.. 0. ....... s.r. N _ ». ~. 1M McIoLR . Dwoo_CC. OnIorR 11..,,"' ...1..... ". _LN Ioc_...., " ,m c-.-',....,... ,_IioI_""""'r"""...... """EL. SIoUJII..rrOI J _ .... ..,...,..""u.. ... " .....,. --...... ..-.,--.- I I . Hydrottphalus _ .. "" ...... _ ............. ""... . J - - . S<I. »0·' . 1911 CW-O _ _ ""h1~ .....1Ma 'lI19 (11 ~ 1·7 • Fi_ _ .........,..... ""~)'OIr«<!*>1" io <lulilna wi'~ _ .,...._1111 <_.) "". " .......,..,0.10"" ........... a.t_HL."""""'E. _~ ... _ , .10. 1064·79. H t... .. oI : ........ "" . 1"...."'" M-V NEUROSURGERY ". " " ". " ". ". ". ". D ". D. M ". ". n. ~. ". ". ». ~ " M. ". N..... I S<! I, 123·6. 1982 . 1l¢I'UfG J. De wI< S ... , Sh ... ·ir<l< ~ n<k .. >I. 'u. olh)"'-'<phoJ ... J N<u ....... 19: 691·1"01. 19"13. 1lc""""R· C,. "hu"be .. ~'M_ N... • f.1 Sd.: 221·1. 1911. EpoIo" f : ~_i ..... _ ..... '" of......, • ..., hydr<>«p<alu,. Moooov "'....... Sci.: lOP. 1912 . LoMoy M.Koohbutf K: V",,,... llJdiff<<t., .. boow«. ~y""",","", h)U<>«pII.I • • and hydro«pII. Cl". /'I.uf_1oIou 11: 191·S. • 1•• 0. 1919. A",",II« A L. Wolli "l_ I. Inl.... i .. hydro<.piI. II .. : 1.o"l.l<rm raul .. or ....,icll 'II< ~ . Cblld< B,.1n II : 111·19. 19&4. Kill .... Rozd;llky B: Ccn&<";u l hydfOO<i>/IIl .. >0<ono1>ry .. i.... "'.~"" 1m.. ~"'., ~ .. n~ .11t 11<_,• . 0 .. MI"d Child 1" ... 0"01 26: XI927.193-1 . Kudo K. T ...... ; N. Ki<n $.<fal.: 1" .... 11'...1' " _ .. _; .. "" wi'" h yd~I ... N..... OSU<1...... 21 . "'''''1»' 1."..... 72~l ' . I9I' . $ohmodok K K. A.... L M. K..,., I '" Tbe "'<tl:nl 17: 66) ·78. 1911'. TUH.G F.E •• n... J.Ct>onI W K... ~I_ Tbe ... .,ott <oppo,.,."ium, A """"",,""' ...,_" i"""",oi,J pmw ... <'I"na] '-'"'s<aPh>. """ l'Of>Mo "'...,. ;" , h;kbn wi.h ....;o,y ........ i•. N... ""u'l'"l")' 19: 691·9. 1996. SccIi"" of P<:diwic No""""'l""Y 01 ,II< A"",rico. A."",;.,,,,,, of No" " ' ' '1Surporu . (<<I.) Pod;,,· Ii< .................J . I" «I . •{)N1I< and SU".,. . 1'1.... Y...... 19I2. _ T: No_InW.ad ........ : ADdOlIl<,,,,I,,, oflb""' • . K....,.... h,,"';al.1<I< .. y"",,. 199(1. B _ SG.II<nd> G I:G",","", Inpll. 1"..,..,<1 ;"· !<"aI.~l oli.I"" 1 0I'''Y; .. 0$<. J ..... Ia" 89: 8 14.2(). 1"6. Noll>au. G: lI..d <;",.,"1.",,.,. r.... ";nj, tel .;, 111«. ,... ... Podla'f"ko '1 ' 106-1 •. 1965. Sh; ....... S,C........, K. Ok_n E W .,,~I.: 101...,. •tt ..... 01 "ydtouphal.J$ i. lo',IIOY· U.. of ...... ll)lomMl< 1O . _<t:<tb<oopi1W ~u", PftIi.1r 1(17' 31-7. 1915. K.. u..... K I... T>tttyT I .K"""" E...1'1" $orial LI'> '".."Io ..... _ r y ......"_.,.,oI_lOI_ It><~i< ~ydn>«plulu' . r«l",ri<> 7', 7'9I'. 1m. DMdy W E: E.>.r;rpotionof,ho 0I0000''' pluu.of,1I< 1>1<..., .. n,';'1e in oomm •• ico<i., hyd«>«j>l>al ••. Ano S ufl6i; 569·19.19 18. Gnlfi'" K B. bmjoom A B; The I~.,.",or .hild· hoo<I hyd.o<><opholu, by "hoo<>jd pi" • • <O>lul .. ion ..... "",foe"lu_",i"I n ... perfu",," B, J No ...... u'1: a: 9S· )OO. 199(1. K.nelk. 1>1 K .... btooo' R . ..... M: ... ......·1...1........ pI"",,,,,,ot.~'bonl ••• Co.. .. pen . NftIl"OfIIf ....1 )5: 525·1. I~ . Joj'La"VOI'. M M. H.Klllfmonn A M. <I 1'1" T~ ....... ic b."I ........,..'" at .. , . odoo«>plc ,h,nI ... rticulo«omy' C... '0fJ0fI. N.......... f .... r . . """• • )'<, • .,.,.1'1...,"". ........ """p«t<4 _ 1''''''''''' ,,,,,,...,,,..,,I0I0: ,_ .J nicu_,: w"" , ) OJ : 1«IO ~ .1997. J.... MfC . Cum. BG. K_ B C1' V,.,ricu· "'un" 10< hydroc<pIo.I." " ....t.I.Io""· ,1 ..... N."''''''".. y lJ: 7S}.'. 1988 . lame. K E. T,bbo P ... · rn ..... <l .. ico'.pplic-.. of ..... _ _ • lumbopo,joo ...1 . ..... IS . _ .. OUIlItfy I : )9,41. I~ I. tout .. J w. Choo><IIc, I p. In.:ous«I ri.k or d, ... , .. "';';'Iopo"~ "''''' ..... ,''''''.,. ..-;...... .. ilh , II! .. I..,.".. 4;~.I . li" " <h. po_,J OIlho· ,," J ", ... """,,17: 412-6. 19?7 . D", N G. Wad< M I,Tho In<ioIo:nceof ..,il.PlY 'fI<r "ntti<ullf oII.",n; proood,rn. J N _ .. M: 19·21. 19$(>. 11«1'"' 101 S. B.umoi ... , B,C.y" J R. ri.b QI ......, .... f<om .h,""o, in .h,idtt...;'h lop"""" NEUROSURGERY ". ". ~ . ". )."D" ,,<II" " " . .,_'1....... ". " ". ". .. .. M. 0),,,,,,. 'in· i"'" ". .....l.. ,.,. . " " " ""'~ ... pOI" ...... 10.011''''''''''·1"''''''''''-1 » ,. cf'lic Ie>ioooo. So" N<urol II): 16-'lO. 1'18). Y."",,"~.) : Ki,., .. "'. . .lpI>oe-rtducoq de.ice> ;. ""'. pa,lo.", willi _. .... •..... ourt hydto<q>ll.Iu •. Ikoch I..' '" .... ~ •• ''''' ..·"h 0.11•• al .... J N<u_ .. 84: 634" I. >I ...... M.Hl.I ..... S. ,~ " ,. • 8o<h ... ·L. K."",lift t. SoI.,,·Ro .. C . ., ~I ' Mo· ctuni<aI dy.I"""ion.,r ..''' ... '''P''i'''..... "'"''' ' eo""" byClk.J\t .. ionol ,Il<,l licooe f'IIbI>« ..,.... '... J NftI""""U· 9"15-ll. I998 . F...,h II "'.S~ •• _ M' R..r;onu<llac ;..... i.. """"OII'pilylO< ,II< ...1..,.,. or "'URI P" '''''Y • MOftOC/" NOUdI S<I" )9.42. 1m . _ . R K. F.... E l ' Kyoiro<",holu.: o..nI .. ,.· 'f< by ..,,,,,,,,,,1,, ""' .. , .... ""OW ..... "';_0""ion>. S" f1I "'<1U"O! ),: 200-12. 1991. Mc ~ R L.OI,.i ... : 51,'· .... ""10 .yndr<!me; R.. ,. .. cA IS ~..... I'<oI ~ , N... , oori il: 11$024. ~. 0nJ ... , M. J.nn, P. flo"", B: E,,,,,icn«. wi,h ,he ",tI ,,"'"The pnmaryoo,,,.1 ...,..ou • .,. ...m ",,,,,,,,. J N... ",. • ... 1.: In·7.1991 . Ji ........ D f. J.: w'n~ R. GoOOne!o I T: Silicon< al· I"iY in ""nu~.lop<fi,on.. lohu." . Childs "'...... SyoI 10: 59-6.1 . 1994 . ~",",,&Ift f.GloMJ O. K.pIOn B 1.,ui ..1 hom ... oJ .. , ..n,""ulop<mo".al ohWII poo:IO<du.a i"pod .. "", .,....n .. . S."Cynt<... Oboto< 159: ,"II).2.19S4. Bf)"'"' M S.iJt<mer A M.T.jm l I. "aI_ AIIdom· ow «>f>l!llic-0Ii"'" or .. nu\culop<ri_ ........ Am5u'l ).4: * '. 19IIS. Ram Z. t,ftd]OI C.C .. ,man I. V.nU1<ulop<ti""".1 .lMJ .. m.I!I.",,"" duo", m;I""" 01"" ,l>d .." ..1<..11<1.,. inlO III< o«<>Iu,". J ..... lalr 5u'l n: '()4~·6. 1987. Ru'" 0 S. Wallhl W, Abdomj",,1 <omp l ~ .. """ or CSF.po.-;",.1t>I . h.mo. M _ "' ..... IS<! 8: n~. '912. M.A.t. .... J L. DeliO<l<lL.<f~I " Go.\rio p<rf..... "'" 410< .... RI<ic"'o-.... ~ "'... . ..«Ilalt " ............ 11: 1,1-4, ,~. ~ K. B.j"'$:T~"""",I""'i< ..,q,Ifi,," of. _~ Iopon_ <........ f. " ' _ f....1 17. n.-6. I'll' . $01<"". T H. 101 ....... 11 J A. B.... ~cll C E: ,""",,;,,,1 ,00""lu. oo:ond.ory '0. " .. "".lop<mon..1 C''''''porI. J 1".. ......,.. 3': 9S-6.1971 . Could .... 11 W T.LeM.y 0 R.MoComb J G: E.>.pori. en« ",iOh Ul< .1 .. _ ""I'h pe';_ ,,".m eo, ........ J N... rnoufl 35: 41'·7, '996. P"", • • I ) M S. Pnb'" V B S. o. .. Iopn<o' 01 pu~ """'"'Y hypo ... _ u .... pi ...""'., or. .Cf!fri<."""rioI """". MOJ"O 00. P'O<~' 82.19'13 . (...... 1"1>&1 .. 0. K.1Uttti A V.D<U.J 101 .<1.01.: ........ bopc< .....1It.• ""nl: A""'''''''''''' .... >IUdJ ,n Ihe ptdi"'i< _ Ill;oo . ,............... ,)2: 376·3). 1993 . W."'h K. $011)110 I. S....neI R. " ~I " OIi .. l , ·maI· I"""".",' , ,., " .... d,_r? J "' ............ " . 604·9. 1912 <....... "... PD. Ann.".,.,DC.Onl<. I M.«aI" T..,;II" ht«U" ... , TII< ..le n lll« 'tun ,II< ..«!'" '"'" at,o. lumtoop<" ...... ' "'ullli........ podiolroe _ " ' _. J _ _ " n : 56i-7l. 199• • Poy_ T D. Pna, .'E. S. ...... T S. .. oI.: A<qu;"" o.iosi ....11_i.." lnolac_.4;"_'. N... f ........ .,.3<I: .29·3<1 . 1994. K... Io, L A. lluS" P. COoK ....... 1 P: s,.....,>< ""' ......... 01 medullObl......,. _ ' " by ",""I. "'1. So .. 1'1' ... 0"01), 141·5l. 19"15 . C..... K 1I.1>I_K S; 1'r"."" ' '''IlI<~ul;.: ....... 1W "0"",,,1... d"i~: A .,..,.pe<Ii •• "udy. "'.... ""•..,.., n: <136-1. 1981. MaonKS . y,-,=CP.o...GB: ... ..,u ............. p ''''. II. Hydnxephalus '" .. ,i •• i.,..,. Oo.;c., ("'SO) in "'un, ""''''P~ <>I poll;' .~2. ,98" .. ri< ~)'<Ifpc<"""I<. ,. J 1'1.......... 6'· " " " " ., ~. " •• M. Foh. E l. 8 ....... I P: Symplomo'i< low 'n' .... n· "", .. ,,, JI"'>Wt< '" ", ... «<1 ~ydro«pa.Iu •. J N... • """'IIoI.OO'·I, I!ltI. rtoc. MorN w. SIi, .... ,id••yndr:ome C ... • "mp 1'1 ............ 2. ()), ..... ,999. £11,.1 M,CamteI P W.o. .. ",i.., ... M. 1",,_ ,,.. ... ,.n1ric .. 1u _Uf< ~<"......,ply ,. <~ik!f'<Il "' ''' ""'no>' •.....m.1I ",'u"",·IIy\W<.ph· oIu,. 1'1 •• ""' . ......, S: SoI<}·S2. "..,. Kit',n, R. Mon .... W. P<l<hm .... R:"" ,'i,·..,n,,', <10 'ynojl(l"'" .1.... oh"n~n, In hj<!<O«p/llh' <hll. d"n. N,.",p<1I'"'''' .): 190·•• •m . Hydt-R.,... .. M O.R">I' H l.N.''ICII F~ R... · p.n,'" "I I>m''''''''y <e1l'I"«I",nl1i<l<.o: Tho .1" ...,,;d, .,"" ......... J N '.'_ ",~ , ')6·9. 1932 S.!mOtI I H: The <0(" 1"«1 "'."0<1,,, f>to ..,.O'I<f>t ."d p..... " ... SW"c 1'1,.,0( 9' 349-51 . ' 911. """'"'" H O.$<h.1t R R. Fo.J l, tll1i:. ..... i·.iphon .noj ",.. ocd •• OO/l'''~ fo, .....""£ ,"h,· d...... ploo lu,.noj »O>Is.IIufll ... Ixi.tal ..... ""..",... J Nt.,... ... l8, 119-38. l l7l Ep><.,. F I.Floi«"', .. S. HOOhw.w C ", . .,al" Sol:o,,,,,,,,,,1 <.. "i""om~ for <0<"",,", "'.nl .. t.. """'ionS«"""..,..1O ,,"Oil "<",",,In. J r-I..,,.. '"""" "2:\1·3 1.,914 , Holn... R 0, Hoffm .. H J. Hto ojt1<~ E B; Su"' ... • porol <Ie«>mprc>I'" f", ,... ~~· ..""",Ie . 1'tw;I"'.... oIIe, "'.ntin, '" 1tydr<>c<pI'II1;' ,h,_n. Chll<ls """"'iI ...... "ob"' pn"""", " ". ,,50<,""" .,. M " A. " ~. ". B "'; n ~; I )1-40.lm ~. lin<ler M. O..hll. SIoI., F H: S.t"''''~''1 <1«0,.. for "'URl .... p<ndeill ,..nui<Ie< MKh .. ....... of",,",,", S..... N... "" 19. ~l!).3. 1983 Ile<loly ". Fewe, H O. w." M... ", · S1i' _"",Ie , , _ wilh~ , .. _if.: Thln;!,·. IUI'.c.· <l<fi .. l.. ' ...... ""'. Ntu_~ 13: 7»-<},11lU. 1'1><. ". Eenunde. E.CotgoimoC. " oJ.: Hyd .... <q>/I>I .. "'O ..... fIX ...'Uo; S.'liul ... _ ......... 1 ..... """' of _ _ ,n, •• Ixi .... IIIe_om • . S.. ", N........ 4S' 76-Sl. 1'196, HOpp<.H,""hE.S ..... R_C.Il .... ,O ... <>I, P<h<:,,,,bnl«>l I«,,,,,, .. I.. , ""'''',nl. Child, N... S)'lIl' 91.lIn. ' !>l!7 M<OoI~ DC. "'" J l' NoS"'" i.. ,."...n;alpu .. ,.'" hydto«ph"u, '" ",.1 .. ",il~ .h ... i> aO>d /1> .... I>,,,,,,,h,p '0 oho: """'U,,,,.,., 01 • ....,...111<"'010.... J /'1 ..., _... 40: 3n.~. 197' . Soh" L, C"""",,,on 1'1><. A.t! ai, ~:)'<koup".lu. "'" """"",,,,nil; Su'&>e>I ........ · .... liocolua.rn... <>f pos..n.unti"1 "",, ...1""nl.'u"",, Su ... Nt. n>! • ,: 81. 1996 Oit'tI<:h U..... m.."" C.Spri'); C ...." S.Ixi.,,! ,,""'''0tI'UI , . . .... ofhye,O<'phll u",nd """''''" • • E>peri<o« wi,h • p"'".u'O<!JII .. blc .. I... Child. No .. SI" J. 241 .... 1917 " ...."" S, Nal:ono Y. I""'",;hi T, .! ~' ,: Monqe""nl w"h.I"'>.... ~pru.......... ofIUDoIu· ",I ...... Iom .. a uoed tr)I ...n<rinIlope!i,.,.,..1 .hunl: C... "pori . S ..... r-I,..-ol lS. )31·J. 199 1 nU.,.""",h R O' S.. bdu,,1 .f.. , ... """, rn<tIl af <hto<tic h~drQC<pIu.'u. tr)I ...,tlClJloc.... • h.n". J N<un>! NaI""" ... Ps,e/lill ' y 33, 9s.\t. 1911'l. Po.idoff l M. F.irinl E II. Sub¢Uf" II<f'I'UIIOnIf.O<' <um.,. I. "",","Ill' ,... «<1 hJ<lr<>«JNIo< '~ild ... .. ,th . ............. !IOCI of tuotw;llio, pe",~ .... """,. ,",I""". J ~"''''1 '00 SSHi3. 1%J. "",I""" 8. "'.... M H. y""", H F.<lo/. Ell",,, <II ~ «n:b<o,pu.oI nuid oho: ",.11 'M b... _. J "",""'"'. 31: Zn·91. 1973, FlUllI ..... K, Sdvnitz I': .. "'u," , .... «I hydto«pholu .. ...cta /'1, ....<101, .~: 19·101,1911, H..",,, S.A<IInu R 0 . Tho ' l"'<i.1 <lin""" II"()i>jem Df 'ytnplOml'l< h)'l''''''ptW''' w"h ' .........1CSF pres.""" " los""",,, n. n. ". ". N. ",a; n .. W. M. " ". '" "'f'I'UI'' '"' 'hun'"" ... 0-""'"'''' ""'''''''''.. 11. Hydrocephalus pre ...... J 1'1... ,0( Sd 2' )07·27. '9M . ...... "" R 0. Fi .... ,C,H.l i.. S, <fiJi.. S~""""",, ,i< _ .. to ~)'<!""""""Io>t wj,h ·, .".".r ....,"""pi.oI nuid p«UIm. 1'1 EnI'J Mod 211 .n·2~. 'IlM. Th .. lJ.Gn.no! .... M, "",ubet M R. O' ...... i" Otor"""'"u"" of ... f"",1 _I""n.no! f",,,,,, w"~ P""S"""""' 1'1,.,0("", K: ,011), 90, '98! . W_J H. B..,,,., 0 . 1"""," '" E. ,,<>1_ Norm.] ""' ..... ~j<!fIX.p/II'"o: 0'0;0"''' on<! PI' ....... it<'", lot >00", "'l"Y. No "'oio1J ~': 517·16. .91 • . S~"""" I•. Oonch 1'1 WC .S".,...IIS RJ: _ " , ""-eo.n r.o--u.l«I ........pte<>Un: 1I:r<!~""" ",,," 1: 12\l1·2.19n. Hu. J.lbom«r 1\ T W M. l'rt<Ii"i... 01,.. of "",. J>O<'1'r)' .... mal """bot dtoi • .,. .. -.n.1 pre""'" nydfo<.ph .... , N....... u""'"~ 21: 381·~1. 198!. V... ikMI",i. J, The .yn4rom< 0( _ I........'" hl'dtO<.pho'''. J Nt.""",... ~I ' 50 1·9. 198' . Jook C R. Moloii B.Lo.., E R, .. <>I.: Mil rtn<lin,' 'n """"oJ hydroc.p...... Si,";r",."" • • tw;I oompll;lOn "'i,h ",I." 1_. of 00"" ..... J Co",· ""1 ..... i. I T _ I I: 92HI.I9S7 S<hwuv. M. C.....1 H.C"d, C L. <I(J1, C_,· «Ilomo,,,,,,,,,,, ... I~.,. of .",n ;n 30 ..... I'hy ...". '1"" 2. '0 II ,an, "'nn N, unll ' 1: 146·S7. '9l3. Holool.¥ ... 1.0-.' ... E.<It '.<On M 1.«<>1.: Fo<.1 ~il",,,,,.noj p.,..""it.l<oU_ of <""""' ro ....... .M "k:; ,n poo"n" "i,h nonn&l.p"'''''''' ~l'a ..... «pIl" •• J N"""""I8<1: ' . l·7.1998. SIoe .. i. H .... O..."'"'"J O.c.o...m.nC B: v..,. ,ric.l ... " •• '~<1 ","n1inl f., "'"",ooho<_1 ""' ..... hydoo«phol ... . J Ntu .... N... "", .... I'$yo <hi"",)I, 1)).7. 1m. v ....... I . ",,,,.uljn P. 1)0.1<, 0 " C. <I <>I_ Nor· mo/'PO<''"~ ..,.droc<ph>1Ioo: I. <",emoVOphy , .. II ... fuI In ..10<""1 poele ... l;t. ","",1 "'« h N.... ,0(.9; J66.70. 1m 0,0_,,_ G. F1 ,.. ~ , L .. <>I, It,.;;· ~ " ~ pI<I'.'" """Phom<""" Be,,,,,,,,,, _1~.I."....,....ph~""<o'T'I","d ~ ". %. u. JO .... lltoy ..r.n...". N...... r.d;o(ot!' ZI: 1S<· 60, 1986, ......""' .... Moone" M. fI<r", ...c..,"', Pr«/ic:si .. ..l ... of.,. ... d.~in ......... I"" •• • ... hyd""""""I ... Mia /'I.~ ,O( SaPt ~ I I. l27· 32.1990. T.",,,,; N. "u'"_; T. W",obIya"" T, <111/, c.. ",,,,.llI<mod)'ftOmin in """"',.""" ..... b)'lrOE.. luII"''''' 13lX. itlha1'O"" ..... hoj ,..;I d,...mi< cr uud~ . J N",........,. 6, : SIO,' • ".Ii.. «plio,." " "" • 1I1oc~ PM.Ojo"""o R G,T""" .. "',CSFoIt!J"" fo< <i<mcn" •• ;""""i!IC .... . nd pi, di>l ......... Clln N _ .. 3l: 6n·S!, 1935. M<Qy.m. I C. SalO'·lOu .. L. $0::""'" P B: Trea'· ",,",of _I.~ u<. n)'ll>oc<pho'", with ...... P'C' .... ' _.... plnll ~u id oh ..... , NftIt'IXU .... r)' IS, ~·8. 1"4 , 81"" P M: !diopl,1H( """",,1.1"''''''' ..." 1«...1" ulll\un<in. i. (>l pool< .... J 1'1 ... <0... ... Sl, l71.7.191j(1 . '00. Pm ...... R C. Moktl B. L. ... !; R' S"'li",J 'n:"'. ",to' of Id><>po"'"' hyd/o>«ph.l", in d<l<,'y po. ,it"" . N.... oIoe1 3S: 307·1\. 1911'. 101 . Lk! ... hO lyiC R,W"""J H.I""" ... E. R..,I,,""" """,pll<oI"",,l" 1501t'''''''p>1le... wi," """",I pr<>",n: s. " N<:ural 3, 17\·'. _m<4,.", .,droc'ph- " "" hy./<o<""".r., CoIamlIJ •• , ai, ... "hei .... '.diou« camorttidily in _ I ......... ..,.drn«phoI",; .... n' """""", J 1'1...... Neu.oou'1l I'$)·,hlo'r) 68:776-31.1000 10J . Humpllay PR 0 , _ " 1 (F. R.""U R W R. Vi· ...., r..!d <1<1", .. ; ...... _ ... h)<Iro<eph.I .... J 111.,. .... 111 ... """ ... 1' . ,: ,91·7 . 19t~. '00 Pre-.,,«:. "'" 1'$,,,...... NEUROSURGERY ,~ CM>,;010 1 .,. • ".1\10.0.""""",u..,tw..1 O<T\II""";.;" h~h< <~,111 ""h .. f'I .~)oO · U6-00 .1 911 "",""'led ,""n',J Ko,i .... I'I . K .......... K T ......., ri , tim, N..." _ ~<"""-'_1"""""'""_""~_ mAIl.... , ... s... ""..... 22. 2n·6, _of"""" Rlad P M.C"-,",, 'H · r .... .." ' _.... ,..,.. • ;. 01.......... ,"'1 r", h~pM/IR J _ .... " . 067" . 19111 107. ,~ . ._.....,..,........ I! A, I"'"' . J E. "<Co<"';"k A Q. .. fIt,0/10. '" .... _ ' - , .... N.....• 011 ~ ..," U -t.I9U. $000 M.TMMoS. ~A •• ,011 Oc:<:i,oitaIlotIo Illlaoa ... . _ ..,. .. """"'1 ... """';,..1'1 ....... -c<1'J I' )Ol).S. Jo)o • • J . _~G w ...... " J. .. al_ O«¥/Uil 'M/). ". _.yoM_..,...r....... a.....o, t _ ......... l. H__ J)'. Fmltril. J A .... lIollo • . l " '. yol . 1 $<_ f'ubl1"" ",,~g.'! . 110. Jt.-I4ItBor_ J I!. r _ C E Cotrl<aI, """1 ~ i _. foI lo ..... " . "","""""",,, __ Ho)'1 W F. WIUI! F B, eon ... llIoIir4"." .ith ..... ,i,1 rKo"", follow l....... III>I./.'..i. ,,,,,,,<l1l1I1.. ormI . "rtb Orb,,,,, .. 60; 1061 ·9. ,'lSI 116. Wt"lI< ..., II n .•.., dc, W_ M.M..... H C I'fopo<.. of c«Ii<.1 ............ ,.,. ..... m.c ............ J AMA 119: 116-9. 1961 SI.." M L: I...,.",... "",,", ......,..u.1.I'Icr.MI'.. .... •• AmJOpb,hOlIllOl IGoO. 4lJ·6. 1911. 1'1• S_oq P 1,8...... "C, Sci" .... J B. .. "". 1, """"",",h)'" " , _1.,10"", or c..· diopuln\ollll)' b,,,,,,, ,_'l' ,.........,. n, ~ I" . ,~ ,~ '" ... ,. 't._•. '" ,,,,mil; """'" 1.19111. 119. '" L>_lotq R. W.w. f • . V.... Ior< _ _ ................... _po .......,... T. " .. AU<! 0pII0. 0l0I61 •• " .... 1960<. Ill. Hoyt wp y""'oIttlt.-. of ""' ....... <atIO . .. .., ""'.. _ ... _ ~ "'"'.... ' ..,in< ...... A"'~ 0,b0_601 . ..·n .w.o. A B. M>ro_ I' .W,' .... E. ....... <...1Ira1 II ). _ NEUROSURGERY o.-s Io1 .MotpII ~ w.s_..~ Y P-S"'"'k·..· _ m. _,;,;.... ""'-"'<•.J N _ _.....' . S(4. " • . 1961 blind ...... ;•• ~_ . N•• ......,.;!o' 1107 · ~ . 191'0 . KUII<J N. 81",11"0<1\ foUow;", 1<lII<Iri,I Joonol.. _ IuIn Nt.""" : 1116-90. 1980. .~. "",ie ncurop>th~ . " <011 . . of oo"JIfO"H' i ~ l I _. Nr. ... JMfIII 2U' :l9H.I91), Loobo, ): ~ _\" '" of.i . .... ,.,..",.1.. pooIooored b/iool .... . n <!iii""," .. 1111 hydtoc.p!lalu. or fol .... · lot (I)'Ofttli< ....,.I"'~ ... cu.. ..... lo" 6, 699-70). I96J . WiIoI'I'l H. Kn ... " K I. II_ ,' .. ,S ,.. . .. 41! ""'..-r" poIi<"" ..... c... ~ n... """'""•11<""" of ....... oncI ... i<>- of ,he Ii,,,,,· ,_.N ....,...f)I..,N· t:?'J.)I. I99 I. 121. M... O F.Zt"';'i. MT. Ottio L ~ 'CS F"", ,," ... lion ", lo .... mj obo. .. rri<aI .....,... " •. ""... h os/....,.U, J4.! •. l"ltl , I t. H,drocorphll u, 12.1. General information 12.1.1. Specific antibiotics ..,M.So",,, antibioti.,. 8~ ind uded hef1!ln to hi.hHghll'artkullln of in-.ernt. to neu..,.u,.. OR AL PE NICILLIN S am()xicillin ... clavulanic add (Augm en1.ini!» \ / \ A good PO drug for &U""rfi.ialst3pb ;nrl'JC.tiOIl8. Good IInReT'Olric and anti..,staphy loeoccal coverage. Absorptioo is una!r~tf>d by food. Av .. ilable fonna are lurom"rized in Tllbl~ ]2· 1. & Adult; 250 or 500 m8 PO q 8 hr. or 875 mg BiD INB use the apptopriaLe tablet to aWlid uetlUive cl.vul.nll~; the lower total dose of clavula nat.c with the 875 mg tablet may pn;>duoe ft.w". GI , ide eO'ec\.I). PNa: 20·40 mslkgld II.moxicilli" d ivldl!l! q 8 hr.. P ARENTERAL CEPHALOSPORINS Higher leoontion _,enu hive pro~~ely reduced uti-ity ag:aiJYt .tnptococci and pen;c;Uin• • producin, S aul't'US First gener ation ce pb aJolponn ll ~ eefll:tolin (Anee"'. Kerzol®) \ I DRJQ IO!FO \, Good for auJ1ica1 ptophylU». c:-llltVeb in h.-.i.n !.loue hne bIom documented. Poor CSF penet•• !.ion ( !hila nllt good lOr mminciCU), Adv.ntage over otheno ~h.lo6pot­ h igher !leNm level. {80 !'&o·mll ..... ac:hievable,.00:1 h.lfli!"te {I .a h..) i. Ionger {.!low8 II 8 hr dOlin,J. Ib: Adult: I em IV II a hnI. Peda: 0-7 days - 40 mNkrld dlvldedq 12 hno; infanl 80 mll\lild d,,,,ded II child - 80 mef\Lgfd divido:<! q 6 hn . [fit,: sa..: Third genention eephall>lIpori n . Potency ofthne dNP are . equivalent 10 .mino,lyro.id. for: E. coli, kleb.lieUlI • .. nd I'rou .... Onlycel\a:lidimei.itdequale for~. Cood fo r .... riou. · infecIlOu. (..... OO",;t;.. endocarditis .ad OIteomyeliU8). 8U)11.1:f"RCT11: dian-hell (peeOOomelllb"nOLl' coliti.). Weediordiathuu••nd may allow lu~rlnrection. {e"te~r, resJsUnt WI 12. Infectiou l'IEfJROSfJRQE;RY pseudomonas. enterococcus. fungus). ,--/ cel\azidime(FortaZ®) \ / DRUG INf O \ l Good for nosocomial infectionll. One of the b!:il drugs for Pseudt:>mcfWs (J('ruginQSO infectiolUl (large doses tole.rat.xl well), but doesn't rover staph well. Good eNS penetra· tion . tis) . SIl)E EJ'T&(:TS: ra~ neutropenia with protracted IIodmini~tration (e.g for osteOlnyeli. R.r Adult : 1.2 gm rvllM q 6·8 b.rs (non ·life threatening infections: I gm q 8 hrsl. Peds: 0-4 wks - 60 mglkgfd divided q 12 h rs; child - 150 mgfkgfd divided q 8 hrs (maximum 6 gmld). ,--/ ceftriaxone (Rocephin®) \ / DRUG INFO \ l Good penetration into CSF. Useful for CNS infections involving CNR IIond for late stage Lyme di!!ease. Long half·life allows q 12-24 hrdosing, U nlike mostcephalosp<.>rins, excretion i9 largely de~endent on liver, therefore 8110me dosage in renllol flloilun!. May he synergistic with aminoglycoside&. SIDE ~ may CIiouse bilillory sludging. R.r Adult: 1·2 gm qd (may be given q 12 hrs for meningitis). Totol daily doee < 4 gm. P eds (for meningitit): 15 mgfkgld initiol dose, then 100 mgfkgld divided q 12 hr •. MACR OLIOES, VANCOMYCIN, CHLORAMPHENICOL ,--/ vancomyci n (Vancocin®) \ / DRUG INFO \ 1 Arent of choice for S. aU,""" r infections that are either methicillin resistant (if not MRSA, better resulto are obtained with PRSP), or thot occu r in patients allergic to pen· icillin or de rivative/:l. Multiply resistantS. llunU$ infec1iollll may require co--trellotment with rifampin . Poor for Cram negatives. Loog half. life. R.r Adult : start I gm rv q 8 h Tl'! for serious infection. check levels before and after 3rd dose, and aim for peaksof20-40 Jlglml (to~ic > 50; ototoxici ty and nephrotoxicity that are usually reversible occur with peaks> 200 I-'g/ml), and troughs of 5-10 (toxic: > 10). PO dose for !l§eudgmembraOOUB colitis: 125 mg PO QID . 7-10 days ($Orne referenc· es re<:ommend more, but this is not necessary). Ped s: ageO--7 days 30 mglkgld divided q 12 hra. Age> 7 days - 45 mgfkgld divided q 8 h r5. - 0 ch loramphenicol (C hloromycetin®) \ / \ Good for: Cram ( +) and Gram (_) cocci. Excellent CSF penetration (even without in· named meningesl. 1t i~ hard to find the oral forro in the U.S. R.r Adult: PO: 250·750 mgq 6 h" (m ay be very difficult t.;> find in retail pharrnacie. in the U.s_). rv: 50 mgikgld divided q 6 hI1l. Ped ,,: 0_7 days old - 25 mgfkgld PO or rv q d . Infant - 50 mgfkgld PO or rv divided q 12 hrs. Child (for meningitis) - 100 mglkgfd IV dividMi <1 6 hr ~. AMINOGL YCOSIOES When given rv, ooly amikacin has adequate CSF penetratioo (and ooly with innamed meninges). Not adequate monotherapy fOT any infectiQn. Good adjunct fOT staph and CNR including sensiti ve pseudomonads. Poorforstrep. All are oro-and nephro-toxic, however toxicitillll occur almOllt exclusively with longer use (> 8 days) . More rapid kill than H-Iactams and may thus may be used initially for sepsis and then changed to a cephalosp<.>rin art..r ~ 2·3 days. Increased activity in alkaline pH. Reduced activity in acidic pH,lIond in presence ofpusandiOT anaerobes (therefore may be pOOr for wou.od infections, nuoroquinolones may be better here ). J:lol!ages baaed on llIW body weight. Obtain serum l"vell! afte r 3rd dose and adjust appropriately. Dosage, of all MUST be reduced. in renal failure. NEUROSURGERY 12. Infections ~ gen t amicin (G arnmycin®1 \! ORUG lM'O \, Ibt Ad u lt l non llal ...""1 N!lction) I V; 2 ms'kg fV lopding dOH tllen 1-1.6 mgr'kJ q 8 > ~ .,ghnl, t rough < 2). & In tril lh ecaJ - 4 It... mllin l.eoance, follow I.v,,-Is \deai red peRk rna q 12.24 II",. wbramyci n (Nebcin®) \ I \ 'I'he be$l aminog lyrotide for pleullomonu (but not n good u oe l\ezid imel. Ib: A dl.l1t (normal Tilns ' rUJ>dionl: 2 mg/k,& I V loadi ng dOile t hen 1.6-2 mlVkg I V q 8 hra maintMlnoe. For PI:' > 60, &arne do.e q 12 h rl, Follow lowet, and &dj u.t (or peak 7.S10 " glml , t n;llli h < 2. Rs 10Iro l h «:lI.l: I) mill initial d')$e, t hen 2· 4 m, q 24 h .... 1lJ< PP!dr. 6-1.5 mgIkWd divkled It 6·8 hrl. 12.1 .2. Antibiotics for specific organisms PSEUDOMONAS AERUGINOSA Cef\nidlrue (Fortad>l;s the dm" OrChOH'. (1ftpa6f.209). GoodCNSpeMl.f1Ilion, large doses tol ora u-d we ll. Amon,amioogl)'«>lldu, tobramicin illhe best an tip- u udomonal. Aa\inoglywoidH gi •• 1J\OU .. pid ki ll and tb.refcml wll..., tM'" i, •• trona sll~pition of poe ud omonali atMt wi lt! orit nid ime ph.. tobramidn ;n ltioUyand then atop th e tob ro..ni om alter a reo. d oys(redutel risk Iltaminog!y<'Olidl! lllltiaty). An tip. seudllmllllal ~ lIicillinl I re not ... effective lthe following 1Irt! B.lart.mlM lu..:eptibl.i): ca rbe nicillin. u carcillin. ml!~locill; n , Inlocilli n. Addinl dly ulanate to ticardllin (Timelltill ~l ,..,du o~ $WlCl'ptibility to B.lad.amalH!. Adding cipranoll8cm frV or PO) to lU>)' IIf t h~ a1)ov" IV medieatlon~ hat. JYne rgi.Uc effec l lbul illnadeq ... te by iUlelffor lOft· tiHue in fection,. auch 118 woond infKl.:OJ1& ). STAPHYlOCOCCUS ... URfliS VanOO(llyd n unti l it is dete rmmed that it i. not MRSA, then use PRSP (10.1. n,rcill io) 'I- gen!.a mici n (Ilm in.o,lyc:e.ld8 give !DOre rapid inltiallr..iU a nd are .yner(i!! lic .ga,nst lta ph ). 5tDp the gentamicin . n.. r. few doYJ (l'ftIUCQ risk ofaminog\y<:OIIide t",u city). For .Q[iJ trea tment of non M RSA S. DU",..., .... ound infeotionl, optioM include 2 """"Iu of: 1. AUllD"n unllll (<<e PQgt'l!P81 2. lit n illoupin (600 mB POq dh either A, trimeth allulfa (I OS PO BIOI B. or cll n d.m~i n FUNGAL SUP€RINFECTlCJt>J For tun,a1 ~up"'ri nfectio" oflhcl Gt lnct in paL;enu on "ntibioti.,. or a<UOids: nystati n ( Mymfl tatin~) (oral suspension ) \'--"-1__ """'_-_ _\-'--, Ilx W a a l. ; 1 «(100.000 "1I1Le) on ellch . i6e ormoutn QJ O. Ilx Adul l.a: itl len Aml ....llowing memanilm;, intact.. 5 ml QID ,wWland Iw, l, low. I( comntoH Or unabl4! t.G 'wallow, 3 cc I"'r NG QI D and '2 (C onLI ..... b QID SUPI"UEtI: in con~nlraliooof 100.000 unitalml. ~ May fl uoonawle tDiflucan®) "'""11.$01; \ / 0I'l.IQ ...... 0 \. _ nuu eorw:entral>on of phen.ytoin, l id/l¥udi""', and oralll ntLcoa.(\l· 1..,1.1, amons nth"" •. Can QU6O! live, dy.fww:tlon. which roay not be ...... enibll!. IU Ad u lu ' (or orOphllrynreal c:andid,"ia. 200 m.r PO the fi ..ldsy li nd then 100 mil POqd for 2 weeks. lJUpp' .IllO: tabl4!Le of~. 100 or 200 m.. Powd'!r for Itn Ll"Ip"n&ion which Un be mind to. voIoI ..... ot3S mt 0{ ei lh.r 10 0/' ~O m"ml. AI.o.Ylli lllblfr in IV fonn, which i. ~ry npenalve. and 1UI" .Uy not n«NUIry d". III eXteUent GI nbsorpt;.o n. '" 1'2 InrKuonl NSUROSURGERY 12.2. Prophylactic antibiotics GENERAL PRI NCIPLES' 1. anti biotia mUlL be;o tissuea at tilDe of contamination (!hue, ",void "on-caU" a ntibiGtiu; give 60 minute. prior to il'l(:u ion) rept.~ adm inistration y;U] in prolonged procedure. typical infect inG organism. are usuaUy predictable. Co~erage for the.. O'llaniam, i, IId~UBte (broadeflinG .pe<Lrum it of I)() vlIlue) 4. in low ri. k oper.tiora (e.g. carotid endarterectomy. whue infections rtlre and lei· dom lire· threatfnin!i') may co.t mon 1.0 prevent than I(> tru t 5. prolon"ation ofantibiotic:l beyond lint poIIL-<>p day provides DO.dditional protection (may not be true;n patienta with . urgical drain,) 6. theoretical aid . .. ffeeu (alteration of patie nt', Oor •• dlPelopment of retiatant strainl in patient or hospit.al) have not been re.li~ed wi tho",! prolonpd adminis2. 3. tration or pre-o p Or poat.-op antibiotia 7. factor. that incr eue rilk of ope rative wou.nd infection include;: A. synemic f9ctors: malnutrition. reoperation , infeaion at aeeondary .ile (e. pecially UTI when GU tract mll(lipulated), prolo"ied . dminltln t ion of an· tib iotiC!! B. local facton: epinepluine, dehydration, hypcWa SPECIFIC AGENTS FOR PROPHYLAXIS cephalos porin&: A. ai"nts of cl!oice where skin flora (a:>8g\Ilsse (- lor ( + ) staph) are lihli""t pathogens B. may sa fel,. be give n even with history of mild, "....,·immediale manifuta· tion . of PCN allergy (e.g. · rashes"). Contraindieated ifhistory of immedia te Or acceler.ted reaction (shock, bronchospasm, urticaria) C. eefnolin (Ance~, Kefzol®l: d fe<tive, widely studied. therapeutic levels in brain t ...... e after systemic administratioo', longhalr'life Dropbylactj~ d!IiI:: 1·2 gm (peds; 25 mg/l<g up to 1 gm) IV 60 min before l u..,ery, then q 6 hr lit 24 hr& pott.op O. lOme S. O"~Ii' IlrIIoint ""' e1'fici.o nt in B-lact8mue degrads tion of cepha. losporina. and cefnolin is partic\llarly ...sceplible. Lowe.. infection rates may ..... ul: .. ith cefamandoht (2 gm initiall y, and then 1 gm q 2-3 hnI intra· operatively» E. a umi,ynthetic peo.icillin may be more a ppropriate if good CSF penetration is neceual'}' 2. vancomycin: allernalive if cepbalOOlporin contraindicated (incidence ofl n&phyladkrudion, i. too hilJ:h fOT routine use). Dote(empiric): I:"; mg/q (up to 1 10') IV pre-op. tben 10 m&lka; q 8 hra for 24 bra pOOIt..op 3. penici llin s: d iudvant.llga: probably len A fe • .non.tr half-life. may prolong bleeding ti me., N8 fcillin il probably the btlt Ipnt in thia group 1. P ROPHYLACTlC ANTlBIOTlCS FOR SPEC.FIC NEUROSURGICAL PROCEOURES I. 2. carotid eodarte~lom,.: routine 11M DOt indiClOted (infection risk too low): when riak of iofeclioo ;. high. 11M oefouoli n (•• for p ........ prophylaxis, lIHabow) e r aoiQIoIOY: ri5k of infection tn'y be imreaNd in prolonpd or mJ.crosurgical procedures.nd in renpera tion.. No lignifieant differellne in the .peciflc regimen \lied was delftted in meta·anaIYI;'·, Option. include: cefatolin (He "boo" dindamicin (300 mglV) preoOp '" q" hn vancomyru'l (ac obow) scme!Kld pnt.lll1lkin (80 tng 1M) pr_p to any of the... 3. CSF . huDting procedu«'a: eft\CIOt')' haa been documented wilen the Infection NEUROSURGERY 12. Inf«tiona rite I. u""'''II11y hi,1I fur lO me . twllIll (e.g. _ u .ly infeetiotUl, i.1!. - fint wCIi!k pOlt-OP A. for llentrlll LlI<! L. ftlec~ :I. PLUS I ~) AnLibouUI1 p<III!!Iibly redUCl! one of the follow'!!I: c,f"w\in (<<t llbot.,.. ) II 191 generation ctphalGllporin (e.l . «'phapiNi (Cef.dylll!)):u. n'&/'kg {up", 1 t mll IVP intra-op ...d II hr. pD5r..<1p I'\tJeH l1li 60 mW!t. (up to 2,1 IV 60 m in before "'.g'II!T)' and II ~ hts posl-<lp I :; dOiet Lota! in ttBtb~J ~nUIr.nicin 4 ml( injected intolh unt l ~ tlm.Or pJIC. mtnl (nQ longer ",yell.hl. in U.s., bu t pl'flflro'alive./'ree pediatric gentamkin may he diI",1.ed appropnal.8ly and used ) 8 , Kaiaer'. luweata no IIntibiot;':' ifinrectiCln rate J_ t< t o'iloI. Ifhi&h f> 20'10) '"I IV) pn:-op very high, ... '" lrin.ethopri m 1160 rna: IV) pI .... a \.lJr.metno""nolf (800 and II 12 hI'S ~ 3 dole. poiIt-<lP INB: thJ.. Iluer infection ral-e I and r Hu lt.l are thul queltionable I) ICP monitor" lIN pog, 5$0 procedurt'a involving indlionl Ih"'''1I1I 0 .... ] or ph..,.."",. ] IlIUL-oaa: Cln!.llm;· e in ( 1.7 mlVkg TV) and cllndamicin {300 mil" IVI pre-op '" Q 8 hl'5 ponop II 2~ hn. Cer,:ol;n & 3T(! lI"eneral;Qn eephlosporin a lll(l eff",u"e when p"en oval' 2-4 hI' jIO!. nod pre·op Ii. spinal surgery: r educt,;on oflnfect lon wu ~1t«J. but not Ilawtic:aUy IIgnifi"""t lIow inclden::e. would Tl!quire Ja~ study) 4. 6. w" A lringle blind pr(lllpectivf .tulb' s howed thf inridenee ofpo,."nWroIurgita( Ql>t!ra· !.ive wound ;nf"dionS were re<ll)(:ed with eerazo]in n gm IV) plua r.ntamicin (80 "" TV) gi ve n onehr boofo", incililo n and" 6 hrl intn-np (none pDII t-op) With ll",i fleJInt f'Nu lu in p&r.ienta without foreign impllmta (upecially enniotomiu: no .ic'nifie.tllt difference fill' spinol operationl, but u umben wfT'l! I mall). AU infectillM w..reSl<lph. or ~pi. dermidi. (maku USf ofgenlaOlirin Quetitionllble). 'JI""'" 12.3. Meningitis Community ,,~uire<l mening;ti~ (CAM) is gene nJly me", fu!mU:Ant lban mening;. til following lIf!ul"Q.l urgie. , p~urel (lbe fOnDer t.end to OCCur with mo,.. virulent Ol'118ni5mlor Impoi red bo&tdefe.'ieI!l, Both Nprelelltmedieal emergent1e6,and 5hould be treated im medililely. f oc:eol n"..... loeic 8igru; are 11I0! in IlCUle puruletlt meningiti,. ~ l.umbw punc/u", On page 6 15 (or 1 di8l"\llllion about when to perform an 12. 12.3.1. Post-neurosurgical procedure meningitis s. 1. 111"'11 orgllnilml : o~",~., Ent.eroba<:t.eriltl;f!lK", PseudG"""",. " p.,~IUJIOCDC'r; 2. empiric "tljbioliet: v'(,OI)"ljo"cin (to cover MR5A)~ cert.ddime lperifieally: v..u::omyell1 (.dult) 1 em IV q 8 b ,.., (cheek leVY! beror", ...daner 3rd do.eand 3, ~. .dJu.t acwrdingly, ~ VIIA<'O,")'I:in, page 2(9) • ceftnidime (F orudP) \·2 guo IV q 8 hn fCir pil!udoUlon... add genlAlIliQn (IV '" IT) Irorll'aniacn twntout to M nOo·MRS.\ S. O~~"". change v:anCOOlycm to IV PRSP (e., . Il8rtillin) 12.3.2. Post craniospinal trauma meningitis (post-traumatic meningitis) Epidellliolo(D' Ottur5 in 1.20«'0f P/ltienllwith moderlte to_Ill bNd inju.ri.... MoatUl _occ:ur within 2 weeki oftnuml, 110;0u,h delayed _ hl"l bM-n ~ribtd'. 75'" or til... hllv. delllonilrahle baaa l 8ku ll fnoetu", t_ ~ 665). lOud ~ hid obviol1l CSF rhinor· rhu . m 12. Infections NEUROSURGERY Pathoge ns AI. eJ<pected from above. thel"l! illl bigb rateorinfectiuo with Qrgllnisl1l/i indigenous to the nau.l eavil,Y. The most 00100100 nrganisma in a seria from G ~ we~ Gram-JlO"'Illve cocci (Slc.ph. Mm(>iilieUil. S. wameTi. S. ellhnii, S. ,pithrmldi•• and SIre.p. plleumo· flia) IIlId Gram-negative bacllli (E. coli, KI,b,~J1o pMumoniu.,Acillf.lo/laCltrotlilroiIUJif. Trentmeot I. a lRO see CSF Futulo. 1'rrot",."" On pagill77 2. antibiotiea; appropriateantihiotica are M'1~t.P.d ~ on CSF JI'Inetmtlon "lid orgaoism HMitivi(iell (adapted to tbe pathogeJl8l'Ommon in the pIItient's locale; in the above "" riel, all CnuD·negative .trains appeared ,"".isllInt to ampicillin ""d Ihird'genel'1ltion cephlllll!porina, bU I were !en~ilj ... e t.o i roipenem and ci"rofl""a· cin; Gram·po8it:ve ~tr.ln& werll"U ",,"sit,,'e \.0 vanCtlmydn). For emp;ri" IInlll»oll""il<'~~212 3. ~. surgical treatment ... " ·coo.ef\lsUve treatIOent": eontrovers;.l. Some (eel that any case ()rp08ttr"u ",ati~ CSF rhinorrhea ~hould be explored"', and th"t~9 G! ~Dtan~ou~ CUliDtion olli!n rl!pres<ml ob.u:uno.tion tly inm~ra(ed brain, $0eaJled ·sham healiog" with the pol4lntial fo, later CSF leak an!ilt>r mening;ti.'. Othe", su p port. the notion that cessation (pDilsi bly with the Ill;s;stam:e oflun,bar s pinal drainage) is a~teptable eontinu e antibiotiC!! f"r I we .. k afWr CSF i, st.uilind. Ir rhln"nbea perlliau at thiR ume, ~urgital [epa;, i5 f"8CGm1T\eJ1ded 12.3.3. Recurrent meningitis Patie11 \.11 ....·jlh re<:u r rent meningitiR fUUS! be evslupted for the prt':aellCe G(aboormal eommufliclltion wilh the 1Il1t8sp",aVin\.ra<1renial compartment. Etio logil!lllndude de., mela;nus (eithe r !pinal or cranial, _ pa.s_ J 18), CSF r;~tula [a", ~ 174), or ne"ren, Ulric cySt rue fX'8~ !lB). 12.3.4. Antibiotics for specific organisms in meningitis RoUI.<! is IV unleu specified othe.rwi~ . S. plllo!umOl1ilu: PeN G I1i!nd M.oice. chloramphenicol) N. mMineilidi., PeN C (2 nd choiCO:l: chl(l1"smphenirnl) If, j,,{1uerua : A, no"· peniullina!e producing: ampictllin B. penicil\in88e producing: chlGra mphenh:ol Croup B Slrep' ampicillin 1- monGCJ'I08'e" ... : anlpicillin S, DIU'fU' A. ini tially before sensitivitie5 knawn, Or ifMRSA Or mu ltiply r ....;,;tant alraina '" re!II l!tant coagulase aegative S. O"~I<' pr"-~alent o r ~us~ct«l: vnncomy, tin .. PO rifompin" PO trimethoprim B. once it is knGW(l that tho u3ph is nm. MRSA: 1. infanl«7dj:melhicillin 2. all oth elll: n"fcilHn 3, PC!'.' Bllng)': vancomyein Or tceJ"a!Qlin";8 both rv .. ['I') 8~robic Grem n"Maliv" rod. (CNRl A. celtriaxone, or cefouujDle, GT monalact.llm tin order Gr p re feren ce, make .1, teral ions b!tosed on S<'lUitivitle,) B. if arninoglycOliide ""Iuiri!d, in traventricular theropy i. jndkal.ed atl.er t he newhGrn ~riod p, CU! ru lli/1(1$fl A, cefta~id ime {Forta~) alone If ooi life threa lAlning D. B. more se rious infect ion. require 2 Rgenls (pminoglycOliide gives mOTe t8pid ItiU, a nd may be w;1>(! initially for 3dllY~ and th<!T, fil.(lpped if aensilivilil'$ to reillllidime are ateeptable): ceftazidime + APAC .. n'gentanucin 4 mil' '112 hn ( ",~ e via intraventricu· la r route if ven tricu.lili ll" il pre&ef1t) NEUROSURGERY 12. Infections OR C. for overwhelmil\li infectiOR: «tftnidime . tobramicin • tica'tiliiD 12.4. Shun11nfec1ion Ri. k orearl)' infection lIf\er .hunt . u.rgery; ~pOrted range i. 3-20'li0 pe r procedure (typic..,ly - 7%). Acceptable infection ,111.41 ": < ~7" (although mal\,)' published aerie. have I r'lA! near 20"", poe.sibJy due to differel'lt patient popu lation). Ri"k factors ror s h unt infec t ion Meny facto .. have been bl~med; $Om, that teem to be better doc:ument.ed include: I. youn g age of plltient" : in fD,elomening«eLe (MM ) p.tienta. wailiD, until the child ia 2 weelul old may signifioantly lower the infection •• I.e 2. length of procedur8 3, Opell neuraJ tube deJect Mo rbi dity of . hunt infections in c hildren Chi ldren with shWll infectioM have. increased moruHt)' rat.e and risk ofseizull! than those without shunt in fection. ThOIIe with myelomeningO<flle who develop ventrieu· litia af\er shunting have a lower IQ eompared to t.no.e without infectiOll'". Mortality r .. nges from iO_I~'h. PATHOGENS Over ~~O( 5taph infe<:tiQll8 QOCur within 2 ween """t.-.t>Wlt. 7~ within 2 _. Source is often the patient', own 1Ik.i.n'". It is £5timated thllt in . ~ofopeTatiol" (or shunt insertion the CSF is already infected (therefoll! eulwre CSF during insertion). Early infection Moat commonly: I . Staph. fpidf'.rmid~ (CO/lgUlase'lIeglltive saph ): 6O-75'l&ofiDferti_ (IlI00I1 common) 2. S.ourfln 3. Gram·negative ""dll' (G NB) : 6-2~ (may CQID/! from intelltinal penOl"lltion) In neoDatel E. ccU lind Strfp. Mrn.oiiti.!IU domiDate. Late infec tion (> 8 mon ths alter procedure) Risk: 2.7-31" per palieDt (typiCIIlly 6'1t). Almost aU S. fpidermidu . Tends 1.0 be internal t.YJlf. 3.~'It ofpatien u. aCCQunt for 27'1t ofinfectiollS'". 'w.te" shunt lnffttions lUay be d~ 1.0: 1. M iodo]ent inf~on due 1.0 SlOph. fp;.u,m/di. 2. aeeding ofa vuevllr Ihunt during epiaode of septio;:em ia (probably very ten) 3. ooloniution from an epilg of merungitis PRESENTATION NOII" peemc . yndrome: fevet. NN, letbvg)', anomia, irritability; may mimicarote abdomen. May 11]10 present II malfunction; 29'l. ofpatienta preMntu,g.nth .t>Wlt mal. function bad potitive euILu.ra. In neooat.. may mllnifa t lIS apneic episodes. anemia, hepato.plenolnts. ly, and . tiffneck". S. 'pidumidi. iofectlona tend 1.0 be indolent (s lIIOl. denn,). GNS inffttion. Uluallyeauae mOil! severe ilIne..; abdnminal fmdingo more COmmon; main clinical ma nifestation ~ fever, .... u.lly iOl.euoitt.ent and low grade. Erythem. and tendema •• long Ihuot tubing OCCW"Ioccuionalty. Sbun t ne pbritl, ,,: may OOI:Ur with chronic low Iev1tI infection ofa ventrieulovlllCu, Iar , hunt ea .... in, immune complex depotition in tenal , Iomenoli, chsracteriled by proteinu.ria lind hem.tu.rill. Blood t e_I.II :ilIK:: < 10K in one fourth ofahunt infectiOM. It i,,. 20K in one third. &liB: tately nonnalln sbu.ot InfectiolUl. IUCI!!d cyltural" poeitive in lui than ooe thlrd of cues. CSf; WBC i, ul uaUy oot '" lOOc:ellllmm'. Gram .taiN may be pcNIitive . '" 12. Infections ~O'III(yie]d NEUROSURGERY with S. tpitWrm,dl,;. milch lower!. Protein 11 oll:"n elevatOO, glucose may below or norma\.. Rapid antigen tu tAUIHId ror«ln.muni\)' aequlred meningi!"'" ulually not "-Ipflll folr tht OTpnl.ffil th~l w nd to cauH shunt i!lrldion • . CSf' cu ltu rea are negative in 4()1l, of CIltH (higher culture yi eld Ir CS F' WBC count i. > 20Kl. EVALUATION OF SHUNT FOR lN~cnON 1. hiswry and phy.ieal direcc.ed at IMunuinilli Jlre!lenoe of.hove ligns and aymptonll with emphul. on A. hittory 11l!:!!ut!"e ofinffCuon at another lite I . eXlIOI ure to Dlhe,.. with "iral lyudromK. includil\l fick • •blinp 2. GI ao uroe(e" . acutl gMtroenle ritia). Of\en _i,ted WIth diant.ea. orarrhu ii II I YDlpt.om tbat "..Ilftlly elU)llIrl'I tGf, , hunt Inftctlon S, ollt ;1 medi, C OllICk tymp&.olC mtmbr.net) 4. lonsilliti..rpbllryn(itia 6. appendJdtil (peritoneal lnnaulmation 6. URr 7. 2. J. 4. Ii. 6. ~l' ilD~ VP shuntou tnow l I)TI 8. pneumonia B. physitlll!:UlIl to RIO mC/l;ngi. mu. I,tiffll«k. photophobi • •,) Hrom wac COWl! wi~h liifferenti.l . hunt tap, ,hou ld ~dcmf in Q.li4!' of.utpe<::U!d wun! inrec:t;on. Sh.¥.lIndl~' carefully to a¥oid inltoch.eing jnfection. GNB requires different therapy In hu highe r lUorbidity than staph. thut it .. df\llirable \.0 ict.ptilY!hue rarlll PIIuen~ :> 9O'if> of th_ had pc!IIili"" G " III·lIa i n~ CSF .mea r (oniy. few C,am 'poIiti¥e inrectio ... hay!!. po!Iilin l"ESull.l). GNS hllYe higher protfoin . nd low1M' g1u.:.o.e, .nd oeutrophjl~ prKom inat. in differ.mual (unpubli~bed d!ll''') CT, UJlu.fIlly not helpful for dj~~lng mfection. Epeodymal enhan~lMnt wben it aero,.. hi diagnostic orvenlnculhla. CT m.), de_tr.te .hun t malfunction .lxIominal UfS or C'I': abdominal paoludOC)'it i& l uueotiWl of inr~tion • LP; usuaUy NOT re.oommended. May be hnardo ... in obItructi¥e hydrocephalus (HCP) with a oonfunctionillJl.hunL onen does not ,;eld the PIIlhoc.n TREATMENT Antibioties alont! (whbout removal of8bu.nt hardware) Although tudieat.ion of shunt infection. wi!.hout remo¥.l ofhrdwal't! has bem "'P'lrWd""-"" ", IIUI has a lower 1ucr:etS rale than wi\.h .hUllt remov.I". mlY require protracted treatment (up to of!> d.ys in some) • .-i6ks probb.m& 1S,0dated with dra;ninl infected CSF into the pentoneum (reduced CSf' abso'l'ti ...., IIbdnminlll "ignohymp\.Omil irn:l"din, '.mdemO!ll.l! to f,,/I· blown p"nlnr,i!.il'· '. ...') or vascular . )'Stem (shunt nephrit;" 18ft fHJIIt 2141. KPl-I.5 ... 1, IUld onen requ.i rel.t leut pe rliallhunt revilion al somepoint in CMSt e.Hfi 'l'T~IItmf!nl wilh .ttlibloties witbout . huntl"l!1llOVal b then-fori! recom· mended only in caietlwn.,re th ""t;ent:. " ~nnirn>lIy ill,;' a ptoOr .ne<theticrisk..". h ... vMuicln !ha.lllli,101lw difficult to clllheteriM!. wt Removal o r IIIhu ot ha.rdwa.re In roDllt ill5l.1ncu. durinj: the illilial tnatment "'itb anultiol;..,. !he.ahunl it ei ther erlemllliJ.ed (i.e. lubin, II diverted . ! lIOme point di.ual to the v,mtricul.r cathtllOr .nd conneded \.0. clOM'd ru.ln.p ')'5t.1!ml. or sometiml!ll thfc eOlire .hunt may be NlII)O\-ed. In Ihe IIII!.I!' caM, _ ClIe.nB orCSF dnlilla,. IIIusliHI pr!1'lid.d ill ahunt dependent CB~_ ell, Ritbe r by i ..... rtion of an t>:IRmal velltrlculardrain {EVD) ...r by int.P. nnittent "eotric:III., tip. or LPa (...itb comlllunifltllll HCPl. EVD .lIo..... ~.u,. m.. nilnnnl of CSF flo..... conl rol of ICP, .nd re~ted " mplinl for WBC derAtVllnat;oni and eu1\IIrn,ln ' ymptomatic pltiwUl or Ih_ with . ~;li",CSFcult"l't!", 'ny hlfr:lw!lrel"llmoYed Ihou ld be cultl>~ 15 only - 6~ .. l terile on shlln! ,,,recl;orl" Skin orpni8IDI ""' rutOdioul and m.y taka .¥Rral d.)'II to 1JrOW. Irtherl! i. an .bdolDilUll PMUOocy.I, the nuid .hol>ld be. dJ".ined \.hl"OUlh the pentanul Q.thRte. befo.. n!OO¥inj: it. E mpirie antibioticlil I. IV va n comycin u.ted init iall), Ipenetr.!Joninl.oCSF .-ull.l in co....,.,nt.. tIOnl181f> 2. 3. tha t oheN m). PO nralllpm m." 1M added for incruted «overlge (10 mgIII"d.y PO q 12 h($) when rulturu rl'.tum . change ¥'noDmycin to tV o.afi:illw I>nle&l p.llienl itI PeN allergk Or colltl>'" ahow MRSA (cood pellelral;on or inflamed >II.millj"' lower lnlticit,. thin nMlhlcillin\, Ifbact.l!ricid.lact i¥;ty i. < I·S. _pin c,)!Isi tr adding NEUROSURCERY 12. tnf"«1.ionl US 4. "fampin intl'aventncula. injection ofpreservat.iv.·free antibiotics fIIay be UlIed in a ddi tion to TV therapy. damp EVD x 30 mioutel after injection Trea tme nt fo r . pecif'ic o"lla ni , m , Poeitiv. culturu from shunt hardwa re removed at the time of ahunt r~iBion in the abtell/>ll ofcHnical , ympl.Om a Or ' pwitive CSFcu lture may be due to contamination and do not require treatment'·, \ . S. Qu .. .... and S. epilk,m;di. A. if ~n.itive (MIC s 1.0 I'g/ml): IT geM" (TV n_ftillin, Or cef/lulin, orrephalothin. Or «phapinn) B. ifre, lltant tQ nllfcillin (i .l . MRSA), cephalothin, orOl!phapirin: PO rifampin • PO trimethoprill>" TV &. IT vancomycin 2. F.nte. oro«U . : !VIIT ampicillin .. IT giln! (If inlrlllVallCular s hunt: add IV gent ) 3. other It rept_d: either antil treptococcal or above enter«oCClll regimen 4 . ae robic GNR.; base on lu.5<:eptibilitin; both beta· IActllllllr. APAG IV &. IT iooicat5. " Corynebacterium . p. '" Proprlonibactenum II'. (diphth~n;lidI) A. if PeN unsitlv.: u" ~ntel"O(OCCa l regimen above B. if PeN re.i.t.9nt: N + IT vancomycin Intratheca l t he rapy Yogev" cautions agaion b..i&h levels (ClluHd neurolopc effKI. in rabbil.l]. he ' UC· gesl.l tlriving for CSF «Incentrationl comparable 1.0 puk blood value. ('.1:. 1().12 ).'grml for gent, or 25·30 ).'glml for amikadn ). Subseque nt man age ment Ooce the CSF i"terile X 3 days. continue antiblotiea an .dditiooal l o.. l 4 d.y., thfln convert tbe £VD 1<1 a ahunt (if ao £VD was not usN. it i• • till recoounended tb.t the shW"lt be replace with new hardware ). 12.5. Wound infections 12.5.1. Laminectomy wound infection Duun in 0.9-5.. OfCII""'5"'. May range from , uperficiall<luvere deM_nt wound infection. The ri, k i. increased with age. long term w:-roid use, obesity, and possibly DM. lotraoperative mild hypothermia (as conunonly DccUn in the openting room) mayalao ;oerea"", thfl risk ofwound infection ( a. demon&lnIted with colorectal ruection"). MOlt are aouse<! by S. <I..,..,.". M.Io.NAGEMErfl I . culture the wound and!or lOy purulent drainage 2. aUrt the PlItiMlt empirieally on vl ocomycin plo,., a third genention cephalosporin (e.g. «f\81idime) 3. modifY anti blot;'" apprOpriately wbeo culture and s~n.ilivity resulla available 4. debride wound of.o Decrotic and devl6CUl. rUed tiuue a nd any visible suture material (foreipl bodj~). Superlkl.l wounds may be debridNi in the oflkfl Or tre'lment room. deep infection. (Dun be done in OR 5. . hallow defectD may be allOWfld 1.0 heal by ucond.ry intention, and tbe following i. on. possible rectmen A. plldo. the wound defect wilh U."lodopboJ411 gllllte B. dre..ina:cI... nge. II leul BID (forhOlpital ized palienl3,changeq 8 hn), remove and trim ~ O.5-t" of PKking with each <iresei ng CMOge t. while wound i. purulent. utilize 112 nrength Betadine® w e i 1.0 dry d ...,inp 2. when purvJence sublides •• witch 1.0 nOl'll1.l u lioe wet to dry C. aOlibiol iel, may be utefula • • n a<.ljunel to wound lrealment initiaUy, . witch I.o oralantibiotiao a. ea r ly a . poasible. I durllion of 10-14 day. total is probably adeqllatc ifl_ 1 wound tare i, being done 6. .arne prefer 1.0 dOH wound by primary inunlion n , il i. critic. I that there be nO '" 12. Infection. NEUROSURCERY I<!llIIioo 00 the ,", ound Ibr healing to UCCur. Soma do"", over lin irrigation II)'Bl.em antibiotic bellda. Relefltion lIu tur"" mil)' be helpful "' 7. with large def~~ orwhen bone end/or durabeoomu exposed, the\llleofa mU!!Cle flap IQn..n perlormed by 1\ pl,,~t.c oW'Xe<ln);' probebly requlr{!d lO 8. CSF leakage requires explorat, on in the OR with wat.e.."tighldl1Tsl closure to pI'!!ven'metljngitil 01' 12.6. Osteomyelitis of the skull The Bkull is yeri l1!8isUlnL to Dfll.eomyelitis, aod hemaWll"'1KIIa inf""ti,;m ill t a",. MOI't Infeo:tiOIlllIl", due to (OnllgUOU! spread (ualUllly from on inf~!ed air sinu" <xCII· .;onally from IUIlp aOscI!lll) or to penetrating trauma (includi.:lg su rgery and r~tal fC80lp monil(lni"). With longstanding inft!C"tion. edema and swelling in the area may becoma viaible radiographically, and is oaHed · Polt'" puffy lu,"or". SlIIphylocoooua 13 the moIIl common organism, with S . oure .., predominating, fol· lowed by S. epidtrmid~. ln neanat.el, E. coli may be the iofee<ing organiam. Trea tm eDt AAUbiot,as alone "I'e rarely cu rative. Trutment is UBual:y 6urgical debridement of infeclt'd skull, biling orr io{""ted t.>uo~ with rongeu ... until a n~rmal snapping fOund r~' ploCt!B the mOre muted sound made by rongeun.ng in f~l.ed bone. In the cue of"" infected cranlOl(lmy bone flap, the flap mU9~ be removed end the edge!! of the skull rongeured back to healthy bona. Closure oftha 1IC4lp withou~ eraniaplu\y ill perlonne<\. Surgery ia fQllowed by at least 6·12 weeks of antibiotics'". usually IV for the first I· 2 weekll. then oraUy fOI the remainder, Until MRSA u; ruJ~d ou~. vaneomycin + It 31d gen. ention cephal09ponn ~re used . Once MRSA is ruled out, yancomydn may be ~hallged to e p«nicil1inue resislllniaynthetic penicillin (e.g. nilfcillln). MD&t tnatment failurll!! oc· curred in patienta t",al~ with < 4 w"1uI ofllntib;otics fallow"'g surgery. If there mte no ~igns ofinfetlion, a CltlnioplB!lty may be perfonned _ 6 IJlOII po!It-op. 12.7. Cerebral abscess EPiDEMiOL OOY ApProJUmHtely 1500·2500 eases per year i1) Ihe U.S" wi~h a higher il\cidenee in de· velOping eoun lril!fl. Male:r"male ratio is 1./j..3: I. RISK FACTORS Risk faC"tonl ioelud e: pulmonary abl)Ormalitieti (infection, AV·fiUulu .•.. ...,~ below). congenital oYlillQtic h ea rt disealH! lie<: below), bac~rial Mdocartlitis , penettatinll head trauma ~e below).n~ AIDS . V ECTORS Pria. to 1980. lhe most common SOUl"'e of (~rebl'\ll ab5c1l1l8 ,,·a. from (ontiguaus spread. Now, IK'matoganou9 disse",inption is the moat(ommon vKtor . HEMATOOENOUS SPRE....O Abloeues anaing by thi! mean! are multiple in 10-50'lI0 orclilies". No source <an ~ fO\lnd in up to 25~ of rUE'!!, The che!!t ill the mostl.'Ommon cmgin: in adult...: lung aoo<'89s (t he moat common), bronchiectu5i~ lind empyema in children. collO genlllll cyanotic beart d iaellle (CCHD) leatjm8kd nakafab-Ke5.11 is 4·7%), especially tetralogy ofFaliot. The i.noronlllid Het and low P<h p* vida an hypoKio::eDvironment ~uiwble for Dbicul proliferation. ThOR with rightt.o-Iel'l (venolltrio.l ) ahun"" additionally loee the fdtering effect&. of the lungs {the brain _m8 t.e be" preferential tll.get for Lhue i.ueclion8 over (lther organll).. 5~reptoco«al otlll fiora;1 frequent. and may follow dental procedure •. Coexistiug cOllgulation defect.. pft.en furth .... romplicat.e managementtl pulman8ry arteriovenou. fI5IUIM: _ 50'110 of the !I! patients have O! ler-Weber · NE.UROSURGeRY 12. Inf<<t,003 R.,n d u llyndrome (AKA hereditary hemorrhagicte1angectesi.J, and in up toS,*, or these patients a cerebral abscess will eventually develop bacterial endocarditis: only ranly gives rise to brain abs«ss" . More likely to be associated with acute endocarditis than with subacute form dental ol"lceas GI infections: pelvic infeetions may gain ac<leSS to the brain vi. Batson's ple~us In patients with S<'ptic emoolil.lltion. the risk of cerebral absct'Sll formation is elevat-- ed in arell$ of previous infarction or ischemia". CONTiGUOUS SPREAD I. from purolent sinusitis: sprl'ads by local osteomyelitis or hy phlebitis of emissary veins. Virtually alway. singular. Rare in inf.nts b«.allle they lack aerated paranasal and mastoid ai r C!!lls. This route b"" become less a1rnmo:l due to improved trealm ent of sinus disease A. middle-ear and mastoid airsinus infections- temporal lobe and cerebellar ab.".,SII. The risk nfdeveloping a cert'brai ab$cess in an adult with active ehronie otitis media is _1110,000 pl'r yea"" (this risk appl'ars low. but in a 30 ~ar-old with aclive ch ronic outis media the lifetime ri.k becom"s _ 1 in 200) B. nasal sinusitis ... frontsllobe abscess C. sphenoid sinusitis: the least common location for sinusitis. but with a high inciden.,. ofintracronial complications due tov"nous extension to the odja· cent cavernous SiDWI odontogenic: rare . kI...,.,iated with a dental procedure in the pa3t 4 weeks in mOl:!t csses". May also spread hematogenously 2. F OLLOWING PENETRATING CRANIAL TRAUMA OR NEUROSURGICAL PROCEDUR~ Post· neurosurgical: especially with traversal ()fan air sinus. The risk ofahsce8/1 formation following civilian gunshot wounds to the brain is probably very low with th" use of prophylactic antibiotics, except in cases with CSF I"ak not repaiN!d aurgically follow· ing traversal of an air ainus. An abscess fnllowing penetrating trauma cannot be \.reated by simple aspiration as with other abs«sses. Opl'n surgical debridement to remOV" for· eign matter and devitalized tiSl<ue is requind. Abscess hll$ been reported following use of intracranial pressurl' monitors and halo traction'N. P ATHOGENS 1. 2. 3. 4. 5. 6. 7. 8. 9. culturu from cerebral abscesses are sterile in up to 25% of cases in gen....al: Streptoeoccus i$ the most frequent organism, 33·S~are anaerobic or microaerophilic. Multiple organisms may be cultured to varying degrees. usually in only 10-30% of eases, but can approach 80·90%, and usually i"e1udes anuerobea (Bacteroid"s ap. oomm~ n ) wh"n secondary to fronto-ethmoidal ainusiti9'Slrep. miUeri and StrIp. o"8i.unu, may be seen rrom otitis media, mastoiditis, or lung ah$ess: usually multiple organisms, including ana"robic stre~., Bacteroides, Enterobacterisceae (Proteus) post traumatic: u$uslly due toS. OUTeuS or Enterobacteriaceae Actinomyces may be associated with a dental BOuTe" following neurosurgical procedures: Staph. epUkrmidis and '"'TI!U, may be ~n immunocomprom.ised hosts including transplant patients(both bone marrow and solid organ) and AIDS: fungBi infections are mOre COmmOn than otherwise "'"Quid be seen. Organisms include: A. Toxoplasma gondii: xl page 232 snd pa8f' 233 B. Noca rdia asteroides: .... , po.se 223 C. Candida albiesns D. Li~teria monocytogenes K mycobacterium F. AspuSiUus (umisafus of\..en from s primary pulmonary infection infants: Cram negative;; are common because tgM fraction doesn'tcross placenta P RESENTATION Symptoms: none are speci fIC for abs«ss, and many are due to edoema surrounding 12. InFections NEUROSURGERY 1M ~.ion. MOlt arc d ... e toincI1IIIMKl ICP(HlA, NN, letllafiY l. H,miplrHia a nd Mi~ ......,. develop in ~ of~~. P'pilledema i. rare before 2)'1"1 of ",• • NawbQm" potent .... t ... rtl and poor ,bility ofi n!an t bT1lin to ward off in fcc:tion cr .... ial en larlemlnt. Common: Milures, me.\ingiti~, irri1.llbility, incre..inl OFe, and r.il ...... to thrive. SOme .... thol"ll SlY lJI06t ne .... b(lml .... Ith IIbscall Ire ofebrile. Tend n1M-to do well. EVALUATION B LOODWORK Pwripbeml "''Be; o.y be nonnal oron)y mildly elev.to&\! in 00·70'lI0 of CD IN ("'B... ~lly ,. JO,OOO). Blood cult ... re.: usuallY ntgati .... 85R: may be n.onn:al (elpecia ll y in conleni1.lll cyanotic heart dlMafie ""here paly. t)'themi.l IOWilT$ the ESR). C ructlva p.otein (C RP): iorectiOll anywhere io Iw>dy r;aft raise the l~ve l. f>ltien tll with brtin t!UllOr a nd olher infllmmaVlry ",nditlon (e.E. dentalet.cellOOl m.y have. and devated CRP level . Se:lu;i ll vity \8 ~~, lpe<:irLcity i. ~ 77 ... 101 . LuMBAR PUNCTURE (LP) The role of LP i, ttl)' dubio .... in a~ Al t hough LP il IboormaJ in "~. there i, no characteristic finclioe diagnolLlc of I~. The OP i, IIi\lally increaaed. a.nd the ....'13C IIOWII ,00 protein may ~ eleva!.ed . TIIeorrending o'1"anil m can rarely be identified C5F obta'lIed by L.P (unl eN.bIC8n rnplu .... ;111.0 "'ntridu) with po$itive c... ltures in _ 6·22..... llIe ... ia a ri.~ orb"enJtentorial herni"ion , upe<"iaUy witb l&I)lIlle~ioM. rrom II fa k ~"l'1 ifMGING For CT findings or .,oaooo. lltaE'l1 or alJtN:ea 1ft Sensi t ivity app/"Ollthu l ~. lA ... kocyte scan wit h 99mTe-HMPAO (pa,bent·. own IlnI tocced aml.einji!:ct~ ' hllA d ose Ut l ~ w ... itiv;ty and .spo!C.rJcity (sensitivity will ~ redllCl'd ir pBtienl ia t ...~ with ataroid$ ..... ithio 48 hI'S prior to Ihe sc.an'IN. MRJ Ip!!OClrGlilCOPY. smioo acids and !tCI!tate or I,dale ano diaJnOlltit r",. " b _. wlow. woCa STAGING OF CEREBRAL ABSCESS T"b/e 12.2 show. the fou r "'ell recocu1ud hlstologit II~ or ter ..... bral a~s. ami Q)~. lates this ",ith th. re!li!tance 10 insertiOll of an a&pirating needle .t the limel)(surlU)'. 11 lak"" ltl~asI2",~b to ptIIgn:lS th roueh Ihis matllralionpr_. and .teroidl tend 1.0 proIoll( ;L CT s t .. gin, .... w «orebrili. h llSlill'\i lar rettu".. to esr', ~'PlUle (.t.toge 3 ) on routine 00I"I' tlllllt a nd non-contralll. CT 'nletall.o"", th~rapeutle [lUpoN""", in d ilf"renUltin, Ih_ 1""011.1(15; thlf. foll_ill-, aid. in dilli~lhin"" cerebriti" !.enclt to ba roo .... ,1I ·defined A. ring-enhlneemlnt: usually appellts by late c:erebri tis _tap, ua .... n"lbkk R. fu rt""r dif"l'u.ion " reont .... t inlt) c.cntr"l lumen , IlndIor laek ofdft.,. ofen· hllneemenlon delll~ KIIn:lO-6O min n"",,r I:Ontrall infu tion (s\.ll1l'8 2) NEUROSURGERY 1 2. lnf~ ". capsule: A. faint rim present on pre· contrast CT (necrotit center with edematous sur· rounding brain t6use eollagen caps ule to be seen) S . Uill!. ri ng enhancement AI:iO delayed IKIInl - decay of enhancement NB: Thin rinll' ~ Dhan~m.nt bu, I.,k ofdoJ.o)'<'d do<ay co .... I. _ bottu"iLh ",,,,brill. !'IB: Steroid. I"OdUat dOlI""" of COCI'''''' ...wonoe ...... , (... peri.Uy in _oI>ri,,") MRl litagiDg Table 12·3 abows MRJ fio<lingllin cerebra l abscess. In the cerebri. tis stage, the margins are iJJ defined. . Table 12·3 MRllfl"lding s wilh cerebral sbacell .... -.- ,." Tl .. webIilis ~ , lesion his91al " t:lIn!er - iso- Of hype_r...e, <:en1&r - low signal. C8Jl&i'1e _ ~ hyperintense, capsule .... wei delined rim, perilesJonal Mma .... low $igrlIII perilesiortal edenIa _ iii sigIIaI TREATMENT "There is no single best method for treating a brain abscess." Tl"eatment usually in· vol,·"" surgical d rainage or e:u:ision, corredion of the primary lIOurce,and long.term USe of antibiotics (ofum IV ~ 6·8 weeks followed by oral route ~ 4·8 weeks). SURGICAL VS. PORE MEDICAl.. MANAGEMENT In a patient with Buspe<:ted cerebral a~. tiuue shoul d be obtained in almost ~ and to identify pathogens (prefera bly before antibiotiC'l). eo: case to confirm diagno.su M EDICAl. TREATMENT In general, surgical d rainage Or excision is employed in the t reatment. Purely med· ical treatment of eadx absuas {cerebritis stage»", is controversial. NB: pa!.hogens were cultured from well encaPJIu la~ a~esaetl despite adequate lev.. b of appropriate antibi· ot;"" in 6 pat ienl.l! who failed medical therapy'"'. Failu re may bedu e to poor blood supply and acidic conditions within the abscess (which Olay inactivate antibiotics in spite ofcon· centrations exceeding !.he MIC). Medical therapy alon .. is more successful if: I. treatment begun in cerebriti. stage (befnre complete enC8PJ1ulatinn), eVen thC>\lgh ma ny of!.heS<! lesions $\Ib.sequenUy go on to become encap!lulated 2. small lesion.: diameter of abscesses successfu lly treated with antibiotics alone were 0.8--2.5 cm (1 .7 m.. an). ThQl!e that failed were 2·6 cm 14.2 mean). ... 3 e m is 8Uggested Ill! a cutofPI, above this surgery ahould be iltl:luded 3. duratioo ofsymptontll s 2 wks loorrelates with cerebri tis stage) 4 . patients show definite clinical impr",·ement within the first week Medical management alone con sidered if: J. poor surgical candidate (NS : with loeal anesthesia. stereotact ic biopsy can be done in alm06t any patient with norOlal blood dotting) 2. multiple abscesses. especially ifsmall 3. abscess in critical local ion: e .g. dominant hemisphere or brain stem'" 4 . coDcomitant meningitis/ependymitis 5. hydroc .. phalus requiring shunt that could become infected in surgery SURGICAL TREATMENT Indicatiorur for initial.I..IUikIU treatment include: I . significant man efTed .. xerted by lesion on CT 2. difficulty in diagno.si. leSpe<:ially in adulla) 3. proximi ty to ventricle: indicates likelihood of intraventricular rupture which is associated with poor outeom ......· .. 4. evidern:e of significantly increased intracrflnial pressure 5. poor neurologic conditioo (patienla responds only to pain. or does not even reo 8poO&e to pain) 6. traumat ic absce$5 associated with fOAign ma terial 7. fungal abscelS 8. multiloculated a~ess '" 12. Infections NEUROSURGERY 9. CT Kan. c.nnot be obtain.ed every 1·2 wee ks SPECIFIC MAN AGEMENT obblln blood ~ ... l: ... ~. (rarely helpful) initiate .ntibiotic then py (p~ferDbly aner bioP8Y l pec:i<rnln obtained), n'ga rdlel5l of whieh mod. 0( t.rutment (medical ..... surgical) is chosen (_ ~Ww ) LP: .void in moat ca_ of ee rebral abac4.u Is« pap. 219) . nticoro ..... I.. nU: ... &eeI in n:>OIt ~a"*, recommeflded d ... ralion i. 1·2 yr1I A NTl810TICS I . Initiml Intibiotiu of choice (when pMhogen unkllown, . nd especi.lIy ifS. a"f'tll$ s uspeetad), make appropri.ta chlnges I I sensiti ... ities become ....ailable. lfthere I. no history oft:ra ... ma or ne ... ros ... rgical proced ... re, then the ri. 1r. ofMRSA iiiow-: "'anoomw:jn: «lvers MRSA. Adult: I If'" IV q 12 hr. Peds: 15 msfkg q 8 hr. Checlr. peak &. t rough levels and acij .... t doae accordingly (_ PtIll~ 209) PLUS 11 3rd generntion cephalOlporin (e.g. ~efotaxime (Cldoran®) PLUS one of the following • metronjdnole (F1agyi®). Adult: SO nlWkJdd tota l l1l ... ally IV(divlded q 12 h rs or q 6 hrs, not t.o exce«l4 pIId ). Ped s: 10 mKlkl lV q 8 hra OR • OR 2. 3. 4. 5. 6. chlQrJlmphmiwl. Adult: I gm IV q 6 hr. Pt.": 15·U m...... g IV q 6 hr • for pollio-traumatic abieeu, uN PO rifampill 9 mgfkgld at 1 dOH ifcultur<! show. no staph (II i, ... sual in non·tnum.ucabtcets), cMnge nafdmn t.o peN G (b jeb dOH): adult: 5 M Wlill TV q 6 hr: ped.: 50.000-75,000 uoiW'lr.& IV q 6 hr if cultu re showl only I tr<!p, may u~ PCN G (high doRl alone ifeultures sbow staph th1lt is 1W1. MRSA and the patient is not alltrJie to penicil· lin or nafallin. s ... bsutu1.e IlIkilli.n for the vancomycin. Ad ... lt: 2 gm IV q 4 hra. Peds: 25 mg/kg IV q 6 hrs C'>'/X0«>«"6 ~Qr7fUJM, M~'1Iill"6 . p., Candltla 'P. A. amphotericin B: 0.5-1 r:nglkglday. ABJ::LCETdD (&!II p/'Iotericin B lipid com · ple:l) 5 mglkgld lhould be used when ~al funaion i, c:ompromised B. or lipoaoma l amphotericin B: 3 m...... gld.y, inc:r<!Ise to 15 """,gld in AIDS patient:s: Tru:opJ4sfIU11JOftdii is a common palhosen, and initial empiric t.reatmen ~ with eulfadiatine .. pyrimethamine il ollen used (1ft page 233) Duration of a ntibioti cs rv anlibiotica f.,.. 6-8 wks boos t commonly 6 ), may then I)'C cyrn jf Lhe CT aboormalitia !!foisl (nrovaK\llarity remaml). NB: CT improvfl1leflt may Iii: behind clinical improvement. O .. Tlltioo oflffatmeflt nlay be red ... ced;r abecef l and capsule entirely e.· cised lurgically. Oral a:otibiolics may be used following IV course. 5-2O'I.oflbsc_ recur within 6 wee"- of dillCOlltinlliog anubiotics. SU,ROIOS Oe<;rta_ likelihood offibrou.t eneaps ... lalion of abscess, ;,ut may reduce penetra. tion of antibiotica jnt.o ab.etu - . Rese .... ed for patienu with CT and clinical evidence of deuorioration from marked mua effect. CTSCAN Repeat CT aftu wu" " _2 (mor<! often if patient de1.enoratee). RecommeDded follo ...· up: a ner I (ull cou rse ofantibiot o«. CT q 2..... wlta ... ntil res· oIution (3 .11 root mean : range 1· 11 mas). Then q 2·4 mas for 1 yr. and subsequently any· time eNS l ymptDml occur. Iftbe.. py it . utCUllful. CT , bollid show decrease in: I . degreeofringe-nhance ment 2. edema NeUROSURGERY 12. lnfectionl '" 3. mua effect ~. .ile of I..ion; takes I to 4 wk, (2.(> mun). 95~ of IftiolU that will reeolve with aIltib,otics . Ione decrease in sile b)' 1 month SURGICAL TR EATMENT Current methods eonsi,t of one of the follow;nl"; 1. needle a.piration: the mainstay ofturg;eal t reatment. EspeeiaUy weU·.wted for multiple or deep I"ions (He IM/ow) 2. aurgieal exciaion: pNVents recidiviam. $hort.enslenrth ortimeon antibiotiq. Retonllnend"d in traumatic ab&«M to) debride fon:ign material • .."d in (lUlIal ab_ " oo.:auH of relative antibiotic resiatance t - ~/.ow) 3. external drainlllt: eontrove"ial and mayor may not be ufed 4 . in8tiJlation of antibiot kli di rectly into the ab&Ceu: has not been utl'llPWly emea· dous. although it may be ufed I I a Int ruort in A'~rllillu' a~ NEEDLE ASPIRATION May be perfon:ne<lunder local e~tthe.ia if nettsaary. May be OJmbined with irrigation with antibiotic. or non:nal . ali"". Need . to be repeated in up to 70'10ofeun. May be the only surgical inte rvention requi red, but 8Ometi.r:ne. must be followed with uci.ion (especially with multiloculated a~"). Stereotactic drai nage may be ideal for deep lesion~ . P~rfo rmed through a trajectory chosen to: 1. minimile the path length throuSh tha brain 2. avoid t raversins th~ ve ntricle!! or vital neural or vascular 1tnK:lul'flll 3. avoid t raveraing infected 8tnJ.CtUIU oUllide the intracranial compartment (in· rected bone, paranaul . inuse&, and scalp wound.) 4. in CllSes of multiples abscesses. tertle!"': A. the l arg~8t lesion or t he one eaUlin, the lDOIIt symJ>l.'.l<m B. One<;! the diagnosis of abscen is confirmed I. anyle.sion~2.5cmdiameter 2. lesions causing significant mllS$ effect 3. enlatgi.og lesions C ultures Send aapirated material for th e following: I. ,"ains A. Gram , tain B. fungtlll stain C. APB stain 2. culture A. routine cultllre.: aerobic and anaerobic B. (u",at (I,Iltu r" this is notonl), helpful for identi(ying (llngal infections, but since these cultu:'eS aTe kept fOT longe r period and an)' growth that OttIIrI will be further tbracterized. fastidious or indolent bact.erial organi$1D!I may 80metimea be identified C. TB culture EXCISION Can only be performed dllrln,the "chronic· phase(latec.~ule.taa:e). Ab_ i. removed as any well e"ca~ lIl .ted tumor. The length oftiroe on Intibiotiu tan be . horUne:I to - 3 days;" .orne"," followi", IoOUoI excision o(aIl aceessi· ble, mattlre IbKe.. (e.I.located io poieofbrain). Recommended for 1b8cft_ asIOCiated with (oreign body and moe t Nocorokl abeoesses (_ be· r able 12-4 Outeomet with ",Dbr.1 a btu.. ""). O UTCOM E In the pre-CT erl, morta6ty r""ed form ~~. With Improvement in antibiotic" I Utpry. sod thfI improved ability to diagnOM and follow mponn ",ith CT andlor MRI. '" 12. Infec:tiona NEUROSURGERY mortality rate has beeo reduced to _ 10%, but morbidity remains high with permanent neurologic deficit or seizures in up to 50% of csses_ CUrTentout<;omes pre sbown in Tobk 12·4. A worse prognoai$ is si$OCiated with poor neurologic function, intraventricular rupture of absce!;ll, and aUnost 100% mortality with fungal a~es in transplant ro<:ipi· enla. 12.7.1. Some unusual organisms producing abscess NOCARDIA Nocardiosis is caused primarily by Nocardia oSUroitk. Cother Nocardio species . uch as N. brosilj"I1,,, are less common), a soil-born aerobic actinomycete Ca bacteria, not a fWlguS) that is usually i:loculated through the re$piratory tract and produces a localized Or disseminated infe.::tioo. Hematogenous spnad frequently ~ults in cutaneous lesions and CNS involvement. Nocsrdiosis occurs primsrily in patients with chronic debilitating iUnesses including: 1. neoplasms: leukemia,lymphoma __ • 2. conditions requiring long-tenn corticosteroid treatment 3. Cushin!!,s diseaae 4 . Paget's disease orbone 5_ AIDS 6_ renal or cardiac organ transplant re.::ipi'!nts The diagnos is is suspected in high _risk patient.s presentinl with .,.,ft-.tissue abSO!!~· es and CNS lesions . CNS involvement occurs in about one-third and includes: 1. cerebral abscess: onen n'ultiloculated 2. meningitis 3, ventriculitis in patients with CS F shunt" 4. epidural spinsl cord compression from vertebral osteomyelitis'" Diagnosis' Brain biopsy may not be needed in high-risk patients with conlirmed nocardia infection in other sites", except possibly in AIDS patient.s "'here the risk of multiple organism infections Or i"fection plus tumOr (particularly lymphoma) is considerable. 'I'Natme n t, Usually includes trimethoprim-sulfamethox8Zole (TMP-SMZ) together with imipenem, cenriaxone, cefuroxime or cefotaxime, Duration of treatment is at least 6 weeks , and TMP·SMZ is usually con tinued for many months because of the risk of reo lapse or hematogenous spread , 12.8. Subdural empyema ReferTed to as subdu ral abseeu prior to 1943". Subdural emp),(,ma (S DE) is a suppu_ rative infection that forma in the subdural space, which has 00 anatomic barTier to spread" Antibiotic peMtration into thi s spae<! Is poor_ Distinguished rtom abscess which fonns within brain suh!! tance, s urrounded by tissue reaction with !'ibnn and conagen capl ule formation. Helice, SDE tends to be mOre emergent. SDE may be complicated bYe<!rebralabSCI''''' (seen in 20·25% of imaging studiu). cor_ tical venous thrombosia with risk of venous infarction, or locali:t.ed cerebritis. Ta ble 12-5 Et iologies 0 1 SDE """,e EPIDEMIOLOGY "''''''1' ' ' In 8<lufts no cases I,,,,,, OIltis ., • 'ecen1 ...,ies" Less a)mmon than cerebrnlabsce... (ratio ofabscess:empyema is_ 5,1). Found in 32ca5e1 in 10,000 autopsies. Male:female ratio i. 3:1. Location: 70-80% are ove r the convexity, 10--20% are parafalcine. NEUROSURGERY 12. Infe.::tions ETIOLOGIES See T(lb/~ J2·5. Most ofl.f.n OCCUr/l 011,0 TelIult of direct utens'on ~f 10(01 infe<:tion lror ely following !;o!!ptlt(!m'a). Spf<'od ofthe infection \.0 t.h.i! intrncranlol eornpartment may I)ttur through tt,,~ valvelfM diploi~ "ains, ofl.f. n with 8~t.ed thrombophlebitis"'. Chroni~ otitis medi .. was tne leading """"" or SOE in the proontibiotieern, but ha.. now been il....pused by paranasal !tim.. d,seol6 especially wi!.h fronl.lllsinUll involvemfM" (may also follow mutoid ainusi!ia), SO£: is a ror<! bu t aometimes fotal complicotion orcrania] tllletion df'IKu... · '. In fe<:tion orp~ultlg ~ubdu",1 hemlltomas (bot h treated and untreatt-d, ill, infants and adultll) have been reporUd". 'Trauma includes compound &1<1.111 frllCtUTeS and penetrBting in,jU'ries. Other etiologiee mdud .., I>st.eomyelitis, Plleumon;a, unrelated infection in diabeli=-. PRESENT~TION Neuroll>gic findingS ,re5hown ;n T"b/e 12-6. Sympt0m.5 are due w maSll ..ffect. inflammawry ;.,. volvenlMl of thp brain and mlminges. lind throm· bophJebitia of ~ereb ,.,.1 veins and/or venoulfolnuses, SO£: should beauspect.et! in Ihe prel!ence. ofmeningi.· mus + unilateral hmisphre dysfunction. Marked tenderneS!! to percussion or presr;ure over a/fe<:\.ed air "in u~ Is comml>ll" . ForeheaC: or eye "welli ng (from emiuary ~pin thrombosis) C\!I.Y·occuc. Focal neurologic deficit andlor sei~ur\lS usually OC'Cur law. hble 12·6 Finding_ on preaenlallon with SOe" EVALUATION CT: rv contTl\$l is usually helpful. CT may ,russ IIIn'e caselI (relatfld ~ early generution _nners, failure to give. rv colltralll. pooracan quality ... )' Ifnormal. r~~t tbeC1' at a loter tin,. ordo an MRI ifdi nlCIII , uapicion persi8\A Findinga: hypodl!frM! (but denser than CSF ) ~o.-n. ,"";""oftr\l>lllple atlleM<l'" creficentic or lenticular elttrucerebraJ IHlon with dense enhancemel)t ofr:n&diel m~mbrane; Inwa.nl displacement of gray.white interface; ve.ntriwlar dUr~rtion lind efTnoenlent ofba"l cisterns lire r:tImmOn findinga" MRI: low signal on T1WI, high signal on T2WI. Pial epend)'ll\allin~: II non .• pecifi e MRI finding in Cr.· S infe<:t;on LP:. pptentlaliy huardou$ (ri~k nf herniatiou). OrgauismIi are 1.JlI".ally present only in cases originAtir.g from meningitis. Jfno maningiti., mode", .... ,tenIa pIeocyt05i. (\50-600 WBClmm'l with PMNs predominating; gluCOS<! normal; open· ing pressure ill 1.l5uolly high" ; protein is usually ele~et.ed \ ren,ge: 75- 1 ~ mg/dl) ORGANISMS The causative organism "uries with !.he 'pecific lHIurce oftha infe<:t;on. SDE 8S8Odatetl wilh . inu$iti.rr is often caused by aerobic ond lln".,."bic .t,eptocoed (He T"bu 1.1. 1). Foll" ...· ing trauma. Or neurO$ucgical procedures. st/l· phylwocci Ilnd G .. m·negstive speciH predomill~te. S lerile (:Ulture5 OCCUr in up to Table 12-7 Qrglnl&ms In adull cases 01 SDE assoelaled witosinusili s .""'. TREATMENT I . surgical dlllinllge: indkat.ed III 1\I.000t ClIl!e!l l nonsurgical managemoot hw; been reported·l . bUUhould onJy be cOll/iidert!d with minimal neurologic inv"lvement, limit.ed lI~tell5 ;On and rna&9 efTec~orSOE. snd early ravorable NIIPP!liHI to anubi. otiu) usually done relstlvelyewe'llenUy e..ly In the course, the pus tend. t<l be atore fluid lind may be more ame nable to burr hole drainllge ; later, loculations develop which mQY n~essiulI!e ~l'tIniotomy there has been cont roversy over the optimal su rgic~1 tre,tn'ent. Early ~ludilll:l in · dicated a better outeomll wilh L'l'IIJliotomy. Recent ~tudi "" show leas difference A, ~riticaUy ill pstie.nL5 with JocsJ[~ SDE may becandidll\.e5 for bQr ... hole ]2. Infe.:tiora NEUROSURGERY drainage (usually inadequate if loculations are present). &peat prooed ures may be needed, and up to 20% will later require a (:I"aniotomy craniotomy: to debride and, if pOSsible, drain ant ibiotiCII: .imila r to treatment for cerebral abscess • initially: a penicillin and a thi rd·generation cephalosporin (e .g. cefotuime) • metroniduole is added if there is a high suspicion of anaerobes • for post--<>pSOE: substitute vancomycin for PCN (switch vancomycin to a PCN iftllere is no staphylococcus) • modify antibi<.>tiCII based on culture results • duratio,,' usually 4-6 weeks anticonvulsants: usually used prophylactically, mandatory ifseizu res OCcur a. 2. OUTCOMe Set! Table 12·8 . Ne\lrologic deficita were present i.n 55% of patients at the ti me ofdi&charge". Age ~ 60 yea,.,., Table 12-8 Oulcome wlth SOE obtundati<.>n or coma at presentation, and SOE related to surgery or t rauma carry S WOnle prognOllis". Burr-h<.>le drainage may be associated with a worse outcome than with craniotomy, but this may have been influenc«l by the poorer condition of these patients. Fstal casel may have associated venous infarction of the brain . 12.9. Viral encephalitis Encephaijtides lha , come to the attention of the neuro.surgoon uuaHy CaU$e imag. ing findings that may mimic maS8lesiona. Biopsy is helpful in some instances, and shunting for hydrocephalus may (>(X8$ionlilly be needed. Those covered in this book: I . he~s simple~ encephalitis: Ut bdoI.U 2 multifocsl herpes varicella·zoste r virus leukoencephalitis: 1ft page 227 3. p~saive multifocalleukoencephslopathy (P1tU.): I « ptJ~ 231 12.9.1. Herpes simplex encephalitis . t Key featu rel' hemorrhagic virallmcephalitill with predilect i<.>n for temporal lobes • definitive diagnOElili requi res brain bIOpsy • optimal tTeatmeat: ea rly administration of rv acyclovi r Herpes simplex encephalitis (HS E ) AKA mul · Ta ble 12·9 Adult tifocal necrotiling encephalomyelitis. is caused by the herpe'S simplex virus (HSV) type I. I t produces an acute, often (but not always) hemorrhagic, no;. troti~ing ellcephalit is with edema. There ill a predi . lectio" for the temPQraland orbitorrontallobes and limhic system . I E PIDEMIOLOGY" Estimated incidence of HSE: 1 in 750,000 to 1 million persons/yr. Equally distributed between male and females, in all races, in all ages (over33% of cases occur in children 6 mos to 18 ynI), through. out the year. P RESENTATION Ta ble 12·10 Presentation in age < to yr. aftered mentation seizure .",.... hemiparesis !ever papiRedema (e~cepl in age s 2 yrs) Patien~ are often confused and disoriented at onset, and progress to coma within days. Adult presentations are shown in ToMe 12-9, and f<.>r pediatriC'l in Ta.ble 12·10. Other symptoms include headache. NEUROSURGERY 12. Infections m DIAGNOSTIC STUDIES DiagnOllis tan o~n be made on the basi s ofhiatory, CSF, and MRI. Treatment should be instituted rapidly without waiting for biopsy, before the ODlet of coma. \. CSF: leukocytosi$ (mOlltiy monos), RBC& 500- t OOOl'mm'. (NB; 3% have no pleocytosis), protein rises markedly as disease progreasea. HSV antibodie.a rna.yappear in the CS F but takes a t least ~ 14 days and is tbus not useful for early diagnOliis 2. EEG: periodic lateralizing epileptiform discba rges (PLED,,) Itriphasic high.vol\.age discharges every few secollds) usually from the temporal lobe. EEG mBy vary rapidly over few days (unusual in conditions mimicking HSE) 3. (''T: edema predominantly localiled in temporal lobes (poore r prognosis once hemoJ'Thagic lesions visible). In one review, 38% of initial C'J's were normal" (maoy wereon ea rly generation CTsulUleTsor were done within 3 days of onset). HemoJ'Thages were appa .... nt in only 12'l>ofthe initially abnormal CTa 4. MRI: mOre sensitive than CT"", demonstrates edema as high signal on TIWI, primarily within tbe temporal lobe, with some e~tellliion ael'Olls sylvian n.ssu re ("trlllluylv ian !ign"}'l. especially suggest i"", of HSE if bilateral. Differentiate from MCA infsrct (which msy aJ.sospan sylvisn fisaure) by typical ane risl distri· bution of the lotter. Enhancement doeSIl't OCCur until the 2nd week 5. technetium brai n Kan: proc:ess 100000lized to temporal lobes 6. brai n bioplr)': falll<! negative. may oecu"" A. indication s: rue,...ed for QuesliGoable CIIlIe8. May nGt be necell88ry in pII. tienla with fever, encephalopathy, compatible CSF findinp, focal neuro findings (focal seizur e, hemiparesis, or cranial nerve pabiy). and supponing evidence of at least one of the following: focal EEG, CT, MRI Or te<:hnetiWll brain scan abnormality B. should be perfonned within $. 48 hra of starting acyclovir (otherwise false negatives may occur) C. /Interior inferior tempOral lobe is preferred site t. the side eh"",en for biopsy i8 the one showing maximal involvement based on d inical information (e.g.locaLi~inguizures), EEG and/or imaging studies" 2. 10 . 10. f> mm deep specimen obtained from anterior portion of the inferior temporal gy"" w ith NO COAGlILATION' On specimen side (cut surface with ~II blade, then c/luteriu pial surface on rum-specimen aide) 3. 2nd specimen obtained from beneath surface spe<:imeo with fenestrat· ed pituitary biopsy forceps D. virus isolation i. the mOlit specific (l ()()%) and 8efUlitive (96,97%) test (or HSE . Other nnd ings (less 8c<:u rate~. perivascular cuffing, lymphocytic infiltration, hemoJ'Thagic nocrosis, neuronophagia. intranuclear inclusions (p~.orent;n 50%) E. ifelectron microscopy (EM ) Or immunohiatofluorescence is available, 70% may be diagnOli.d within ~ 3 hra Gfbiopsy F. biopsy tissue handling I. avoid macerating specimens (or histology 2. tiSllue (or E M: placed in glutaraldehyde 3. tissue (or permanent histology: placed in fonnalin 4. tiasue for <ulture: It. I>"OOl i"g: .pooci m~o ill plua:d in 8", ril~ "pe<:i "'~R oonUlin~r and sent directly to virology lab. Iflab is dosed, tillsue may be: i. placed in regular refrigerator (or up to 24 hrs ii. placed in -70' C tTe.!zer for indefinite time (virus re mains viable fGr up to 5 yn) iii. DO NOT place in ~lar ftteur (destl'Oy!J virua) b. cu.iwr es gener/llly uUte at least 1 weel< to become positive c. cultures checked for 3 weeks before being declared negative G. biopsy tesulla: of 432 brain biopsiell meeting the aoove criteria, 45'1> had HSE, 22% had identifiable but nOll HSE pa~hology (e.g, vascular disease, other viral in(ec~ion, adrenal leukodystrophy, bacterial infection .. .]. and 33% remained without a diagnosis" TAEATMENT General&upportive meaSureS: to control elevated ICP from edema. includes: elevate 12. Infections NEUROSURGERY HOB. flnonn't.ol. hyperv(ntillltion (dnomethasone unproven efficacy) (ab!.o aee lCP lreolnuml ""'US"''"''''. page 655). Phenytoin is u~ed for !l(!izure proph),lfLril. Antivira.l med ica tioDs Ganclclovir is gaining f,\Vor Ove r acyclovir_ ~ acyc:lovir (Zovira:<®) \ / 0A\b1f'l1'O \ , IU Adult: 30 mglkglda),. In divided q 8 hr dose. in minimum volume of 100 ml rv Oujd over 1 hr (caution: this fluid load roay be haunlou • . especioUY$incecerebral edem~ i, al ready u8ua\1y probl~tDaticl for 14 -2J day. (tome relap!lell hav( been reporW after only 10 dllYS of trnatmMI.) & C h iJd r en ,. 6 J;lOIIlIge: 500 mg/m' rv q 8 Iin)l 10 day>l. & Neon atal : 10 r.>glkg rv q 8 hn; for 10 days. Outcome Six month mortality following tnatment wfth aeyda-·ir wos infl uenced by-. oge 16% under age 30. 36'11> \We T age 30) Glllsgow coma aoore IGCS) a~time ortreatment initi ation (25% for GCS .. 10.0% forGeS> 10) d uration of di~el,6f! before Ulllrapy (()'j& for initiatinll' therapy within" day~. 35% ifaner 4 days) 12.9.2. Multifocal varicella-zoster leukoencephalitis Ca uM!d by the herpt"s varice\la-ZOllt.er vi ruB(VZV) which i. responlible for varicdl9 herpes zoster (HZ) (shingles). ~nd po!llo-herpetic peu .... lgia ($"" fXlIJ/' 387). VZV is" " herpelvirus that is distinct from the ,",rp'" .imp/ex~_ Symptomatic_ler -related encephalitisoccUf"6 in < 5% ofimmunooompromised pIItfeot.05 (ineiuding AIDS patients) with cuUlneQu s zoster"'. It typ1C11lJy faU"",. cul.8neous AZ by 8 shon time (ave rage: 9 days) although ""su h8ve been reponed whre nlany Illonth.o hllve lap •• d ft , ManifeBtation ~ include: alterM level ofconsciousneu. he~~ sche, phot.ophobia. m~_ ingismus. Although focal neurologic defJcits m8y occ:ur. t hese liTe UnCOmmOn. MID m8y ~how multiple, di s'orete. round and oval lesion.'! .. ith minimol tdema (best se<!n 00 1'2WIJ and minimal enhancement. Unlike herpe~ .. impl"" vi rus, VZV '" difficult t.o iBolat.e in cult ure. On brain 6ioflSY. look for multiple d",c rtleleaioDl wfthin grey and white matler_ with Cowdry type.A intranuclear inc!u$,on bodie. in oligodend roeyt.e• . astro<:ytea, and MUtOns. i nd D positive direct fluousctlnt . ntibody telI l directed IIll"in.ot VZV. r here is a case report ofVZ:V encephalitis tn>ated wjth IVacyciovir6"_ fcbic~npoJ{). 12.10. Creutzfeldt-Jakob disease 1 Key feotures • on inv aria bly fatal Mtephlliopathy choracteriud tty rapidly progressive de men tia. ataxia and myodonull death u.8uaUy OCCUrl within I rr.0f onget of&ymptoma 3 form~ I I transmi~sible (pOs,uhly via prions), 2)"utoloroal dominant inherite<1, 3) sporadic characteristic EEG linding: bilateral shllt'P wave (0.5-2 per sewnd) pathology: ~t.all•• 8pongillll1.>5 without ioflamlIl/Otory ra!!ponse Creullfeld Wakob.:Jisease (CJl) ) i. one of" k.oowo rIlJ"1'human dilll!63e$ ollSOCiated with tronsmillSible s pongiform encephalopathy agents. slsa cs Ued prions (prot .. inaceous infectious partlclle"). Although eometlm~ij al$O refelTed to na ' 610w viru$". these agents conttlio 00 nucleic acid, and ara alao re3i.sta ot to proussea that inact ;vatll conveolfona l virtlllE:$("'~ T(Jble 12-12). Priona do not provoke an isnmune respon..e.Tha prot-. r""istenl protein ailloc:iated 'with di5e1lH IS designated PrP- Or P rP'l'. and Ul lin ;.of = ofa naturally DCt;uning prou.ss ..... ensitive protain deAignated Prf-> or Prf'C. NEUROSURGERY 12. lnfe~tfons AnnulIl incidence MCJD: 0 .5-1.1:' per miU'.,o population", Over 200 poople die ur CJO in the U.S. each year. CJD oe<:urs in 3 form" transmissible. inherited and sporadic. Acquired prion diseases: Natu",) route ofinfocti'", i. unknown and viruleno;eappeara low, with lack afsignificant disoomination by respintory, enteric, or lU,'J[uu\ contact. Then> is no inrre!llled incidence in apouses (only II. single conjugal pair of cases has been verified ). phyaieisns or laboratory wnrkers . There is no e~idence oftt'ansplatentaJ tranamission . Theonly known casesofhori~ntal transmi$$i<:In ofCJD haveoe<:UlTed iatrogen. ically (ou below). Kuru has been transmitted via handling and ingestion of infected brains in ritualistic Funereal can.naba/ianl practi~ among the Fore (pronounced: 'for. ay"J lingllistic group in the eastern highlands of Papua, New Guineafl, a practke whkh was generally abandoned in the 1950's. Kuru is a 8ubacut4! . uniformly fata.l disease in· voJving cerebellar degeneration (the word "kuru" meatls"to tremble";n the I""a.l language"'·"). Mtls! tltItIiatrogenically transmitted casesofCJD occur in patienb > 5-0 yrs old, and is rare in age < 30. The incubation period can range from months to decades. The onset of symptoJJl.!l f"Uowin!!" dired inoculation is usually f&'lter (eommon range: 16.28 moS), but atill may b.. much !"IlgE'r(up to 30 y ......... with corneal transplant", and 4·21 yrs with hGH transmission). Inherited CJD: 5-15% ofeana of CJD occur in an autosomal domiTabl e 12-11 Comp!lfison 01 VCJO 10 sporadic nant inheritance pattern with abCJ. . normalities in the amyloid gene"'on chromo.oome20 with a penetrsn"'" of 0.56". Since familial CJD is domi. nantly inherited, ana.lysis for the PrP gene i. not indicated unl"llS ther~ i. a history of dementia in a . tr" liMIt de~ relative . Ii· Sporadie CJD: ItI~ 90% ofcasellof CJD. noinfectioU.9 or familial source can be identified", and these cases are eonsidered sporadic. 80% (l«ur in persons 50·70 yrtI old". Sporadic cases show no abnormality in the PrP gene . New varia nt CJD: C85e' of atypi_ cal CJD are we]]·reoogn i~ed . A new variant ofCJD ( vCJD) was identified in 10 cases ofunusuaUy young individuals (mediao age at death: 29 yrs) duriog 1994·95 io the United Kingdom". and haa been strongly linked to the 1930s epidemic of bovine spongiform encephalopathy (BSE), dubbed "mad cow· disea se by the lay press. None of the vCJD patients had periodic spikes on EEG characteristic of claS!lic CJ D. the dinieal CQurse was atypical (having prominent psychiatric aymptools and early """,ballar ataxia, 6Omewhat a imilar to kuru), and bra •.:! plaque~ .howed unusual feature!! alao rem;n;8C<'llt of amyloid plaques seen in kuru. A COIIIparison ofvCJD to sporadic CJD is shown in Tablf 12· 11. Iatrogen ic transmission o r em Tabla 12-12 Ope/"8!lng room .Ierillzallon procedurealor CJO" . ,. Fully m\edive (recomrnsncled) prOCGdurtS autocJavlng for 1 hr at 132"C, Qr in I N5<XiIJn hydrodde (NaOH) for I ,. steam mr,ersle>n hr at room ~alur 8 Partlalfy eIfective procedures A. steam autoclll'ing II ei1he1121' C or 132' C lor ,. c. . 15-30mifIs, or 'm:ne!s;on in lNNaOH for ISmins. or IoMr con<::eO~arions « O.SNl lor IIIr a1 room te~. or Immefsion in sodium ~ (household bleach) undiuted or up 1(1 1:I0 oiIution (0.5%) for 1 hr" II ~ proce~res: bOiling. UV or ior01g radiation. eIt!yIeoo oxidIr.1JIh100. loonalin. bell·propioIacIooe, cIeIer\jel"lls, qua1emary ~ compolll(ls. l~. 1IIrohcIIic iodioe. acetor1e. pola.ssi1rn permangarnue. rQtble ....... Described only in cases ordirec~ con tact with infected orgaN. t ir;aues or surgical illstrumen\>i . Has been reported with: corneal transplsnts"'--, in tracerebral EEG electrodes st.erili~ed with 70% alcohol and fonnaldehyd~ vspo r after use On a CJD patient'"'. operations in neurosurgical O.R.s after procedures on CJD protienb,;o recipi· ~Ilts of pituitary-derivedA human growth hormone (hGm", and dural gT8.ft with cadav- ". 12. Infection s NEUROSURGERY eric dura mater CLyodura®J. Recommended stedli~at;on procedures for auspected CJD tissues and contaminated materials appear in Tol>I~ 12·12. Pa th ology The typical fonn ofCJD produces the dassic histologic triad ofneuronalloss,lIstro. cytic proliferation, and cytoplllsruic vacuoles in neuron! and astrocyte. (sta l u. 8pon gi. oa'.), all in the ahsence ofan inflammatory response. There;s a predilection for cerebral cortex Dnd basal ganglia, but all parte of the CNS may be involved . In 5·10% of cases, these changes are accompanied by the depotition of amyloid plaques. Immun08t.aining f!IT PrP"" Is definitive. Prese nt a tio n One third initiaUye:o:press vague foolingsoffatigue, .leep disordera. or reduced appetite. Another third have neurologic I ymptoms including memory loss. confusion, or uncharacteristic b;.havior. The Illst third have focal signs induding ~",beUar ataxia. aphasia , visual deficits (ind uding cortical blindne"'l J, Or bemiparl$ia, The typical course is ine"orable, progression of dementia, oA.en noticeably wone wook by week. with sub· sequent rapid development ofpyramidDI trDct findings (limb weakness and stiffness. pathologic reflexel), and late extrapyramidal findings (tremor, rigidity, dy ... r. thria, bradykinesia) and myocl(mu s (often stimulus trig· gered). Clinical sign. ohporadic CJO are .hown in Tol>lt 12·13. Supranuclear gaze palsy is an occasional finding, also usuaJly late"' . In utly stagea, CJD may rf!Bemble AJ,heimer's disease (SDAT). 10% of casea prellent as ataxia withouLdementia Or myoclonus . Cases with predominantspinal cord findings may be initially mistaken forALS. Myoclonus subsid"" in the tenninal phase •• lind ak· inetic mutism ensues. DIAGNOSIS The complete "diag· Table 12·14 Olag nosllc cr1tena " 01 CJO" nostic triad" (dementia. PatllOloo;tk:aUy eonllrmed (WIth unequivQI.:aJ SI)OOgifolm d\ange$) myoclonus and periodic cWnicaty: requ~es bran biopsy lsee teJO EEG D~tivity) may be abo B. IoofICI at aulO9SY sent in up to 25% of cas· o...ration 1·2HlI* Clinle.1 crlterla "~~ ea. OiagoDStic criteria de\eoo. riodicEEG I'!1erII dOsorOel have been published" al ,""".~ 01 periodic (monlhs) shown in Tobit 12· 14. No EEG adiYity patienL! in their series ciinicaIIy delW1e with a diagnosis other than CJD fulfilled the OR dinic.atf probable • criteria for elio.ically deli· d1nieally possible nil<> CJD.1'h .. ",,,,,t oom' ., paUenlS ..... 1I> "",mal motIIIt>oIic: I18IU$ and spinal nuid. H thOle .re mon condition other than eM,.......tlooUa, or "",at $)'II'[)IOmS and Iht!1 mu"",'" tigidi\y, or iTat>CJD fulfilling the criteria oIher IIIm/1y member hair died 01 pall'lOlOgicalty"";fiII<l CJD. thert up· for clinically probable \llaae the degr. . 01 cet1alnly to lhe n...1'-Il"-r category CJO was SDA'l'(especial· Iy difficult to distinguish in the early stoges). There is a CSF immunoassay for the 14·3-3 brain prolein Cut btolowl. ., ... . ., .... • • • • ""- • • • .," """ d' ," D ifferen tial di a gn osis CSF examination to exdude infections $11th S8 ttrtiary syphilis or SSPE is rec(/m· mended . Toxicity from bismuth, bromide. and lithium must be ruled·out. Myoclonus il usually more prominent tarly in to:<.itlmetabolic disorders man in CJD, and seizurea in CJD are usually late". A, W,..,;" no lonll<' . riok orCJ'D with ...... th h""'IOM;" <he U.s. . ;nee dw.ributiol> ofpit"i",,,), derived hGH .... hlOltod in 1985 a l>d"",.,..nt hGH 10 obtained I'm.. """.. bin ... t DNA te<hnol"IY NEUROSURGERY 12. Infections '" Diagnostic. teah ImagiDg: nO cha.racteriat it CT Or MR finding. ThHf> &tudif!8 are freQuen~ly normal, but are _ntial :on OIle .... ut othe. """dilions (e.g. " e.pel-simplex enoephali. tis. te<:ellt It..oke ... ). DiITulHI atrophy m~y be present, especially late. MRI may ahow inerel1M!d ,ntolna;t)' on T'2W\ in al'flu typicalJy involvt!d i bllJlw ganglion, nri,lLum) in up 10 7~ of C8aes \Mf'Ol pectively)"', Thil i. nouspKific but may help differentiate CJIJ Freno SOAT'" blood tc.tII: serum aauya for S ·I00 protein are 81' itlllenlit[,re and nonspecific" thllt it CDn Dilly btt u~ed ItO an dillglll"'tiC udjunct CSF: A. routine lab!!: usually oon:nal, although protein may _iollally ~ el~ated B. abnonnlli prote ins! L abnormal protein! ( ISO" (31 ) have been identified in the CSF of pIILient.!l with CJO", but tlle I\$S~y il technitally difficult 2. prot.eins 1301131 were Identified 81 the I\lmJlJlneuronal protein 14-33, and II rl!latively aiD:lple ;mmulloasaay forthi. WRi de;;eloped for use on n Utll .. 9550 1\1 ofCSf"I. Oeloe<:tionohhe 1<4.$-3 pTo!.!!;n 10 theCSF has 96~ 8,,-ngi tiyit,y and ~peciticity for CJD among pati"-n!.!: with demelltta . Palfle poII;tiye. may occur in other conditio", in volv;ngexten9;y,,- neuronal dutTUtticn induding, acuc.e.CVA, ~erpeli encephalitis , muiti-iofilld dementia, prim a ry CNS lymphoma and rar~ly SDAT (most case. o(SDAT tell negatiy .. ). ReqUire. CSF (cannot be done en blood) EEG, charaderi,tie-fioding of bit at.oral, Iytrlluetrical, periodic hi- or triph8l!ic ftynchronou' ~harp-wB"~ comple>cel, AKA periodic IIpike., AKA p8f!udoperiodjc .llarp·Wljve comple>Ce1 (0.~·2 per ile<"Ond) h9Y .. ~ 70% lIefIeitivi ty and 66% a pedticilyM. They r_mble PL6Ds h "'l' page 145), hut /Ire r elponll!v,,- to no>ctou . atimulUI (may be ahBent In familial CJD" /lnd in the recent UK variant (""e «bow» - S PECT scan! may be abnormal in vCJD even when EEG i.8 normal". howllver the findings a~ nolspecifie for vCJD b r aill blapay: see tk-Iow tan.mar biop.y: patianUl with variant CJD (vCJO) tUay haVil dete<:t.able le vel. of variant type ~ of th e ahnormal prion protein {Pr pS<} in th e:. r lymphoreticuillt !yatem, which may be accused by a 1 tm wedge-hiolMY oron~ palaline tonlil (uaing ca refu l aseptie precautions )"" Brain biopsy Due to lacio.ofan efT""tiy~ treatmMland thepoll!l.Itilil for jatrog~nic infection in aurgery. biopsy is ltie,.".ed for c,: nea where estabH9hi "g Ille dillgna,us iJ dHmrd ;mpo~nt, or lIB part ofa Teiiearch stu dy". or when diaJllostic testa are equi .... ocal and other pole·n · tially In'atable etiologies aresWipec:ted. T rea tment a n d prognosis Given the lack ofden>On5trated infectivity (with t;",uell other ttlan brain or CSF), ISolation P/"l!C8ul.iOM 1UI'1l Wi gowns or moskll ace felt to be unnecess.o.ya. There i, no known t reatJ:nenL Th~ disease;$ rapidly prog:reulve. Median su""';"al is 5 months, ""d 80% of patients with sporndic CJO die within 1 y".. r ofdiaKJIDsis'". 12.1 1. Neurologic manifestations of AIDS TYPES OF NEUROLOGIC INVOLVEMENT ~0-60"" cfall patil.'nl.3 wi th Il<'qulred lmmunode.ficieney IyDcittlme (AIDS) will dt. v.. lop ue urologic 8)'I1lptn(lll, ",ilh one third ofth_ presenting initially with th eir neurologiccD"'plainl"'·"'. Only ~ 5% cf\l3 tienb Ibat di e with AIDS hav", , no ..... al brain on autojN>y . One study found th e CNS complication. of AIDS ahown in Tobie 12- 15. The most common condi:io n~ producingbl C NS 185;0115 in L tOlCopluP1osiB 2 . primary eNS lymphoma 3. progT\';I$jve muJlif_ lleukoeneephalopethy (PML) '" 12. Infect iona AIDS"': NEUROSURGERY 4. cryptococcal abscess Ii Manifes ta tio ns of CNS tOl:opla s m osis Ii mass lesion (toJ:opi/lSmosis abscess): the moslcommotllfl.'l ion ca using masseITect in AI DS pa t ients nO·8O%of cerebral mass I.,.. sions in AIDS") (s et ~Iow for CT/M RI findings) 2. meningoencephali t is 3. ence phalopathy I. CNS klxoplasmosi, occurs latt! in the course of Ii TV infection. usually when CD4 counts are <: 200 cells/mm'. Primary eNS lymphoma (PCNSL) Occurs in ~ 10'l0 of patients with AiDS". PCNSL is aasociated with the Epstein.Bsrr vi ruB Is« P"8t 462). Features of PML 1. caused by II ubiquitous polyomllvirus (II subgroup of papova vinIll, small 'IOnenvel. oped viruses with a closed ci rcular double DNA·stranded genome) called "J C virusAo (J Cv). 60-$0% of adults hav" an~ibodies to JCY" frequently manifests in patients with sup· preS!!ed immune systems, induding A. AI DS: currently the mos~ common underlying disease associate<! with PML 8. prior to AI DS. the most COmmOn as· sociated diseases were ch ronic lym· phocytic leukemia & Iympboma C. allogr-aft recipients: dUl.' to imm\.lIl08uppresaionl'O D. chronic ~te roid therapy E. PML al$Ooccurs with other malig· nancies, aDd with auklimmune disorde ... (e.g. SLE) CMV .1IQIIP.... fI\is oocasiona~ OOCUII 3. pathologic findings: focal myeJinlo!S$ (de.......'.c. fIt _ al .... OIIhe _ _ mye liDation . .". affect.8 white matte r) with oj PML In AIDS: 4'11. sparing of AXOn cylinders, aurrounded by enlarged astrocytes and bizarre oligoden. drogHal cells wilh eosinophilic intranuclear inclusion bodies. E M can detect the virus . Sometimes occurs in brainstem and cerebellum clinical findings : menta l stalu. cbanges, bH"dness. aphasia, progressive cranial nerve. motor, or sensory deficits and ultimately coma. Saitures are rllre 5. dinicaJ cou"",: usually rapidly progreasive to death within a few month, <>cca. ;o" .. lIy 100\jj'" .urvival """,,UI"II inexplicably"'. The .... i. no GITOK:tiva t ... atm.mt. Some promise initio.JJy with anti-retroviral thernpyS" 6. defini tive diaguosis requires brain biopsy (senaitiv;ty: 40·96%) although it is in· frequently employed. JCV has been isolated from brain and urine. Polymerase chain reaction (PC R) of JCV DNA from CSF habet'" reported, and iaspecifi( but not sensitive for P ML •• Prim a ry effec ts of AIDS infection Neurologic involvement with infection with the Human Immunodeficiency Virus (aside from opportunistic i" rection and tumors caUlled by the immunodeficient statAl) includes: I. AIDS enceph alopathy : the most common neurologic involvement, occu", in ~ 66% ofpa~ients with AI DS involving the CNS (HrY) \0'" w" II. otte. Iho Initiol. of 1M patient in who", it r. ...1 di.."....t"td. not ""nfused wi'" Jo.kobC..... IZ ~ ldt ( 1 prion d, .....,) nO. wi.., J . ",u taw" Caoyon >i",. (.Iao Olnfu.ill&ly •• II.d JC vi .... ) II .. nKI~ · . t ....dod R!>IA oi",. \hIt ll<."CloionlUy d __ <'>«PMIi,;. in ~um .... ) NEUROSURGERY 12. Infections '" 2. AIDS demen t ia AKA Hrv dementia compleK 3. aseptic meningitis 4. cranial neuropathies: indudi ng "Bell's palsy" (occasianally bilat.eral) ~. AIDS relat.ed myelopathy: vacua!ization ofe pinal cord (S~ M~lofXJlhy, page 902) 6. peripheral neuropathiu Neurosyphilis AIDS patienta can develop neurosyphilis as littlella 4 mOIl tTora infection"(unlike tbe 1~ ·20 )'MIlisually required in non-imruunocompromised pelienta) 2. neurosyphilis can devel\lp in spite \If what W<Iuld \Itherwise be adequate treatment for early syphilis with benzathine PCN ..... 3. the CDC recommend s treating patien~ having symptomatic ar asymptomatic neurosyphilis for at le ... t 10 days with probene.:id 5-00 mg PO QID plus either aqueous crystaUin.e PCN-G, 2.4_miltion units IV It 4 h", (tol.al of 12.24_million uniwd), Or aqueous procaine PCN·G 2.4-mil1ion units [M q d. This 10 day rogimen should be followed by benzathine PCN 2.4·million units 1M q week II" 3 week.. . Benzathine PCN iIIl:iQI recommended initially"" 1. NEURORADIOLOG1 C FINDINGS IN AIDS A series of200 cansecutive AIDS pa tients" with neurologic symptoms followed to biopsy, auUlpsy, Or for 2 yrs .howed the following on inilllI..l CI': • 81 patienta (40%) had initially normal CT. only 5% of which wen t on Ul develop progression of neurologic abnormalities Or developed or abnormalities 75 patien ts (38%) sbowed only diffuse cerobral atrophy; 5 of these subsequently developed focal OT findings fihown to be TO%opiasrna Bandii infection 44 patient!! (22%) had ", I focal lesion See Tablf 12·16 for a compar· ison Gf neuroradiologic findinp in Ulxopla$ffiQSis, PCNSL and PML. Tabla 12-16 Comparl 8Ofl 01 nauroradlolog lc Ie-s lons AIDS' 'n CTIMRI findings in t oxopl a s- -r. m a a b s ce8li l. most cOmmOn findings : large area (low density On CT) with mild Ul made,ate edema, ring eManCerT.ent with rv con trast in 68"competible with abscess (of tb~e tbat did not rioi en· hance. many showed ~.ypo­ denae areas with less mus effed with slight enhollCl!' a(lb,""'a!lons: Ttm) ~ lO>CapIa.rnosI$. PCNS!. a primary meM adj9C1!nt to lesion), eNS !ympI\orna, PMl • P/OQ,8$Si-.. rn.J1~loc8llMlkoen· well circumscribed margins" 2. most commonly located in ballo! S3n"lia. are al80 o(l.e ... . ubcortical 3. onen multiple (typically> 5 lesions") and bilateral 4. usually with little to moderate mass effect" (in BG, may compress third ventride and sylvian aqueduct ~ausing obstructive hydrocepbalu s) 5. most patient!! with taxoplasmosis had evidence of cerebral otrophy -""., CfIMRI findings in PML (ue Tabl~ 12· 16) Note: ilie appearance of PML may differ in AIDS petienta from non-AIDS patients. l. CT: diffuse areas oCIO".... density. MR I: bigh intensity on T2WI 2. normally inV\llvu onlJ' white matter (spares cortex). however in AIDS patient!! gray matter involveJ1)l!nt hu bef!n reported 3. no enhancemen t (on either CT or MRI). unlike most toxoplaSlT\QlIis lesions 4. nornasseffect 5. no edema 6. lesions may be solitary On 36% ofOT. and on 13% of MRla 7. borders are usually mOre ill·defined iliaD in Ul~oplasmosis"' 12. Infections NEUROSURGERY CTIMRI findings in primary eNS lymphoma (PCNSL) (see To.bls 12·16) NB: the a ppearance ofPCNSL may ditre. in AJOS patientli from nOl\-AJOS pal;tinu. muillp le Issians with mild mus effect and edema that tend ~ rinK·enhan~ on CT, 0. appear a~ a~as ofhypoiotensily urroun<;linlI .:ent.,,1 Hrea of high int.-naily \largelle,ion) l.II.geu. onT2Wl MRI (unlike non-AIDS CIlllea whieh tend to en· hanee homogeneol,l.lllyttl 2. the re 15 a greater tendency to nlul tic.. ntricity mAI DS patients than in the non· immun oauppreasOO population ll' 1. Imaging fil<:ommendation s MR with gadolinium ill recommended .. the initial.creeni"g prooedure ofchoire for AIDS pa tients with eNS "ympl.O"'1I (low~r fal!!e oegativ~ fII te \han cr-\. MANAGEMENT OF INTRACERE8RAL LESIONS NeW'Olluriioal confiuiUltion it ofuon ''''lue5t.ed for biopjly in lin AIDS patient Wllh '1u .... tionable luian(B). Tbs di~gnoslicdilem ma ill ... ually for low den!lity lesions on CT, and in tire United Stale!! is primarily between the following: toxopla.mOlltlr : treated with pyrimetha mine IUId 5ulfadioline(_ ~Iow) PML: nO provon efTecti"" t~atment(anlilllt roviral the."py may helpl" l eNS lymphoma: u~ lIally treatold with RTX (lIft-eNS lymphomtJ, page 4'61 ) 1'8: tends ~ be unlikelY ucept in HaitiRD popUlation note:: cryptoc:QCcI1S l'lno~ common tha.n P/IIL or lymphoma, but uluallY mani· rut.! as ~rypt.oeo<:cal menjngiti~ ta nd Ml. U. ~bIa4tinr lesion}!",e p(Jge 239) RECOMMEND.... TIONS PML co n usually bE identified rodiogrophically. How .... er , :radiognophic imaging alone ClInnot reliably different iate toxOpll1Sm06Ur from IYOlpflOm, o. from lOme other ~on' t urrent condit ions (pa,tienUr with toxoplasmosis may hav. otber ,ill1 ultllneou~ dinA"'s), Th erefore, Ihe foUuwing :r~c"'nm~ud"tiona are mads: ) , obtain b&llelin" toxoplasmo.ei s titera 00 all known AIDS patien~ i NS: :>O% oflhe. ge nera! popu latiWl have been inrKted by 1.00;0 and b.lve poI!itive tilers by ilge 6 yean, 80·9!l"7t ""iIl be positive \;Iy middle adulthood) . 7hechaneea-of to>eo Ilrehigh. er with seru m anUbodil'!l > 1:IGH (most are> !:258) 2. mUltiph! enlllillcingleaiun5 with baaai ganglion involvClment in a patien t Wh081! \.nxo t\tenr eh ang~ fn)m negative to poaitive have II high pr<lbability or being '""n 3, primary eNS l)'Jllphoma (P CNS L ) A. with line.II: les ioTll, 1)'I\'Iphoma ill mONilikely than taxo S . if pnll~ibiUty or PCNSL i, strong I . couzilier LP (contrAindicated In prellf!nce of man effectl •. high volume LP ro r cytology: PCNSL ClI n be d iagnbae<l in . 1025% of cases using . 10 OIl of CSF ifee f"06'" 463 for more details) b. or send cs r for polymenl~ch.ln reaction (p e R) amplification of viral DNA ofEp.gtein·Barr virus orJC·rirus'·' ithe age ots re"pon~lble for AIDS-related PCNSL and PML, reapeetively/ 2. 50merecommend ear ly bioPByA ta identi ty PCNS L ca_ \.0 avuid deIByinr:: RTX for 3 weelus whilBllSIIe$Sinll ,..u""nRa to antibiotica'" .. in p"u.." t .. lth p ... aible t.oxopl ... ml>&;~Ii. e. pOIIitive.tol<o titenand CT findlnr~ no~ atypica l ror \.0><0) even If other cxmditionl ha~e not been excluded: A. empirically SUitt: pyrimetl:HlJl)iOe Waraprim®) (200 mg 1000ding dose, theu 75·100 mg/d ), sulfRdinine (75 mglkg PO loading tOile, then 25 mglk, q 6 hrs), fol k add (5-40 Ing/d, t>9U~Uy l O mg with nch da-.e of pyrime thamine) B. if lulra a ll~'1O' dev~lops (which eommon ly occur'll). chMlge $ul(adiaO<ine to cli nd amicir, 400-600 mg PO or 600 mg IV q 6 hni C. a l~mativell for complete intoJu11nce: I. lIpirllmy<:in ( Rovamycin~J S-4 gmsId (ped~: ~O'IOO mglkg/d 1l 3 ... ,..k&) 2. etovH'l UOne O. Ule~ahould be B dinkal end radiognlphic respo!1W wi thi n 2-3 weeQ,n E. irresponw 1¥ good, reducedoaRge afte r 6- 12 weeksto50% ..rthe abovedoaea and maintain fl)1' Uk F. if th~~ drugs are cont.inue<:l, it should bepo.nible to maintain control rOT re-- NEUROSURGERY 12. 1"(Kuons mainder of patient's li fe «(u re ill not generally possible) G. ifno response to the ra py a lterS w....k$ (80me remmmend 7· IOdays'''), then conSider biopsy' S. perform biopay in the following settings: A. in patient with negative toKOtiters (note: patienl.8 oecaSlonaJly have nega· tive titers because of anergy) B. accessible lesion(s) atypical for toKO (i.e. non-tlnhancing. aparing basal gan_ glia, periventricular location) C. in the presen~ of extra neura.l infections or malignancies tha t mllY involve the CNS D. lesion tha t <:ouid be eithe r lymphoma or toxo (e.g. single le$ion. _3. A. ) E. in patients who have lesions not inconsistent with toKO but fail to respond to appropriate II nti· toxo medications in the recommendd time (_ a/JoLr«) F. the role ofbiapsy for Mll.:e ohancinf,llesions is less well defined ae the diago06is does not influence therapy (mO$t are PM L or biopsies are non-diagn06tic). it may be useful only for prognostic purposes'" G. oote: the risk of open biopsy in A.lOO patieol.8 may be higher than non· immunocom promised patients. Stereotactic biopsy may be especially well suited, with up \.0 96'10 effic.acy. fairly low morbidity (major risk: significant hemorrhage, w 8% iocidence) and low mortality'oo. '01 6. stereotactic biopsy guidelines: A. ifmultiple lesions are preaent.(hoose the mostaC<lee.9ible lesion in the least eloquent brllin a..., a, or the lesion oot respondiog to t reatme nt B. biopsy thecenterofnon·enhancing lesions. or the enhancing portion of ringenhancing lesions C. recommended studies on biopsy: histology; immunoperoll..idase stain for Toxop/(lIIma gondii; stains for TB and fungus; (ulture for TB. fungi, pyogens PROGNOS IS Patients wit h CNS toxo have a median survival of 446 days, whiclJ is similar tothat with PML but longer than AI DS-related PCNSV'. Patients with eNS lymphoma in AIDS urvive on averllge a shorter time than similarly t reated CNS lymphomll in non· immun()Suppressed patients (S months VB. IS.5 mos). Median survival is < I month with no treatment. CNS lymphoma in A.lOO tends to OCCUr late in t he disease, and patients olten die of unrelated causes (e.g. Pneumocyslu carinii pneumonia)"'. 12.12. Lyme disease ~ neurologic manifestations Lyme diseue ( lJ) ) is a complex multisystem disease caused by various species of Borrelia spirochetes (io North Americ.a: Bar~/ia bU'1ldDlferi) tranllmitted t.o humans by the tJCC<ks scapu/ari$ or pacifo;us ticks (the Americsn dog tic k is not involved). It W8l!l fi rst ~gni~ed in Lyme, Connecticu t in 1975, lind i$ nOw the most CommOn arth ropodborne infection in the U.S"OI. C LINICAL FINDINGS The..., s..., S clinical stages wlmh can averlap oroe<:ur sepa rately. Stage 1 (early localized d isease, erythe ma migrans and nu·li ke Illness) Systemic signsofinfection usuaUy begin with a flu_like illnen withio days w weeks ofinfettion, sympwms indude: fever, chills, malaise, fatigue Or lethargy, backa.c:he, head· ache. arthralgia, and myalgia. Regional or genernliwd lymphadenopathy may occur. The hallmark ofLD is erythema c bJ"on;eum .... Igl-ana (ECM) (classically II "bullseye ra8h~) which begin! 3·S0 days slter the tick bite, and <>CCurll in 60·75'10 of patients. EC M usually begins in the thigh, inguina! region, or axilla. lind consi~ b: ofan e"panding macular rash with bright...,d borden and central dearing aod induration that usually flldes without ~arTing in S·4 w~ks. Within 30 days of the tick bite, spi rochetes may be demonstrated in a.c:eUu lar spinal fluid. Stage 2 (early d isseminated disease) Several weeks w months alter infection. untreated patienta develop more serious or12. Infections NEUROSURGERY gan involvement. Cardiac and neurologk involvement IIl.,- oc:rur. M3nj("~ttllion5 in_ dude : I . cnrdiac: oe<:urs in 8~. Conduc lion deftl':'ts (ususlly A-V blocll. ,renerally brief and mild) and Ol.,YOperiClirditi~ 2. Mu lar: panopbtbal",i~is. i""h"",ic optic atrophy, and inte",titial kerntitis OCcur rarely 3_ neurologic: OCcurS in 10-1$" ofpahents with atag" 2 dise ...& A. the clinical triad Clf neurologic mlInife.stationa of Lyme diseaae i~ 'Qof: • cT>lnilil n"urWI (especilllly thpt mi",jelLing Bell'. ""IllY: Lyme diaell"" is the mOSI common cause ofbi I8tunl ·Be Il'~ pal,y " in endemic areaa) meningilis radiculopathy B. other po!l.!libl" neU{ologic involvement includes: encephaliti,. mye litis. pt>ripherol niul';t1. Neurlliogic findlnp are frequ~nll, migratllry, and _ 60% IIfpat illfll.l have multiple neurologic [email protected]. In Europe. 81llUlwlOrth', 6yndNwe (chroruc Iymphocytk meningili., peripharpl neuropalhy, and rodiculopillhy) is tbe Il)0l<1 common m ~nifelltotillo. o'ld primarily affecUl th l< periphenl nervou~ aYlle,o' •. Ne uroiogieaympJ.omll usually ""'lIlve gradually. Shlge S (late d iseaae) Anhriti~ and chro~ ic neurologicsyndrOIll<!' "'~y ~ur i" thiH etage. Arthralgia.. are COm mOn in 813ge I, bul trullarlhn·'i8 Ulmllily doe .. nllt begin for mon/.h lo yealll" after in· fection, lind i8 S""n in _ ~ o(n.._ '''. When arthritia O«UnI. it may affect the kDee (89%), hip (9'JI». shou lder (9'1o),lInld~ (7%)an<llor elbow l2'Xo) '" Neurolob"C involveme nt indudHl"" L cnrephll.lopathl' 2. enccphalomyelili"'" 3. pen pheral neurCopath,.. 4 . lI13xla 5. dementia 6. sleep dillorder 7. n euTOlllIyeh iatric d isease and fatigull syndromes DIAGNOSIS There i, no leSl indicative of aClive in faction . The $pl r~hele i~ dimeult to culture from iufecled human s . DiagnOllil .. eel$)' if a hiRJ.ory of travel to endem ic a n""" tick bile, e nd EC M a re identilil.'d . Thblf 12· 17 sllowl the CDC cri teria for chegnosi s. Table 12-17 d lagno,ls oj " Serology It take.. 7- 10 da}'1 Fram mitial infee.. to develnp alltibodies lo B. burgdor. hut it lakes _ 2·3 wlul before IInt.!bodiel elln reliably bedetuted in un· •...,0 ..." potien!.lo ("'libi~ti ... ~n reduc .. (FA . Immuno/l"",_ antibody the iromWle rl!llponu.!"". If the lif'llt ae· ,",un le8t is negative, it s hould boo repeat."""'" fn<dOJlosliolle:at. fI&UtI)Iogie 01 ce«lt.<: ed in 4_6 ween if the clialeal tuspldon of LD ia I lrong (seTOC<lnvers;on from ncg~ live til pIIsitive is lIupport;ve of B. bU'7ldor(eri infection). "'alse pCIBitivl)l! tan occur with oilier borreli.1 and trPponemallnfectionll (e.g . ..yphilis, however, VORL lest will differentil~ the twol. Enzyme-linked iromunosorbenl eBllay (£LISA) del.ettll fgM or IgG. Antibodi"" loB. bU'7ldorf~r;' iathe u~uBI l:e!!tmethod . lgM illelevnted Bcutely, and!gG ~du ..Uy rile. a.od il elevated in almO!lt 1111 petients Ilt 4-6 weekB and if UIIual!y !tighe'lt in plI tlenta with &rthriti9'oo. Western blo't !lIpy help identify fai:Je..polIiUve ELlSA re~ult.s (more .ll(!ruriuve and Jpe<:ifie than ELISA, however, l"I!IIulta may vary betwe.!!n labs). Amplification B. tmrlJdorf~ri DNA by pol)'TllerlOS8 thain ruction (PCR) yjeld~ a more very I18n~ilive test ~iOll r~rl, or NEUROSURGERY 12. I nfed;on~ lhIIt may Mvttaicnilicant faloe dud organisml. polIiti~es. and can be poeitive even if th e DNA is from CSF Elevated CSP IgO antibody liter. to 8 . burgdorfui may Ottur with neurologic invol"'rt>eflt'''. CSF findinll in lat41 dioe..e are usually wmpatible .... illl aseptic meninriu" OIit«lon,1 band, and increased ratio of IsO to albumin may occur''''. TREATMENT m.'" 'If Antibiotic therapy i, more effective early in !be illne... 12.13. Parasitic infections of the eNS Th .. followinl it a list of lOme of the many p.o.raaitk infectiolll that involve the neTyousayitero. Thoae that poteotillity invol~e neurosurgical int41rvention have _ daggerCf). 1. cysti«rcosi.,: lee Nfu'WY'lk~rr:o.i. below 2. toxoplu roOllist : msy Ottu r .. , ronlen;t,1 TORCH infection. or in t.he adult u.su.lIy with AIDS (1M NfuroloRk mani(ufC.tion. 0( AiDS. pal" 230). Toroplcuma gond;; i. an oblilate int racellul. r proto_n thtt il ubiquitous butdoe. ooteau" c1inkal infection except in immunocompromiaed hOllt41. Histologic feature.: necro.i, containinl2-3 run tachyz.oitelllcytblll 3. echi nocoo:cust: He pogt 238 <I. amebiasi.t 5. ..,histoeQmi.. i, I poruitk inf«tion. "Lib. d""~r .... t"-Ib.' .... _ ... lihl,IOU. ....1ve .. U/WU.tIkaI.ueolioa N EUROCYSTICERCOSIS CysticerCOollis is the mwt wmmon parasitic infection involvinl the CNS"'_It ;' caused by C,,'iotrcu, ctUuw-. the larv, I . t.age of the pork t,,,,,wonn TClfn", fOlium, which has a marked predilection for neW'al tiuue. Cyaliceroosi. iI endemic in atu. 01 Me!<ico. Eastern Europe. Asia. Central.nd Sou\.b Ameriea. MIl Mric • • The incidence of oeu.rocysticercosis(enCYltmento(]arva in the brain) rosy rncb ,,'lit in lOme are..'''. The incubation period varies between monllu! to tiecadea, but 83'9lo of o:aae. ahow . ympto .... within 7 yeanl ofuposure. LiFE CYCLE OF T. sotlUM 'nlere are 3 stages to the life cycle: 1...... (or onoosphere), embryo.nd adulL. T. MIlium can infect m.n in two different way.: .. the adult worm or 81 the larva. Infect ion with the a duJt worm (para!lit ie infeetion) TIll' type of infection results from etting undercooked infes ted (meuly) pork. The e~ted embryo it rel<!'ued in the . mall bow..!.nd can then rosture into an _dulL ".. ~groented adult worm attaches by meanloflo ..... auckera and two I'Owlofhookleu to the .... all of the .mall in~ltine wht:re it absorbs food directly throuKb il>! cuticle. Man i. the only known perm.n,nt hoel for the adult t.lpewonn. for which ihe human GJ Inct iI the .ole hl bit.lL Proglotu.a {Ol.ture aegmenta. each cont.t.ining repn>ductive organ.) produce tIP which are liberaUy eJU:reted in the feon. Infeetion with the larva 00:::"'" ".. dileaH ~~ wheo _nimala or humana become an iOUlnuediate oo.t for the larval.tage by ;"&aU", viable un produced by the proglottid. In the dL>Odenum of man alld pil, the Ibell of \.be ov. diuolves and the thu.sly hitched larvae burrow throop th. Im,lI bowel Will to enler thl lyD'\phatics Or .y.lemiccin,:ulation and lain aeee.. to: brain: atiro.ted to be involved in 60-92% ofcaset of CYBticel'COllis .kelettl mu.de .,. ' Uhcutaneoul tiMue The IlIOIIt roromon routeJ ofinplltion ofviable egp I re : 1. food (Ulually veletablea) Or water contaminated with egp from human f/!Ceil 12. Infection. NEUROSURGERY f<l<8I.o,.1 autoinoculation LU a n indiyidual ha. baring th~ adult ronu 0( tile tapeworm due 10 l.~k orgood unitary habits Or facilities aUlOlnfection by re~nt penatalait of grllvid prolllo!tiw. from the inteitlRe into the ltomllch (a theore!i"i pO!I~ib; lity IhM is unproven) 2 3 OnOll In the ti&aueofthe iotlitrmedilll')' hOllt. Ibe Ill/"Ya d~velop I cyst waU in ~ :2 mrmU., and miliUM. in _ " month. to lin embryo . Many 6Dlbl'}'Oll d •• wi thin 5-7 yno , the~ somelilM!! caldfy. ln th~ emhryo.li .. dunnoll! in the mu..cJe, ·wailing'" to be eatet\ af't40r 'l'hich tbe tyde repHts. pra.. TYPEs OF NEUROLOGIC INVOlVEMENT Involvemen t of thlapinal cord and periphenl "uYel ie rare. """0 type. of CYlts tend to develop in the br. in''": I eyati". rc:uI cel lule •• e: ~l\Illir. round or ova.llhi/l·wa]~ cyst, flU>Ilnl in "Ie from . 3 to ZQ m.m tel.<lioK to fonu.o th" pH renchyma or nll'f'OW , ubA rllchnoid .,,0;1 2. I paNS. Thb cY'! OXInlalnl \I loo leJl; (h"d), il u. uall)r .ta~, prod1.>Cfll only mild iunllmmlltion durin, t be active ph. .e cyat'lle r cua nllclt1,,~ua: larcer (4- 12 em), ~W. aetivoely prodlM:;ne g-r.pe-lik" duster. in tho! banl . ub.rachuoid 'P"~ Ind produc.. 'nte" .e innammltion, Ther<!! are no lar-..uin tlludqs\&, 'l'heKCYIIII u. uaUy dq:ene rate in 2-!1 yea"" ill which the ClIpsule thiekeu. alld thl elear eonte"ta are 11191.0. by. whitllh ~I which unde'l:~ calcium depo$W<In with «InCOmitanlsh.rinJo:ap of the c,..t ,,.t l.ocation ofth ... cy,\& te"d$ to fall in to \ of 4 JITOUpl: \, meni"e.al: {ou.d U! 27-!I6~ofta.ea with n ... ur~1 InvOlvmlenL Cy.tI.r. .dhl""nl or {r""noat;ne and are Iocatad ei ther tn.: • dorlQlat<emJ auN.rtlthnoid If»I~ u8ually C RUIII""'r type, uull"l mini , mal.ymplomt • ba!.llubarachnQ,d apa", : u.uBlly the e apa"dint C norm"'u, (0= prO. ducLng arachnoiditis and libro&i, eompl1llin, a d..-ouic nlenln,itia with hypoglYCOrThachia. Can obstntct foram",a ofLuachka and Ma,HMi,e p.ooucin, h~phal u. , or ean c:lu.e enlnlpment of ball I e""'rna- cra· nial neuro;»<thie. (including visual rlisturb.nc::ej. EIlnmely high mortahty with this bnn 2, ""re nchym.l: found ieo 3(1.63-.; focal or general''f<!d ... i-w.urs O«u"' in ~ 50'10 of tMH (up to 92\10 in IhHIIfIleried 3 , ventricular: found in 12.!8"J-, poIIibly lIaini", aecea ,-iii IhI! eh oroid plel<ut. .... dIlIKIII.~ O!" frw I1GBt;n, cysts occur, c:I" block CS F flow and r.UM. bydroo!ph. ah.. w,th intenailtent ;ntraeranial hyperten.ion {8nu.'• ..,ndromd 4. mixed lesioo.: fGund in _ 2~ CLINICAL Pre5el.tation:aeiZllre., ~ign.o ofel~.ted ICP.1'ocaJ defidb related to the lcabon or tll a <:).. t, Ind alte," m! IItal .tatul a re tbe!DOel tllrl)lOOn find ,np . SymplDma lillY''''' be prodo..ooed by the imu, ullologic tHet;on to the ;Ilreatation. Cracial nerve paltiet can 00wr with basallracbno,dit is, Subc:utan~ nodul... may 10mHimH be fell. LtBoRATORY EVALUATION Mikl periphenJ _inophilia CIOn o<cur. but i. incoosis tent and thu s wlf~1iabl .... CSY may be IIGrfOlll. t:o.ioophiLI are IftIO in 12-~orClUet and ,uaf:llt. po .... itic i,,{mion , Pn:I~n may be flevDud. StoGl: !eM Ihln 33"1tof ClIMI bIIve T toI'um OVII on the ltoI)l & rology CYlliten:oai. IlIlliborly lite ... delenwDII!'d by I::USA Ire ~ 1I.idered . ignltltant.t1'601 in lerum , and 1'8 <II the CRF; checki n, (or tite ... ..... ~ir_' thP!ll! lhnlllhold& in the auum prodU~I' tal \hI t i. ltIClte Mllsihve and >II the CS F ill nlCll'e specH;" for cy5tia;r. co.iI, FI'" lI.,auve rata Ira hither In case. without nwningit:il 0. with leu sentitive IUU, Tha "",wer flUyme-linJo:ed im munoell'Ctrvtranaftlr blot i. _ 100'10 lpeci fic and hiKt.ly alLboulh MI\I.ti ¥lt)' il l..- in eaMI with a "'lita!')' (:)'lIt, se.,.iuve"·, R.4OcGAAPl-/IC EVALIJATK»I Sol\..tip"l .......,. mllY . how .,.ldfit.ltJ,gnt In lUbc:utllroeoU1 n«lulu. a nd in thigh and lbou lde r muadH, S hlll · rn' tbow caleifieationa iu 1 3' 1 ~ of ellllea with """urOl.")'~tiCl!r<:OI!is. May be NEUROSUHGERY 12. lnft'Ctiolil linille or multiple . Ut uaUy ein:ular or oval in ,hllpe. cr The follo .... inll findings on C'f' bave been defUibed (modified' ''' "' J: I. rio, arthanein, cytUl of veriou t t izea representin, livu., cystiee",i. Little inflam· mateT)' fe.ponae(edemal occurs IS lon, IS I. tve i, alive. C her. ct.criatic findin, it sm,ll (e 2.5 em) low detllity cyaUl with eccentric punctate high density that may represent tbe Beolel( 2. low den t ity .... ith ring eohancement.een as an int.crTl.>elfiate l tage between living cylt end e.leified ranUlant rl!pn!8entu.g int.rmedi. t. l tage in granuloma forml. UOIl . Resultant inflammateT)' readion can c.ule edeme. Ind b n l arachnoiditis u. cyat$ loca ted in hull suba rachnoid apace . Onen rin, I nh.ndn, 3. intraparenchYll'lal punctatol CIIldficationt (graouloml ) IOmetimel .... ith. but u. ually without l urroWlding eohancemonl. leen with dead par.litel 4. hydrOOllphalu l . Sometimes with intraventricular cYl ll which mtly bl ilcM tense with CSF on plain CT'" and may requirecontru t CTvl ntricu:'l phy'" or MRI to be demonurated TREATMENT S teroidll May temporarily relieve ~YlI'lptoma. and may help dec:reue edeme th.t tend. to (IC. cur initially during treatment with antihelminlic drugs (I., . delUllmeUuuor>e 16 mgld iniofacute tially, lubsequeot.ly tapered'- ,. Steroids .hould probably be reserved for _ deterioration during therapy' ''. Anlibelmintic drugs CoruC06teroids should be u$Bd (if poasible •• tart 2-3 d befOl"ll! treatment., continue during therapy). Any c)'llticen:oc:idal dn.>g may caUBfl irreversibl.. danage whe-n \11M to treat ocular or spinal CYl ta, even with corticosteroid \1M. PraziquanU!1 (Biltricide®) il an IltItihelmintic with ac:tivity agai ... t.U known species ofsc:hi9lO3om ..... Given .... 50 mgftg divided in 3 doees (.. """ (\oft. for pediatri ... ) for 15 daYI . (.here ia a l ignificant reductioo in Bymptom. and in number ofty.ta seen on CT' ''. Also dn.>, ofchoioe fo r intntio.al.tage infestation. . A1bendazole (Zenl@latI) 15 mglkg per day divided in 2·3 dOBeS, taken with a (Itty meal to enhance absorption (.am .. dose ror pediatrics). given ror 3 month . ... "I"!. Niclosamide (NiclocidelS.nd others) may be given orally to trea~ adult tapewOnn.l in the Gl tract (not@: pruiquantel is drug ofchoieel. R.x I gro (2 tableta) chewed PO . ... peated io I hour (total ~ 2 gm;. Intra ve ntricular disease: The,e is no COnHtlluS 00 the efficacy ofmedicall.reallm'nt for intraventritu lar cysta'·. 5u.rge ry SufKeT)' may IOmeti "'" be n_ al")' to establish the diagnosi •. Stereotactic biopsy may be weil l uited for lOme casel. es pecially wilh deep l...iII.... CSF diversion i. nec: ...... ry ror patient.. with ' YlI'lptomatic hydrocephalus. although tubin, may become obstructed by jp1lnWomltelJ& innammatoT)' d.. b"s.... SurgeT)' mtly be indica ted ror lpinal ."..Ia"· and for intraventricular c)'IIla whim may be Ie.. respons ive te med ica l therapy. The latter may IIOmItimes be dult with ul in, ltereotactiC IA!C:hniqufll andlor endoscopic inatrurnentation''' . Contact. Both .. uenta with cy. t icercosis end their personal contact.. Ihould be K Tftned for tapewo rm infection ai~ a l il"l(le d _ ofnidOlllllide or praziquantelwm l liminate the tapeworm '-. CION conlld.l of persont with tapew(Wml ahou lei h.ve acreerung by medical hi l toT)' I nd H rologic ~ti.n1I for cy.ticerentis; if lUu " tive of cy.ticercosi, a lI<!urologic .,UIII and CT or MRI t hould be done. ECHINOCOCCOSIS AKA hydal id (cyll ) d ifUM. Ca uHd by Incysted la rv.e ofth l!oc tapeworm &hi· nococc:u. grntUdOIO in endemic are• • (Uruguay, .... ua tr. li. , New Zea land ... ). The dot!: i. the prim' ry definiti ve hnIItofilil ad ult won:a . lnterme<liate bolla for the l. rvll.tage in· clude . heep and ""'0. O¥a are u Crl!ted in dOC f_ and contaminate herbage e.ten by eheep. After ingatioll , the Im!)T)'OI hatch end the pa11II,i te burrow. through th duoden.l w.ll t<l pin hematoee_ . c:caa to multiple o rg.tII (liver. lunp, heart, bone, blllin). 138 12. lnfectioRf NEUROSURGERY Oog:t Nt these infested orgal13 arKI the par8Bite enter! the intestine where it remailUl. Man it infected ei the r by uting food cont.llm;nll.\.e<! with ova, or hy direct contact with infected dop. eNS involvement occurs in only ~ 3%. Produces eerehral CYSI8 that Ire confi ned to the wh ite matter. Primary CfatAa re ulua lly B(lli tary, MC(\nda rycYlto (e.g. from embo liUltion from (/IO rdi •• Cyl.ll8 that ruptu re or fl"(lm h. t.rogenk Olpture nrcerebral cylt.t) are uaualty multiple. The CT den.i!), of the cyst illimil8r to CSf', it doea not enhanee (. )though rilo enhancement may oa;:ur lf t bere is an inflammatory Te8Ction), and there i. litt!e I UlTOundins edema . It cont.ain'lIerminating para sitic particles called "hy. datid sa nd" eon to ioing _ 400,000 aeoleca.lml. The <:ylt e nlarg<ll slowly (ra tes of _ I em per YNr a re quoted, but thi. i. variable and may be hiehe r in ch ildren ), and lISual1ydoea not present until qui te :arge with lindinga ofincreaHd ICP, ae1ZUrH, or focal delicit. Pa!ient.l often have eoI lnQphllia and may have positive serologic teJItl for hydatid disease. Trea tm en t TTeatmen t i~ . urg"k.l remova l of the intac!cysl. Every effort mUI! be made to avoid ",pturing these cyst.l d l.lring remova l, or else the fQOl_ may oont.am in ate the a<lj.afltnt ti guu with ]'I<IQible rtcurrenceof lUultiple cytt.a or allergic rtao;:tion. May uM acijunctive medical trutment with ~lbenda"lOle (Zentel®) 400 mg PO BID (pediatric dose: l.5 mJo1k&ld ) . 28 dllYl, Ll. ken with a flilty meal. repeated .. nKeEnry'''. 12.14. Fungal infections of the eNS Mo. t are moedk~lI~ treated conditiolUl l hat do nO! require neutollurrlcal inte",ention . They tend to pre se nt eit he r wilh chronic meninciti. Of" brain a~••. Some oft... more com mon onn indude 1. crypw:occosis:.t />l,low A. cryptococcoma (mucinous pseudocyst) B. cryptocottal meningitia 2. candidiasil: i. n_the most common fungal infection oft.he eNS, but is rarely diagnosed before .utopay. Very rate in healthy individu...ts 3. aspergillosis! may be IISsociated with cerebral absceu in organ tranlptanl pe. tient.ll (supagr218) 4. coccidiomycosis: caused by the d imorphic ru ngu$ CoccidWUk. immili • • En~n;lic in 80uth weBtem U.S •• Muico, and Central Alnerica . U.ually presenta .. meningitis. with rare repo>ta of parenchymallesKlM '" S. mucormycosis (phycomycoa:is): U5uaUy occura in diabetics ~ ptJgt 586) CRVP"TOCOCCAL INVOlVEMENT OF THE CNS CNS involvemeol i. diagnosed more frequenO,y in living patient.ll thin Iny othe r fungal distill<!. Octura in healthy o r immuoocompromised patient.. 1. cryptOCO«:Om. (mucinoua paeudocY5t): a parench}'IN1 cotleetion which 0<:CUf$ al. n'ost excl ulive\y in AIDS petientl. Noenhancement oflhe ltlion or the meninges. U.ually3·10 mm in diameter and are frequently located in lhe bQal ganglia(due to .pread by llIlIIlI penoretotl) 2. cryptocOCClI meningir;': A. occurs in 4-&1. of pelientl with AIDS"" B. ca n llao o«ur withoul AIDS: IIOlli variety can in~eet the bnlin ofimmunOcompe~nl hottl'" C. may be auocilted with increaHd ICPiwith or w:thoul hyd rocephalul on en,deereaaed viaull acuily, andlor cranial nerve deficits D. I.te dettrio ration it> t.he IbMoc:e ot"documented in feetion may respond 10 deeadron ' IRJ q 6 hf$ tran.itiooed 10 prednieon, 2S mg p.o. q d'''' Tr-eatme n t 1. 2. antifunlalagenl$ (e.g. flucon awle , In orl.llria.ole or amphotericin B)"· A. petieOt.l "ith H[V require lifelong trellment B. non-H [V petienta have aliroited treatmenl COUrN manapmen t of inlrao;:ranial hypertelUlion UC HT) (with or without hyd roce phalu.): contrOversial. OptiorUJ''":: A. ifinitial openinl preuure COp) on LP ia WNL Cc 20 cm) Ihen a repelt LP in 2 weeu ill rc<ommended to ....... cu/lute! llalul . nd to re~vll l OP NEUROSURGERY 12. InfeetiolUl '" B. f(lr doeument..d ICH'f. initifl.! manogement is daily LPs. drain ing enough CSFIO redu<:e ICPby~. Daily Lf>. may beiuepended when prt'5SUre~ "'" ncmnaJ for Rverru tOMe~ut.ive dllY' C. c"aH with p"r~;"'U!nt IC HT Or th""" with visual deteriorat.i<,ln in ~pite ,,[Beriall.J'~ may be ,,:ulnaged .... iUl: I . lumbar drain: temporizing. Drain 10" height of. 10 em ofCS F 2. ""rmonentahunL: !>eilher di ...... minntion ofinf""Uon tJu-uugh the distal sbullt nOr ~~tion ofa nidus ofinfection ",frndo'1 to m~ical therapy hlU been deliCribed "" D. iumbo""ritoneDI shunt b. VPor VAHh unt'''''· 12.15. Spine infections Spine inf~tiol\ll may be divided inlO the following major ClltegOries: I. Vilrtebral os~myeliti~ ("pondy)iti,l: «f! PIJ6~ 243 A. pyogenic B. non pyogenic. gt"IUlulornatou, 1. tuberculou •• pondyl;ti! 2. bn",ellO!!is 3. nsper gillOli5 4. \)lut0n'\y005i~ 5. c.occidiomycosi. 6. inf""Iion with Cotldida trop;/:aU" 2. discitis : i~ pnge 245. u~ually 1U8odated with vertebral O/iW!olnyeHU. (spon dyiQdiscitis) A. spontB""" .... B. polt-ope rat!ywpo l t·proc:edure 3. epidural abscess {fte bi!loml ~ . aubdural empY"1I'B 5. m£ningiti! 6. apinal cord Bfmess MR)uperi,nce uggeat.lhal pa~ients with in fectinus spon liylitis will dlOVelop an B850ciu.ted e pidural a~us ifWltreated. and thn epidural empyema i8 u n usuwl ,n the ahsell«! ofvertebral ost.omyeli lill'''. Thul . Ihe diseovery of one of these ronditions Ihauld pTalDp t a aea.",h fo r the ot her. 12.15.1. Spinal epidural abscess , Key feature.; should be eon~;dered in "pelieat wi t h back pIIin, fe~er, Rnd 8"pine tendern"," major ri5 k factol1l; diobetell , IV drug abuse. throni~ rena! foil ...... alcoha1iam mllY pr-odu«! p~.i .. ~ m"jf.!opalb.y. ,ometimes with precipi\DuS det.o.riorotioo. therefore ellriy su rgery is rt!C<lnunended eye n if 00 neuro deficit fev .. r,sweat. or rigal1l are common. but norma l WBC IlIId U!n>penUure CIIn OCCUr dllSJlital pres£ntat ion oh skin boil (furuncle) DCCUI1l in only - IS~ EPIDEMIOLOGY Incid ente: 0.2-1 .2 per I O.GOOhospital ftdmiesionumnuo liy'''. po~!libly pn the ~'''. Average age: 57.5:t 16.6 ye;)rs'·'. Thoracle level ill the mos t commOn site (_ ~). follow~d by lumbar (351'» then .cervical ( 15%)"J, 82')1> ~re pOl:l, rior loUIe cord. and 1$'11> Interiorlnone1tl!ries''', SEA may span &oro I to 13 levels"' , Spinal ,pidurlll abscen (S EAl is ollen u~inted with vertebroJ o$teomyelitis (In one fl(!riea of40 cases. OIteomyelitis Otturr~ in all cases of anteriar SEA. in 85"" af elT' cum fe renLial SEA. a nd no CaSl'S or poste rior SEA) and ;nl.ef\Oerl.eb,.,.1 di.<cit is CO-MORBID CONDITIONS Chroniedi5easu pssocillted with compromised immunily were identified In 65'1'0 of 12, Infections NeUROSURGERY 40 ca.u"·. MlOCiated eogdition. ig~luded dill~tet n'ellitua (32\1», IV drug abuae( IS<J,), chronie ren"l failure 112,-,», alcoholism I I~J, and the following in only 1 or 2 pa.tienta: cance r, recurrent UTI. Pott', disease, and positivity for HIV . Chronic . teroid use and ~ cent .pinal procedure or trauma (e,g. GSW) a~ . 1110 ri sk factors''', CliNiCAL F&'TURES U.u.Uy p~senta with e~eruciating pai n localized over Ipine. tender to percuasion. RII d icular .ymptoU'll follow with . ubilequent di,tallXlrd findin"" often beginnill( with oowel/bl.dder diUurbance, abdominal distelllion. weaknns ~"ing to perl· and quad.ripll!gia . Average tiD'le i.3 d"yl!'roD'l bIIck JIIIin to root . ymptom. ; 4.5 day. from root pain to weakne ..; 24 h.. from we,lulea. to parapltgia. Fever. sWUtl Or rigol'l .... eomn>Qn. but .re not alwaY' pretent"'. A furuncle may be identified in 15%. Patil!nta D'lay be enoeph,lopathie. Tbi. may range from mild to severe and m.y fur· ther delay diagn03i •. Meningilmul with . positive Kemig'. lim may occ:ur. Patientl with posl-operative SEA may demonstrate lurpr .. ingly few ligna Or .ymptoms (i nduding lack or teukocytolis, 1.. offeverJ nide from loul pain''', * Pathophysiology o r spinal cord dy.function Nthough soroe rod l ympt.Oms may be due to mec hanical comp~..ion (i ndudinr that due to vertebral body eollapse). th i. i. not alWIYl found '''. A vascu lar mech.ni.m ha s also been postulated. and vanoUi eombination. of arteri.l aDd ~nous pathology have been described'" (one autopay series . hawed liull! arteri.1 eompromiae, but did ahow venous compreQi on .nd thrombo. is, thrombophlebiti. of epidural veins. and venoW! infarction.nd edema of the spinal cord'''). o..:uionally, there m.y be ;n f« l ion of the spinal eoro itself, possibly by extenlion through Ihe roeIl.iTIIH. Differen ti al diagnosia SEA should be con3idered in any patient with b&c:ltache, k;vl!r,lnd .p;n. tendemeas''', AJso see Diffrrl!fllial di06f1()$js, M~lopalh)' on plge 902. Differential diagnOllili I. meningitis 2. acute tra nsveru myel itis (pa ralysis is usually more rapid, radioeraPhioc atudie. art: nonnal) 3. intervl!rte:bral disc herniation 4 . spin.l cord lumor. f'>. post-op SEA may appear simi la r to pHudomeningocele'" SOURCE SITE OF INFECTION hl!mato(enoul spread is the most common lIOurft ( 2~ of cases) either to the epidural ' paCl! or to the vertebr8 with extension tol!pidural space. Reponed foc:i include: A. akin infections (mOllt common): furonde may be bund m 15'Ao of cases B. parenters] injections, especi ally with IV dNg .00M'" C. bIIete:riall!ndoearditis D. lITl E. ~.pirat.ory infection (including otitis media. 'muaitis, Or pneumoni.) F. pharyniNl or deotal ab",,", direct extellIion from.: A. decubitua ulcl!r B. psoa' abloe.n: peoas O1ajor muacle .ttaches to ttan.verse PrDCelSeJ. ~rle­ bral bodieJ (VB) . nd in tl!rvl!rtebral diaQ ofapinalcolwnn .tartingfrom the inferior m.rgin ofTl2 VB, e~tendill( to the uppe~ pa rt of 1.5 VB C. peoel ratinr t rauma, including: abdominll wound., neck wound., GSW D. pllllrynre.1 in fectiont E. mediastinitis F, pyeloneph:itls with perinephric abKeQ followi", . pin al ~uru (3 ore ofthne pIltitnta h.d readily identified perio· perative infectiQIlI of periodonta, UTI, or AV. r;, tula ''') A. open prootduru: Hpecially lumbll r diIotetomy linc:idl!no:e'" _ 0.67'1» B, t:loeed prooedU'H: e.g. epidural catheter inae rtion for 'pin al epidural anesthesi."'·!», lumbar p"nctu ... ' ..... • hiWlry ofrecen t back trauma is common (in u p to 3Q9l.) no IOlIrct un be identified in up to so-. of patienll in l ome 'eriel'" NEUROSURGERY 12. lofections ". ORGANISMS Operative cultures are most useful in iden tifYing the responsible organism, lhese cultures may be nega tive (polISibLy more common in patie,,1.$ previously on antibiotics) and in tbese Catell blood cultures may be positive. No organism mlly be identified in 2950% of cases. I. S taph. aunluS: the most com mon Qrxan ism (cultured in > 50<lt) possibly due to its propellllity to form abscesses, its ubiqui ty. and its ability w infect normal and immunocomprornised hoo;ts (these faclll help explain why many SEA arise from skin foci) 2. aerobic & aMerobit SlreplOCOCtu8: second most COmmOn 3. E.coli 4. PK udo1JW1WS aeruginosa 5. Diplococcus pn~umon"'t 6. &rralia null"CelC<!M 7. Enurubacter 8. chro"ic infectio"s: A. TB is the most common of these. and although it h95 become less widespread in the U.s. it is still responsible for 2&% of eases of S EA'''', it is usu· ally associated with vertebral ost«lmye!itis (Pott's disease) (see 1"ubtl"Culous wrtebrol O!Ileomyt/iJi.:, page 245) B. fungal: nyptoooccosis, aspergillosis, bruC<!lIosis C. parasitic: EchinCCOCCU8 9. multiple organisms in ~ 10'1> 10. allllerobe. cultu red in _ 8% DIAGNOSTIC TESTS CBC: leukocytosis common in acuu group (average wnC. 16,1001mm3), but usuaUy norenal in chronic (ave. "'DC .. 9.8O<Vmm3 ) ,,, . ES R elevated in most", usually> 30'''. LP: performed eautioualy in suspected cases at a level dista"t to the clinically su8· pected siu (C l.2 puncture may be needed to do myelogram ) \Vith constant .. spira tion while approaching thecal l ac to detect pus (danger of transmitting infection tosubarachnoid space); ifpus is encountered, stop advancing, se"d the fluid for culture, and abort the procedu re. CSF protein & WJ3C uSlllllly elevated; glucose normal (indicative of parameningetll infection). 5 of 19 cases grew organisms ident.ieal to abscess. Bl ood c ult ........: may be helpful in identifying organism in some cases. Allergy batt ery: (e.g. mu.mps and Candida) to assess immune .ysum. RADIOGRAPHIC STUDIES Plain film s; Usually normal Wlless the r", i. osteomyelitis of m:ljsC<!ct v"'rtebral bodies (mo.... common in infections a"terior to dura ). Look for lytic l<'!$ions, deminerslization, and ~\loping of end plates (may tske 4·6 weeki! afulr onset of infection). MRJ, Imaging study of choice. Diffe .... ntiates other conditio", (especiaUy transverse myelitis or spinal cord infarction) better t han myelolCT, and does,,'t require LP. Typical findings: TIW I - bypo- or iso·lnun${! epidural mass, vertebral ost«lmyeliti. shows up as reduced signal in bar>e. T2W1 - high intensity epidural mDSS that often e""~noe ~ ",,; Ih gadolinium (3 p"Ulrnl of.nha"".",."t: I ) d.no. ho,n08.n..,., •. 2) inhomogene<tus wit h seattered areas of sparse Or 0-0 uptake, a"d 3) thin peri pheral enhancement'"') but may show minimal enha"cement in the acute stege when comprised primarily of pus with little granulation tiuue. Vertebrlll 09teomyeliti!l shows up DS in_ creased signal in bone, associ.'lted discitis produces increased signal in disc and 1088 of intranuclear deft. Unenhanced MRI may miss some SEA"', g3dopentetll.udimeglumine e""ancement may slightly increase sensitivity..•. Myelo gram: Usually show. findings ofextJ"adurBI compression (e.g. "paintbrusb ap. pea rllnC<!" when complete block is present). In the event of complete block, C 1·2 puncture is needed to delineate upper extent (unless post-myelographic CT shows dye above the lesion). See cautions above regarding LP. cr Bea n: Intraspinal gas has been described on plain CT' ''. Post-myelograpbic CT is more 5eruoitive. TREATMENT Early surgical evacustiorl combined with antibiotiC8 is the treal.ment of choice. AI- '" 12. Infectio"" NEUROSURGERY though the.r. ate teporu of patienla managed with antibiotial alone'" '''' J: immobi1i:uo t ioro' '', ",pid and irnversible det.erioration has oc<:l!rred e~en in pIItienti tr. .ted with apPf'Opriale ao ubiotiQ wbo were initially neurologically intact''',''', 86% of thou wbo det.erior1lt«! were initia lly treated it with arHibiotic. alone''', Therefore it;8 recommended that I>OlIIursical management be reserved for !.he following plItienti (reference'" modified"';: L thoM with "rohi':liti~ operative ris k factors 2. i.nvolvement of lUI ext.el'lSivtl length of the .pinal canal 3. oomp lete Pl' rll lys i. for> 3 doy, Sur,ery Go.b are u l.oblis hin, diagnQl;' and causative o rganism, drainage of pus and debri. dementofJTllnulation tluue, and oony stablHution ifneeeal3ry. MoslSEAare posterior todura and are app/'OlOched with. e.xtena ive laminectomy. For posteriorly located SEA and no l8\Iidence of vertebral Oftoeom~li li l. instability will u~lIally not follow simple laminectomy and appropriate po.ttope rati~ antibiotiu'M, Specir,c ant ibiotics If organis m and .our« unkoown , S. 010"", mos t likely. Empiric antibiotics: I . 3rd generation cepha lOllporin. e.g. cefot.axime (Clafora"') PLUS 2. vancomycin: until methicillin rel il:tant S. 0""'" (l'IfRSA) ean be ruled out. Once MRSA i, ru led out , witc h to syn thetic penicillin (e.g. n.fdllin or oueillin) PLUS 3. rifa nlllin PO Modify antibiotie& bated 010 cultu re ..... u!~ or knowledr of 800m! (e., . IV drug abUlle.. have s higber incidence ofCram·neptive organiarm). Du ration of t r ea tme n t For SEA, 3·4 week. oflV antibiotiQ followed by" weelUl of oral ... tibioticl .... ua.lly suffices. 6·8 weeg of IV antibiOlict are l uggftlted if there is documented concomitant vertcbTIII OOIIt.eomyeli til:'" (although .orne argue that o.t.eomytlitil is pTflent I"'thoJoci· <:ally in mostcasese"en ifnotd emons trated radiographieally, and therefore the resbould be DO treatment difference Iletween th_ gTOUPI'''). Serial ESRa may.1soo ruid. dura· tion (fllilure to reduce suggesUI raidua l infection"'). Immobilitation for at leut 8 weeu during antibiotic therapy i, ..-mmended. Ou",,,,,, Fatal in 4·31% '""(tbe higher end of the range tend, to be in older patinlll a nd U! tboee paraly<ted before surgery"'). PatienUl with HYeN neurolosic deficit rarely ialprove, even with l<Urgical inte.,.-ftltlon within ().12 h .. o£Ollset of paralysi s, althoup" f.w_ fll!$ have "'own a chance for some recovery with treatment within 36 hra of".rlllyai" ... .., Reveraal ofparalyais ofeaudel spinal eonj s.:ognlenta if present for more than a f. w houra is rare (exoeption: Pott's di~...., has sow. retu rn). MorteLi ty il ul ually due to oriS' ina l focus o£ infection or as a oompiieation of l'Hidul!.1 pa.raplegia (• .S' pulmona ry embolism). 12.15.2. Vertebral osteomyelitis f or differential disgnOOllia, 8ft D"'t'u(li~ k,ion, o{llw "P'M. p81'1939. Often aseoeilted with diacitil, wh i: h may be grouped together under th e tena,porrdylodi«it~ , VO h .. fut ures s imi lllr to lpina l epidural ab.eess (SEA) (su pu.ge 240). Vertebnl body eol1a p$<! aDd kyphotic deronnity is common with poaoible retropul • • ion of necrotic bone and diSC' fragrnenlll againn the spioal cord Or cauda equina. EplOEMlOLOOY VelUbral o.t.eomyeli L;1 (VO) compri," 2-4% of all C&SM of OOllt.eo myeliti s'·'. Inti· denCCl il 1:250,000 i" gene ... 1 pOpulation. I"el dence appears to be ri,iDg. Male:femal. ra· t;on i, 2:1. The lumbar fpine il the moeteommon l ite, followed by thoracic. cervical and sacrum ''', Risk factor. : I, IVd rugabuH '· N£UROSURG£RY 12. InfectiollB 2. diabete$ ~llitu8: sU$Ceptible to un""ual bacterial infections and even fungal osteomyelitis 3. hemodialysis: II diagnostic challenge since radiogTaphic changes o[osteomyelitis can occur even in the absen~ of infection (see 1Jf!'lrucli~ le.io"" o{the 'pine , psge 939 ) 4. illlmunosupprusion A. AIDS .8. chronic oortioosteroid use C. ethanol abuse 5. infectious endoenrditi£ 6. following spinal su rg'l.."'Y or invu;ve diagnostic or therapeutic procedures 7. may OCCu r in elderly patient.. with no other identifiable risk !"aetors'" Complications that my IIttru&: 1. s pi nal epidural absce .... 2. 6ubdural ebscess 3. meningitis 4 . bony instebility 5. progressive neurologic impairment 6. un ique toCl!rvicalspine involvement: pharyngeal abacells 7. unique to tha."dc spine involvement: mediastinitis CLINICAL Signslsymptom.· localiZ@dpain (90%), fever (52~, with rever spike. and chilli being rare), weigh t lOS!!. paraspinal muscle spasm, radicular symptoms (5()·93'70) or myelopa· th y. VO somet;mN produces few systemicei'fecta (e.g. wac end/or ESR may be normal). ~ 17% ofpetients with VO heve neurologic symptom s. The risk ofpe ralyais mey be high· er in the older patient, in cervical VO (vs. tboracic or lumbor). in tbose with DM or rbeumatoid orthritill, and in those with VOdue to S. aureu. "' . NeurolOgIC finding>lare UllCO mmOn initially, which mllY deley tbe diagnosis"'. Sensory inval"vement is less COm· mon than motor and long-tract Signs because compression is primarily anterior. SOURCE OF INFECTION Sou~s of spontaneous VO: UTI (the mos~ oommon ), respiratory trnc~, so ft.ti""ues (e.g. skin boils , IV drug abuse ... ), dental 110r&, blunt tralUl"la to th~ spine. In 37%of ceses a ""u~ is never identified "" Potentie l routesofspr~ad: arterial , spinal epidural ,..,nous plexus (Bateon·s plexus). or by direct extension (e.g. foDowing surgery). Spontaneous spondylod isciti1 in adult.. usually involves bone primarily. and once infection i8 esteb1iahed in the subchondral space. spread ill to the adjacent disc and thence to the adja~ent VB"'. EVALI.JATION Imaging A comparison of the sensitivi. ties and specificities of various im· aging modalities is shown in Tabk Table 12-18 Accuracy of various imag ing modalities for venebfal osteomyelitis'''' , 12·18. Pia ;" .. -ray: <:hangM !.:Ike from 2-8 weeks from the onset of in· fection to develop. Earliest changes are loss of cortical endplate margins and loss of disc spece height. Bone &can with technet.ilUl"l ~m.HOP: may be positive within I· 2. days of infection. False positive increesed uptake way be due to degenerative changea, recent su rgery or fracture. MRI: TIWI sbowsoonO llent low signal from the vertebral bodies and intervertebral disc space. T2W1 shows inCTe8sed intenai~y from the involved VB and disc space' .... Laboratories WBC: elevated in only ....3$%{rnrely:> 12,OO()), 8$$OCiated with poor prognosis. ESR: elevated;n almost all. Usually:> 40 mmlhr. Mean: 85. CRP: may be mOre sens itive than ESR, and mey tend to normalize !DOre quickly with appropriate treatment''''. 12. Infections NEUROSURGERY Cultureslbiopsy Culture: blood (positive in ~ 50%), urine and any focal s uppurative process. An att.empt atdirectculture &vm the invGlved site shGuld be made. ld .. aHy. cultures shGuld be dGn .. before antibiolics are st&rted. iffeasible, percutao<'Ous biopsy with CTor fluGroscopic guidance as required is optima l. The yield of needle biopsy cultures ranges from 60·90%. Open biGPsy is more seJl.'litiv... but morbidity is higher. CUllur" sbould in· clude: aerobic and anaerobic. fungal and 'l'B. Organisml:l 1. as in SEA, the !:lost commGn causative organism is Stcphylocoeeus 2. E. coli is a d.l.9t8llt aeeond aureU8 3. organi6ms 8!lSQ("iate<i with SGme primary infection sites"': A. rv drug abusers: p ... ",damtJna& aeruginOS<J i . COmmOn B. urinory tr" ct Infect.IGna: E. coli & Prot~(J.8 $PP. are common C. reapira tory tract ;nfecl ians: Strtptocoeeu. pMum"ni".. D. alcohol abuse: Klebs~lIa p""umonia~ E. endocardi tia: I. acu i.e endocarditia: Staph. au",,,. 2. subacute endocarditis: StrtptOCfJC("$ . pp. 4 . unusual organi~ms include: nocardia (S« pQJJe 223) 5. pyugenic infections are uw:I.x polymicrobial « 2.5%) 'l'ubereulous vertebral osteomyelili" AKA tuberculGUS spondylitis, AKA Pott'a d ia"u". More common in third world countries. Is usually symptomntic for many month s. Us ually arrect.s more than one level. The most commGn levels involved are the lower thoracic and upper lumbar levels. Has a predilection for the venebra( body, sparing the pojIterior elements. Psoas abscess II com· mon (the psoas major muscle attaches to t he bGdiea and intervenebral discs from '1'12LS). Sclerosisofthe involved vertebral body may occur. Definitive diagnosis requires the identi6cation of acid fast bacilli On culture Or Gram stain of biopsy Olaterial (may be done percu!.8neou$lyl. Neurologic de6cit develops in 10-47% of patien ts''', and may be due to medullary and radicular innammation in mostCIISes . The infection i~lfrarely extends i.nto the spi· nal canal"', however, epidu ral granulation tissue or fibrollis Or a kyphotic bony deformity may cause cord wmpression ''I. The rule of surgical debridement and fu sion witb TB is ~ontroversial, and good results may be obtained with either medical treatment or surgery. Surgery may be mOre appropriate when de6nite cord oompreslliGn iii documented or for complications such as abscess Gr sinus formatiGn ''''. TREATMENT 90% of cases can be managed non·su rgically with antibiotica and immobiliution. Characteristics of potential candidates for non ·s urgical treat· ment are li sted in Tablr 12·19. For de!.8ils, see T~tlrn!nt. page 242, for spinal epidural absceSli . The incidence of treatment failure is increased when parente ral antibiotica are given for < 4 weeks"'. Recommendations: rv antibiotics for at le .. t 6 w""ko (longer if ESR " ot "'''nnali~ing) folIl)wed by 6-8 weeka of 0191 agents''"'. 12.15.3. Table 12· 19 Candldalealo r nonsurgIcal treatment In pyogenic apontaneoua apondylodllcitta''"' orgaih$tll iclentifltd antOJtic 5efISitivi1y single cisc space invoIvernl1f1t wiIh iii· lie YEo JIvoIvement minimal Of no ne<KoIogic delicil miJ'lmat« no $pi'Ial insIatlftv Oiscitis An uncommon primary infection o{the nucleus pu..lPOSU8 with ~ndary involvement of cal1,ilaginous endplate and vertebral body (VB) . May occur following a number of procedures (see EpidAlmiology, page 249) Or may be "spontaneous' (the latter being mare common). Often a benign. self-limited disease. Similar to vertebral osteomyelitis, el<cept osteomyeliti s primarily involves the VB and spreads secondarily to the disc space. Features a nd manage ..... ent commGn to spon!.8nwus and pG$toperative discitis are dia· cussed in the "gene.a.l" section below, followed by sect ions describing chancte riaties unique to each (see SfKJII/OdtM/J.$ discW , . page 248 or Pos!"ptlroU,", diuW$ on page 249). NEUROSURGERY 12. Infections us "1&ny tadiogrephk fe~~ures o{gpOlldylodi.dtia lind Ulmar (met.astati"ond primary) are ,imihu·. but t umors tareJy invoJvetlle dill: !<pIce ..... hereos mOil infec_ tions ""gill in. Dr beror~ too Jong. i"volvlI the ru"" SI""'e. OISCfTlS IN GENERAL CUNICAL ). lympt.onl8: A. pain Ithe "rimary symptom) I. local pain. moderate t.o (.,·ere. nacerbated by vlrtu9.lly any motion of the spine. U&U~\ly w..1I1ooaliz.ed t.o th"I"Vi!) of involvement 2. radiating to 8bdomenlj,. hip. leg. scrolu.m, groin , o. perineum a. radicular symptoma: in SOO;;'... t.o 93'ii,w depel'lding on till! .erieli B. fever and chill, 1<I<IIy 30-50'iC.:sre febrila l 2. ligna: A. temlaroea B. paravertebral muscle 8p88m C. limitati()fl oflllovement RAOIOGAAPHIC EVALUATION A characterial;" IlIdiograpbic finding tbat helps diBtmgtU yh infertioo fronl n"~t.a· Italic dileaS4! is that destruction ofthe diK sps«!! is tlJghly suggeltive ofinfeclio n, wher&lUI in generaJ. 1lIml!r d~ IWl. cross the dio<: !~~ (911 Diff~f'Ulliati~ (oc/'mr, page 939). PlAIN X-RAYS U$ually nOl helpful for early diagnosi•. Sequence of chang>!Kon plain film$: • earUelILchange9: int.enpe.ce na rrowing wIth lOme dtmjneraliu~jon of tile VB. NQt Been < 2·4 .... k$ following onBet ofcllnil....1 symptoITt$, nOr later than 8 ""lui sdertlllia (eburnation) ofadjaeent cortical margin! wilh in.rea-' den";ty oradja. cent areM of VB repTl!5enting new bone fOml8tion, slarling"·12 week.9 following onset or clime.1 symptoms irregulari ty oflhe IIdja<ent ven.ebnll endplate~ .... ith Ippong of the pediclu (ea · ~ept for tuben:uloail;. which may involve the pedicle:aJ in 50'10 O f CBH~ . the infe:tion remaiof confined to the di.~ Spacf. in the other 50% it IpreadB to adjacent VB a late finding is wideni llg (ballooning) of the disc ipace with lrQ6ion of the VB dn:umfenmtial bone (ormation ma.y Iud to f!Jruberant ipu r formation between VBI 6·8 monLhs into COII",e ofillnes. aponLaneoUll fiulon ofllle VB moy oc<"Ur MRI Demon.trate$ involvem.mt ofdise 8paCi! ond ofve •. M"RI ""n RIO I"'nlvertebrnl or epidural spinal abscelll but i8 poor in aneuing bony flllion. All aellliil ive II. radionudide bone KIln. Characteri~1.ie 6.ttdiog: dec-reul'd Bignal from the di!!C ancl ldjlll:el\~portiOf1 of VBH on T1Wl . and lntrelllled si,gnal !\'lIm these ~tnJcture. on T2W!_Charilctenstk nnd_ ing"l mayoctur 3--5 day! aft.ero:lut oflympluma. MRI al.., rul".-outothercaus"'" ofpo!!t0" pain lepidural ab8tess, recurnmtiruidua.J di.K herniation ... !, The u-fad ofgpdolinium enhancement ahow" in Tobie Table 12·211 ~dollnium en hanoen"lenll n di,enl, 12·20 i.strongly Buggestlve of L.ocalioll or gadolinium NumNr (01.1 or NUlIlber (out 01 di$citi. (lome aaymptomalic InhBI>te"","" 1 ~Ilenlt with 15 pBlltI1lt patients may ha~e some of wUhoul dlKIIls) dlaellla) thell@finding1l,buttheyrarely ver!eblalbone millfOW 7 h.veaIlP". CT ,. • "'" , 7 , 7 MlIY a1lo RIO paraverteI>ral or epidurol'P1nolabacen. and il better for aueS8inll bony fllaion . With the addition of wllter IOlublli tntrath eocel enn trast. ~Lao a9~~ iJle spinol tanal for colnpromi.se. pOI$IefIOI" aMU£us hbrosus 12 rnfection9 " NEUROSURGeRY Dia gnos tic c rite ria ThrH bas.icd\lwges on CT'· Of all 3 are present, pathognaJTlOllic for discitis; ifonly the lot 2 are present , then only 87% specific for discit'.): 1. end plate fragmentation 2, paravertebral soft-tissue _e ll ing with oblituatioll of fat planes 3. paravertebral a~88 SPINE POL YTOMOGRAMS For P<l'IUlperative d,,,dtis (P OD): performed through level of previous discecUlmy. Otherwise, eent.er tom0I.'Tam S on painfulleve!. SCINTIGRAMS Very sensitive for disciti. and vertebral 05teomyelitia (85% sensitivity), but may be negative in up t(I 85% of patients with Pott's disease. UI5e$ either tedl.lletium·99 (abnor· mal as early as 7 days following onset of clinical symptoms) or gallium-67 (abnormal within 14 days). A positive scan shows focal increased uptake in a<ijaeent elldplat.e., aod may be differentiated from osteomyeli tis whicb will involve ooly one end plate. A positive 8caO is not specific for io:lfection, and may also occur with neoplasms. fractm-es. and de· gene rative changes. L ABORATORY STUDIES ES R. [n III1n .immuoocomprom.ised patients, ESR will be elevated in nlmOB! all cases with an average of6O mmlhr (although it ean rarely o«ur. a normal ESR should call tbe diagnosis into ques t ion!. Interpreting ESa may be more problematic in post-<>p discitis (su ~ 249). ESR rna)' be useful to follow as an indicator of response to treatment. C r ea ct;ve protein : Su C·rea.ctilJf' prolein on page 249. is o~n nonna!. and rarely is elevated above 12.000. WBC : Peripher al PPD: Applied to help R'O POtt'l disease (see Tubflrculmu; wr1~bral OIloomyeliti$:, page 245). may be negative in 14% of casea'''. C ultu",s: An attempt t hould be made to obtaill direct cult urn from the involved disc ~pace. These may be obtained per<:utaneously with CT or otber radiographic guidanCf! (reported up to 60'1> positive culture rate; if available, s lIudeotome provide.. a higher yield than e.g. Craig needle biopsy), or from intra-operative speci men (NB: surgery for open biopSy alone is usually not indicated). Staining for TB must be done in all cases. Blood cultures may be positive in. 50'1> or cases. alld are helpful in guidillg choice ofantimierobialageDt ",hOlD positive. wac PATHOGENS Staphylococcus aUl"('ur is the most common organism when direet cultures are obtained, followed by S . orbu8 and S . epid.ermidis (S. epidermidit.a the most common pathogen in PODJ. Gram negative organisnu may also be found, illduding E. coli and Proteua species. Enteric nora ;D POSl-OP disc itis may due to undetec:ted brP.acb of the an· terior lon/litudi.nal li~ment with bowel ~ rforat'on . PHuOOm<>fl(U Ot rugillOlO may be more common in IV druil abusers. H . flu is common in juvenile diadtis c,,,,, below). Tuber<:uloU8 spondyliti s (Pott's disease) may al80 occ ur. TREATMENT Outcome;s generally good, and antibiolics l.Ogether with immobiliut ion are ade. quate treatment in . 75% of uses. Oc.:asionslly su rgery i. required. Also see Mar.agt · menl, page 250 under postoperative disciti . for other aspects of management. IMMOB!LlZA TiON Probably dOl'/! not sITed filial ou\come, but generally aITorcls earlier pain relief, and may allow return to activity at an earlier time. Most patienta are started on strict bed rest, alld are fitted for a plaatic-typoe body jacket in which they are allowed toambulate, and in which they remain tor 6·8 weeks on NEUROSURGERY 12. Infections '" the average. Alternative fomm IIf ;mrnllblhJat,on indUlle ~pica COlit (provide. better immobilization) and a ooraet·type b".~. ANTIBIOTICS CUmlnt thinking is that mllflt p8tienu should receive antibilltitll. gu.ided by the reo s uIts ofth'" direct eultures ""hln positive. In the 4 0-5~ ofcaaes ""b ~re no orgllnilnn is 'solated. i;)roll.d spo:ctrum ontiblntic511.hould be uaed. Two alternat ive tn8tment 1'111115 suggested: 1. treat with IV II.ntibiotie~ for ao .. rbitrary-period Of time. Ilsually . 4·6 w~ks. f.,l_ lowed with 0",1 antibi~tics for an additional 4.6 weeks 2. treat with IV antibioti~1 uuti! the ESR nnnn9!itU, then change 10 PO SURGERY Reqlli~ in only _ 25~ "r casea. Oebrideme,a lJIoy ~ dnn .. throllgh the previolls ill.mlnedomy sit... Ikwever. if lilere has be.>:n significant bone loll!! and Inatability, then an anterior d~tomy and (uII.10n through II retroperitoneal apPl"'IIAI:h !My be rnquired. SUrg<'1)" is reserved for; t .Iit\Ultion~ wh e~the diagnosil iauncert.Bin. especially when neoplasm is _ s trong con~ide'8tion (CT gu.idt><i n""'\l" bi"P$y may hell! he",) 2. dec<lmpress(nn nf neural.tNctures. upeci.lly with associated .pinAl epidll ral ab· $~a IIr compression by re~ctivl'-g-rjHlulot; on tlUlle. A8<:ending numbne~$, ...... ekIlea, or OlUn of neuTogenie blodder herald cauda equina I)'lKirome 3. dra;n~ge of a55(lciated abllC"'I&, upecially septat.e<!ab.ceues Wat lIIig11.~ be recs(. titl"llnt to CT KUided percu(aMOlls needling 4. raNlly, to fuse an Ill\$table spine. PoorlY 'endor&ed (n tbe face of active infection. el~i~lIy since. mllSt 10 on to BPIlnl.alle<>Us fusinn Approac hes anterior diacectomy and cOl"('(!Ctomy remov.. the offend ing infected lisliue. wilh using Wile crf!4lt (or. in th thorade . et:ion. /I p<l5terolll~ero( approacb. with the &tNI mad& f,om the re&e<:wd rib if large enougb) 2. PQllerio. laminectomy lDay be odequllte for emel"\lt!nl decompress,on. bu~ d""" nOlllll(lW "<!<leIS to the aite of palh(llogy in Oilrvical or thorack regioDs I. Ht.ruljt"f8n. SPONTANEOUS DLSCmS No I1!C<'nt history of lIu .gery or in:ltrumentatlon. Higher incidence of n~urologie def· icits and I'IIdieu1op>lthy r.h,n with pot;toperal;ve disciti, (POOl. 'two di..!!tinct type!!: I, j llyen ile: more romll'OO : age ll~uulJy "" 20 yrs ("~ belQ1~ ) :l. adult: uSllally OCCUMI in aUlCeptible p3l;enl.a (diabetic •• IV dl:Ug abusen) JUVENILE D/scmS Aile lIIuully"" 20}ln, with p peak between 2·3 yeal1l. Probably due to lbe preaenee nfprimordial [.....ting arteri~ lhal nourish I.he nucleua puJpo, us lind which involuu al _ 20-30 Y'" age. Lwnhpr . pin .. i. <no ... ""<nmcnly i"",,/ve<l Ihan th"".,;c<I.oerviCIII. Cnm· WIlO prese.otation; . eful8 l towalkorlltand pro~(ng to ",rugl to sitUl youug-children . Back pain is mosl. CtllDmOO in children :> 9 )'rs ace Low grade- fever may\)Ol presenL ESR Is uSllally 2·3 II nonnal . WBC i3 ~mel;mes elevated. H. fI .. Is a lJIore Ctlmmonly IM!f!n pathol!"1m in W. grllUp . In mo.gt tMef, there is c:wnple1.e resolu!.ioCi in 9·22 w~kP.with<lu l re<:urrenoe.in lon,tenn follow·up sludie6' '''''~''. Surgery is ",served for the rare ease ~hat progresses in apite of an tibiotics. f<lr IIpir\81 in.tability. 0. for recu.rent ""Be•• MOtit authors reserve .ntihio:,.:>; fur patlent.!l with'''' '· -'' ~ L pw;il ive clli lures (blood cultllres or bioplycullUT"Sl 2. elevaW<! WBC oount. IlOn$titutiollll] ~ynlptom •• Or hIgh feye r 3. poarresp<'lMe to re$t Or immobllir.a tion ( . neu,..,logie ~quelae (~el)" f'II",' Antibiotic. should be. given flIT a toblllf4·6 weeks. Start with rv ant lbiotiC$. and when clinical symptom) Improve convert to PO for the remainder of therapy. u. 1.2. lofectioll8 NEUROSURGER Y POSTOPER ATIVE DISCITlS Unless otherwise .peeified, the following identified retrospectively at Duke''''. i~ based on a "eries of27 p<.l!I1.-<,Ip cues EPIDEMIOt..OGY Indden"" after IUr:>bar di~lOmy' '': 0.2-4% (realistic utimate iR probably at the lower end ofthia range ). May lllao OCCur after l.P. myelogram. tervical lamineclOmy, lumbar sympathectomy, cilemonucleolysis'''. discography (U t paIJe 296). Fusions lind othe r proOl!durea. Very rare after ACDF. Risk factors include: advall(»d age. obe~i ty, immu nosuppression. syatemic infection at the time oflurgery. PA THQPHYSIOLOGY There is Klme controversy as to whether 80me cases of p<.l!It-op di""iti, ~ not infectious'''. an autoimmune pr0ces8 ha" been implicated in some of these so-called "avascular" Or "chemicsl" or "aseptic' diseilis case$. These cases are less OOmmon than infectious ones. ESR and CRP abnormalities may be Ie$! proMunud in th""'" patients, and biopsy of the disc spa"" fail. to gnow organism, or show signs of infection (infiltrat'!s of Iymphocyteto or PMNS) on miCTQ!!OOpy'''. In septic ellSes, various mechanisms for infection have been propo6ed: diTect inocu· lotion at the time of,urgery , infection following aseptic necror;:is of disc material.. CUNICAL 1. int'!rvai from ope ration to onset of symptoms: 3 days to 8 mos (most commonly 1· 4 wks post-op. usually al\.er an initisl period of pain relief and ,ecO"ery from SW" gery). 80% present by 3 wks 2. symptoms, A. moderate to (usually) severe back pain at the site of operation was the most common symptom. uacerbated by virtually any motion of the spine. often accompanied by paras pinal muacle SpDBmB. Back pain is uaually out of proportion to the findings B. fever (> 3S· C in 9 patients: literature reports only 30-50% are febrile) and chill s C. pain radiating t(l hip, leg, scrotum, gnoin, abdomtn Or perineum (t1"\.le sciatica is uncommon) 3. signs: all had para"ertebral muscle !pasm and limited range of motion of the spine. 13 were virtually immobiliud by pain. Poiut tendemes>lover infected spine occurred in 9, upressible pus in 2 (literature repor\.8 0-8%). No new neurologic deficits were no~ . Only 10-12% have MSociated wound in fection '" 4. lab findings: ES.R: 261'27 had ESR > 20 mmlhr (60 .. ave .: > 40 in 17 pa tients; > 100 in 5 patients; the si ngle patient -: 20 was On steroids). ESR ;ncrf!S/!ea .. fter un· oomplicated discectomy. P':'alOng at 2-5 days, and can fluctuate for 3-6 w~k.oi bef\lre normalizing'· '. An elevated ESR that never decreases after surgery i. a strong indicat(lr of discitUi C-reactive protein (C RP)'"': aD acute phase prot~in synthesized by hepato· cyteg that may be a mOre specific indieatorofpos1.-<,lp infection than ESR because of rapid decompoSnion. [n the absence of disci tis, CRP peak.oi - 2-3 days pos1.-<,lp (to 46 :t 21 mgIL after lumbar microdisceet(lmy, 92:t 47 mgll. after conventional lumbar discectomy. 70:t 23 mgIL after anterior lumbar fusion. and 173:t 39 O1gIL a!\ar PUF), and return. to normal values of -: 10 mgIL (" I mgldlJ between 5·14 days post op lYJX;:; ele"ated > 10,000 in only 8127 (Iit'! ratu'e: 18-30%) RADIOGRAPHIC EVALUATION Also, see Rodiogrcphic ellOluol«m, page 246 under Discill, in general . In postoperative discitis (POD), the average time from surgery to changes on plai n x-ray is 3 mos (range: 1·8 mosl. Changes are detectable earlier on polytomograms l3 wks to 2 mos) . "verage time from first chaoge t(lspinal fusion : 2 yrs . NEUROSURGERY 12. Infections '" PATHOGENS 5« T".b/, 12.21 . Most st ... din report S. ".... . Table 12·:ZI Culture rll. ult. Ole most commonl)' identified organism. l""OUnling for - 6O'i\o ol"positiw. cultU~I''', fol. lowed b)'other'Ulph .pecies. Also reported : Gram· .,.,g. tiV(! orgln;'m, (indudini £. ~j), S!"P uM. daM. St"pt(}'tOCC'" .peeiu anatrob.., TB Ind fun· ",ul I I •• Blood cultur.. were. potitiV(! in 2 of6 (boOl S. 0."",,,,). For culture tec:hniqllH, IN /xIQW. MANAGEMENT L admitting I.be (in .ddition to routine): ESR, C·rll.ctivlI pratei n, 2. esc. blood c... l· turn 1n.lguics. mutele re lUll nt.l (e.g. dinepam (V.llum(1J) 10 rna PO TID) 3. 'ntibioti~ IV IllItibiotia for Hi wks(or until ESRdecrealle,l, then PO for 1·6 mG$(typicsll)' 6 weeks) most , tart with . nti .$laphyloeocc.lantibiotic. (initisl ",mpiric th"'rapy: vanoomycin .. PO rif.mpinhnd I broed .pectrum antibiatk(e.g. ""box), mod· ifY bal<!d on 8Inativitiu i(poII;t;ve (ultuns.rt obUlined 4 . .ctivity rntriction (one. 0( Ole. fallowing used. usually untilsignHlcant pain reHeO: . plnal immobilintion wiOl s pia c.1t ar plastic body jacket , trict bed rat activi ty with con.et 5. SOlllllluthGn recomlllend steroid therapy initially to ..~ilt pain relief 6. cuitu,n: performed if radiographlsuspicious. usu,lIy performed utili~ing percu· u,neou. CT-ruided tecilnique A. , ilel 1. disc aJpirllion if evidence ofdisc space involvement 2. ne«lling ofparaspinal m.ss if pUllent S. send cultures for the following: 1. 7. sUlins I . Gram stain b. fung.1 sUin c. AFBsuin 2 . t;ulture I. routine culturn: aerobic and anaerobic b. fungal culture: OIi, is not only helpful for fungu.!, but .ince thue cultures are kept lOr loncer period and '"Y growth that occur. will be furth~r charaeterized, fll.8tidious or indolent bacterial or· ganisms may sometinwl be identified c. TB culture 3 pati~nt.l in Duk~ series und",rwent anterior discectomy and (u.ian s ne.r unsue· ~lJIrul medical therapy ""'COM' 9 p8tienb developed bon;, bridging in 12·18 rooa; 10 d.vltloped bony r",ion in 18-24 ~. All potienb eventuaUy becnrnoe pain freoe (or Iignil\cantly ImprOVe). Thi. i. not the in aU .erin, where lKlIlle n!port 6O'ltl were pain free It FlU. IIlhe ... found ,light welt pain in mo.t patient.l, and yetothe ... report Iflvereduooic LaPin 75'.4". 67-88'" return to OIelr previa", work. and 12·2':;'" received diaability pltllliGn; 01_ n ... mbers art .imi· lar to the outcome fram dilc ':.II"Iery in general. Na difference io outcomoe wU found for the variGul activit)' reltrictionl.pecined, 1\)1 • .:.opt for earlier plin relief with first two typt1i lilted .t.ov.. taM 12. Infections NEUROSURGERY 12.16. ,. References ,,"i.., A II. A""mlC.w;., prop!lyw.i, ...w,...,..", , r..&1 J ,. K.",,,,II. of Mod lU, 11,9·31. 1986. F.."", PT. W'UO>Jo;WI>,Un, C.M<\..o., .. 11. l.: Poo_ .. "',.,. of .. r<;II; •. mrll>::;I Ilt!, ..... «f.<O\," '.'0 "".". tni.,;'..." . "".' OS. 'ltty II: 141.7 . 1913. OS.CI ...... OC.llu,u j P. "'Q/' «~Io>P<>'in. ~ mphrlOC<l<.oI "«UJ ". ,," ." y)" £1><_ M I. e:.m-.. OIl S/>ek<..,.,. A." aI.' PIi, ""'I)' "00." F"'." " I" ... ", "",,,.1 _04 ,.f"",on .. JAIII ... 263: 961-6. '. ,. • ,. •• •. ,m 11.,,«, F <l: Eff..:.<y of P"'P>yl ... ,• ...,lIto.. ,,,, for ",".,,,,amy: A ......· .....1 ... . Noo' ...... '1' JS: ..;.0·92.1994. YOU", R F. Lo"' .. rP M: "";"00'" prop/Iyl..i, r... pcc .. ntion of Il0l1''''''''''''' .... m",.,,,aI io fecoLon. J N _U'Ii16: J()]·S . In1, B.t .... l. T_If.S.S>k<I!ariou p, "4/' ""''''''U· mali< meni","i" B..... iolQu. h)'<lroc<phalu,. ond <.""om< . N.... ........., JS: <n·l. IW<. Et;.m.' M S M. Foy I' M: _ ·".....,11"' OFf,,,u· 1... 111< co .. foe .... ",at ",poir. II, J N",,_'lI~ ' "",Lope..".. .1Hl. 1990. u ..... w ' C... t.<><p; .... nu", " , i _. in,_ lie'" i.~ •. C~. N..."",", ,12: lll·Sl. 1966. Horwi .. N H. I.... yC S: Com...." .. HoI .. ,I. " ." """ ......... " ....;"li""_ 1Io<"'rioIot.7. hydroctpt.ol., • .,.j <NI<QmI: . _ ..... , lS: all>. 19'JoO, V",.. R' Ce"l>A>Ito;1!Il n.i<l.hu .. ,nf.<1i"n., A .i<w, Pt<I .. " l nlo<' Di> o. Ill·'. 1985 A""", ... i lot. lI.i<Mn<l; A. C. .. t>ro>po ..1 nulll ,hu .. ,.f........ i. <hi!cl"n, A "1>11 of Ih< !O ........ •'''~ be,...".., tl'II: "iolOU"I," hydroc<""' .... 'S< .. 1M: ,im< of"'un' »I>o< ....... ond ",1«""" Child. N.",S)'" l. 106-9. J9I7. M,Lon< O. C.~"",w"'i D. ~ .. mo"<1i A," 41.. Ce.· uoJ "''''''''' .~ ... '" i........ ... O.. i,;n.a {"'lOt i. lIIe '00<1101<"1« of '~,Id ... wi,h ntydom,",ntoe<l<. P..Ji.,C'b 10, 331-42, 1~ll . A"",bor A L. Weillns' .. I: lnl.." k hyclroc:eph. ,10 •. L.ooI ·....., ="1" of '.'1""1, ....",,. Cbllcb 8 ..", II: 117·2\1. 19801. O'Brien M. P..... A. 0.", B: Iot.n" .... ", of "" ... """ ... ohu", 'nfec:' ........ CblIMB .. I.~: JOot·9. ... " ... ". ,m Woi<JS L. Md .....inR L: Shun'· .. ~odl_ ulonep'OI'''''' N.."""" ... y 1: 1.j6..~> '97, s."""" of PM;',,,,, N.u"""",oty "I<too: A.....,"... "'''''''''ion ofNewol"""ol S........... (<<I,) P.dl... ,10 "'''''*''&<1')' , I.. «1 .. 0 _ "'" Sua",," , N.w York.l9fl.. Fra .... p T, M<:l.ouno II L. T,....,.,.."., ofCSf .... 1II ,.f_ ..... ""'" ;"".","'" pl., .... , ar."l;Mo"" , .... py. J r<.... _" 00: llO-OO. 191". I ...... H~. W.... ~l W. Wil .... II D,""'': .....!p«• "" .. ndomi...:! _~ c( ,hefoP1 In <."'IH<>Sj> .... noid """III ,"fecoOon. _ ' l t T y 7: 0S9.f>l. 1910. s.: ..boI: P. Co<tnn. 0 0, K.,,10 J R W: The ,,~ . nif"' ...... oIl1ooc"riolo, ... lIy poII~i" .... riallo~..i"'..w "".., _""'" i.1h< _""" 01 Olher • itn. or.huo, "'f«,ion. J /'I' ''''''''''IlO. 611·1J. ,~. W. ". n. St-d"".n A.O, ... "'~ MS .SoIomon M p, ., 0/, M"'lemen, of inf«l«Ibm;no<"'my""",lIIIs. N"""""pry lS' )(11·9, 199'. Ku", A.S... I<,O 1, /..enI.atdt R. I'<,oof"'OIl .. ""'. ~nn"l0 Ifthoc< ,he 01 ......,,,,,,1. w""tIII •• 1"", ... ond """',n "",p;"lito"... N En" J M«I J14' l109-U. J9\lI5, Ootn.."" P 0.<:>"''''' 11. H>l'InJ: Pri""'J'lo<co .. or ,.r"""", .p, .... 1""",till •. N... , ........., 16: 7<l1. 9,'990. NeUROSURGERY in<""'""" 'W, «_ . ..-..«>n<..,.. ....I9Il. N.".. D"._..",OO, R""' .... dI: ... loplnl "" "",,,,,,,1>I>«< .. . J 010/ 1(1.1 : "6&-n.I990. HoU;" S ". H.y .... i H.O ..... S W: 1"'''''QlliO, .b""'... of ocIo"oscni< Gri,i • . On! SU'I ll, 177· 91.1961 • Wittwm F II. Nolml 0 K. McGoI!&nn K M. 8";. .boc:eso; A .... «ImPli,"ion 01 bolo .'4<. A,,~ "",.M..J IIlf>o.hit 7l: 49()..1, I~l . On",,,",, I A. IIlro<hb<rJ II, 11,,"..... 11 K: 9'hnT,,· 1Ie...... th~I""""I<..."., .... ' ... kol:ooyte """ , "",pilI "'" C·""" .. p<O!<i" koc" ,n ,.. d,rr.. • ell'IOI di,,_i,oltnin .1»«"" •. J N.u'''"P'I77. JJl·6.199:I. F,;':t. p. No]"", P 8 : 8ro/0 oil",.... In u.',aI " ..""'. 'j'>Um i" f.. tiomdi .......nd ,htnPI. R"", K L.(..J J. MIIWI DoH .,.,... ... York , 1991: ppoOil.91. B,,,, R H.&."..... 0 R: Ctini<oI ...",.oI"hu",". b<..n . bo« ......... iol CT of, ... «W .... iofu ..... J _ ....... , S9:972-3'1. 1911 . H..... """ II S. B,..dI: A I. OsIaIw>itn 1 L: lou"",,· n'ol . u"""' .. '~4ilUl<. J A JI.I" 111: I~2- 7. 1911 . Block p. C .. ybo 1 J R. Chu>o<too: P: "'... "''''''' of tn," .1>«<.. b,- .~".m"atl~ adm'oi ..<RO<l ",,'Ola· k., J N....""'. aJl. l'O.l-g. 1'173. R""""'um 1>1 L.lloff I T.No<man O."QI.: " .... ope"';,.. _ _ OJ ... "' ..... _ . "' ....... «1 ",,,,·n.k pOI ....... J 1'1 . ......... S2, 11l·~. ' 910. R.dl< A. Zerbi D. :z..cc...11o M. Of 1'1.: B",...',," .1»«.. 1»11, b,N "'""'~'i<",lI : 7.2-6. 1991 . ui<l..,." S M.O<;"', fH.Oli.; A: In"' .... n<~I .. """." 01. "",,,len' bnin . _ , C..... pon 10...",.......,)6: 11!l-9l. 199$. S'opbono' S: s.~ _""'" ofb .. ,,, .1»«... N.............. ' n: 724-)(1. I~ . Hotl""' .. O. V;il<"",,, J..Q. I.cbl""" II : """m'" . _: A ... ~.Il, u_1< 1<.... . Appi N""""" YIlot~ 16&-71.J917. 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""oIf I.C"~o.G . •.,ill._ Pou,bIe "''''''' '" PO""" '~'",,"''''' orc.... .r.kI'·I""o~d"" .... N ~J U ... 2\IO-691·].1'lJ4. """"",IIi C. S.. ",ri«I J, II..",,,,,,,,,, G,,, III" o..~ of ><code ...1p<r>On·lO- p<non ".."m"""" ofc",""r.kI1·'III;Obdil.eM< by, ....", 1.0_ L 47!·9.19n F,odki. J E. L B. Mill. J L ", <>/, c ....,r.1d1·Jombd;_ in ,,""ilO<)' JfO"'Ih hot· moo>< ",cip"'" in Ih< U•.;!«I St. ... . JAMA 26~ : ScfIont>o,,,,, 1l8O-4. 1991 . " n. 1\0,,, .. " 190-). 1931 . MUI'Jli. A J.CooO";. W I. AmO:dJ J<. " .. ,., 1.uoo, .. ~"I'nf<<<kmo in ><1,1" and <M"r<tI A.. h Ot.I..y . ~ H.... N «k s.. , ~ ,, ~, 14;4 _~ . 1989. COIf,. S R. M I . Tnu,lI 1.<101.' S.b<I ...1 ........ ""lO<ill<d ""~ ~'IOi'i.'''''''_ J lion. J.la 'S''1I71)'''' 1l31..r.l.1981 . W'i,brt. ~ S.t>ci."le""'r<""· Clio",,1 ooo! ..... pu«d ... ...,p>p/oi< <'(In<1 .. ;on,. Ar<lt OJ. oW1-:iOO. I93<i. Mou"" H W.Ito"jI, R A P.E""'''''''A. "./: N.",· ' ''1",.1 of •• ~",I .mpyema: C.,., IepOll . J 101 ... , .",,'1: 6l : 121·)0. I98S. Wilk,n' R H. R.np<!WY S 5.1.,1> ). N..".· ,"1'Xfry . Mc(;""'·Hill . N<w Yor'r:.19lI.l . N<illEW. LIIl<,. R.Torn • .,k T A.".,: M'&fI<Ii< ,.,.,. ..... imoC'''''''' lOII\OVIp/ly ", • ..,i., of II<rpoo .. mpk. ''''pbl;'i •• J ro-.., ..... ...... 61 ' " "".ral.",· ~. " ". n."" • Itooenl><'1 R N. WII;", C L. S...... P, " .'.' """"'" '_;..luo><Ili"l"....... .,.j"' ..... «>o>U .. ;· n_ ffOM ""10",, "i'h<lO<"""' ........ C",,,,.f''''.Jok<>b di..- AM N...... ' loU·7. lm, B....... P. Cit>bl C I. Am). J L. ,,~I.. Cl>emk,' <Ii,. inl«,..", of C", ... foktt·l.kob .im. N EotiI J ,'.1'" J06' '179-12. 1911. /I..,..., P.C.. "",. f,e.... i&"< P." 01" em",r.",,· lok",,<li...,.: CI,ok" ".1,.,;. 01. _>«"'i~ ,. · ...,0( 130 ",_,_,i<,lIy .. ';ford c,,,,. A". 591 -602. 1986 fink .... ""'" M,S.utlnt A. Zen-I.~. I , MR im.,· ~oIa.. 'itI.Id,-hl."'d ;","" . Rod"*'D 199. 79).1,1'196, Cern H·J, He.ke, H. e<rvos·s.",,,, I. C.. L<Zf.IdI·I ... .., di ....... Con'<I ...... of MRI ..d """,opot'l>:>loJic f,ndi." N•• ~ l'. 1481·1. .,...';.1, ....1>«,,'" N<."" w, .. " , " ". " W ". " " .. " ... ". o. Ono M. Wiltl•• S I. S<h .. , E. ,, 1'1.: D>o.-i. 01 e", ... f< Id,·. okobdi .. _ b,- ....... ",meo' ",Sloo ~olo "'N." """.".:I,h", « .. -<:on'tOl"";1 B, M«IJ )16: ,77-8, .I 'I9! . H"" ...... MC. M.""C R.A ..... ' DM . .,,,,_: ... I>,.".,..... 1pt".";n, in'" ..,"' ......pi .., noid 01 "..ito .. wim CI<,,,f""'-I.k.ob d;o,."" ro- E.JI J M... l" : Z79-U.I9$6, H. i<h C.llonOO)' II .CiI»>C l.tlQI.: Tbe 1. ·3-3 """tin in .... t>fO:Ip; .., o.id ... mut...- for ' ..........ibl •• ..,..,ph%pI>loi<> t'i E<tJtl J M«I ))S: 9'l4-JO. 19%. S,.;nhof!' II J. Rllc k.. S. H< .... ~ C. ".1_, At"" ..'" ond «lilbi"'Y of P<' od",.1t>rp wave tornp ... · to ,. C... "f.Id'-I...., d ... .. A.-.h ro-.., .... ' l' '6Z·6.19%. <It: Si!>-. R, p,,'moo I. Hll<lloy 0, ,,"' : Sin; k pi><>"'" emi ..... """'PO'''' ,,,,,,,,,,,,,,,y ,1\ lite .... "' ,f,· • .. ;.", of""w ....... C..... f.,d'·Jok"" d; ...... : Cow r<p:trt>. a , Mod J )16: '9l .... 1991 , Hill A f . S""envorth R I.J";o<' S ... D/' In .... 'I.· '''''' of ,&Ii ••" C"."I.I<I·/lkobdiou", .od a<1I<t <II ....... wi" ,.,...il ~<l9IY .. mpk •• I.. ..... ' 3Sl: Ill·9. 19II'J. Le.T R M. B........ " Of. R"",."',,,, M L: N• ...,.. 101",,1 m"if"", ,,,,,, 01111< O<Q.I,.,j i""'"'"""'ft· , .. ncr .roo:l ...... 1"105): E'I>«"""" UC5f "'" ,. ... w of ,II< I;, ....... . J N......... <& f>!. 47!-95 • I98S . .~i_ D M. r."hOlI M: ~"""I it """if.... • ''''''oIlflV 'Df<C'l "",_ A ~. ' n ~ 101«1 121: 769· SS.I994 , 11<" .. ) R, K. ..ovtl' B. Po>t J O.,,"'_ l'roI .... ,"" ","~;ro<. 1 ~""'''''''''''Iopo' ~ y ....,., ..... w;'" h•• ",,0 ; m"mnodcr";"'1 .;"" ;n f«lion: A ... "w of lite Ii".."". wi'~ • «pori of ..,,_ ""' •. A... 10' l<,oM«I107' 71-17, 'W1. Cin.:~10 S F. ROK."'''''' M l; U.. of cr .... MR i""Ci .. ","i" ;,,,. i'" inn<t:Ooi.llnion>..., 10<10;. no< ,he """" for biopI.r ; .... 105 J r«U, ... tI,.". ""."form 1Itt"''' """" "" . n 710·2<. 1990. PO'''''', o..i.- R E. Cnffi n 0 5; l'roI"' .... m,,'olo<.o1 1e .... """'.ph.lopothy ;n ... ,05 J AMA J6.i: 7~·ll. '"' In. WC_H. II W A; M.,......,"" "'"o( . ...... ond I"r«,ooo •. e ... " ... p <& ll) (9); 110.1'193 . '~Nl I N<.,..... NEUROSURGERY ". o.mtle'L M .J<."'. _ ",/w"",~_" f"O,~,·,i 1.lfoc<>! '"'_~""""~1 ~. M a ndtll, d o ",,", aod ..." ... " po-lfIOipl<s ond ptxti« or I. r<fll _ d.Is<......1.1 ...... 11 (; L wi 11<..." J E. 1«1'.1. O'Lu'th,I II...;.;.... _ . York .411> «Ii,..... «I., 199~. Vol ~'PI' loIIX)-6. Knopp !. B.Up"" . 8.S .... d..,.. '" \...,<>1: ""'" ,. ... .... ,...w ,"'..i..... hifOCOI l<oI<o<oc< pN.k>pOll>" C~ ' i<.1 and '''''OlI''p!'IOc 1< ...... ... . " "" .,01 )7- ).4.1·9. ,m . 8<"", ". 1'«0"'<)," J ~.M .');. L: PlOIoot<4 •• ,..", 1...:1 po~;.1 AIDS_i.ooed II'''!=''' muU ,f<I<&I N• ..,.._ ).8. 10000S. 1991 ~. Ell .. B. "'"""in I,Qok! R. nul., lJ ,.." "' .. i1 .... of ... ,00·''-'&1<6 p,_,i., muM.foa) ieul oo.· coopI1,IoPl'hy ",i,n combi_ ,.,i""",.i,al ""'rapy. Ufl<t' ISO. 1997. JoM. D R. T...... , M. f"<l<n",,,, 0 : in ,iI< .. ,.,,1 or "".I(lO)pl"WIi, byc.on<.""" in· "',h lhe "".... ;m",_(", .. "", .. N •. /'I En" J Mtd ll~: 1$69-92.19'1 ~. L.l.ho"S .... Hoo. E w .~ ..,,·7.. ""'rS ...... ~I' In .....,.,of, ... "...""I....--..yu.mbjl ..poM_ pollidum : 1"'9lic",.,... 1"..6,,,,,,,,,,, IN! ""........ A.n l ., Mtd 109: 8,'-6l. 19n. Ctn .... "'" one ... eon..", 11.""""""""" .. ..,..1".. di_inl IN! " ..,r", .ypIoili, ,. HI V.,.f«otd po. ,iem, MMWR 37· 60().2, I98S le.y It. M. ~ .... bIOOm S, L V· " '.ro,ldiolo@icr."".nl" n ... lDS, ....... "'wol 200 <.0"". AJ/'IR 7· &33-'1.1986 J..... ilIO. H.... IWO I R. t(.nn«ly C, "DI, "'Co q.iml i-mmoncder",,<o"y M.J1I<1i<: "' •. onaJICO pou.m. of ",.i •• n"""'·. ",.", .. oh polholot;ic """"I""", . Arob I'i.u .... 4}: 731-6. 1988. Sodl« M. N S.OO:lIwd II C: M• ..,".... of i.'".,,«bnI ",.... 1. p.';"n" ... ilb HIV, ... f<1'f<I'poc'i .. ,tlIdy .,un d"""uion of di_i<: pn>b" .... QJ:\Itd 91: 20'-".1993 . Scbwtilioof., B w. H....li.k J R.1'I><>o. 0 .... <1111" I'ri".,.,., 1.,,..,,,.i,1 o;S lymphoma: Mil. .... nile .. Ill .... AJI'<R 10. 12S-9. 1919. '00 s., Y T. fl«lo"'" J H. Ooo>i. II. L: ""mar)' « n...1 11"'f'1>ooN 10 "",,",m) i.. _ (10:. r><ie""'.y""'''''''' ... <li.",, 10"" po'hoioJ.,,1 .. "", ... ... _20; ~nI9~ . C; roq", p. S,.,."i.1 M. VIIO L. ".1,. Epr.tei.·!h,,."", OS ........ 1n.id from pot"n" .,',h AIOS-"Io,"" "-'""'1 ly""""",o 01 ,... "'.. ".. . Of."". 'y>l.m, Laa.<<l l-<2: ·l 98-'O I. 1991, 102. Cohn 1 .... Modi'" M C.C...... W. <lDI.: Ev. I... "o.ol.iI< pOl"y 01 """,i", ,........ , of •• ..,..:ocd ""o~",."n«pho' i'" in """' ... ..-i,h ,,,. ... qui"" immoO<Joler""ncy.y""""",.A",J Mt<! 16; Sll·J.I989. 10l, o..~ 1 E T, C,nNie 0 L. Dn-n"". J. Tho rol< 01 U<fOO<l<1k: ~1op'Y ,. ,.. ""OIl'''''''' or "IV·",',,· "" 100:.1 In•• k:,io,\I, """ ..... '1"' 1 J(k 8l}·9. ",u k""_ p"'Jcpo I ~I . " ,.'= fue,'" "'1"",""" "'''Of)' " ... Po""" " .,oolrorno, . ",no!; " "". "",,1[""">01"1> 0( 46: m.S.I990. C,.,.,. ..to""''"•• ,m. ,~ ,~ 1.<', II. M. R.....11 E. y""lbl..... M. .. DI_ Tho . m_ cocYof im., •. &u.(Ied .",_""i.ln.n biofrI1 i. ,..,.ro""",.lIy .,"'_"' ocqui..., ......... no<Io:r.. <ie"'y.y,..), ..... ~ ... " /'I..., ..." ..yJO. IJ16. 90.1991 . .'1icoloro ... . GoIo:<o M. )';0' 0. F., .. DI.; Comj>u"". Owl '00"001 ...... y """ ' .... OIOC"" br",. tuopoy; ' """. '''_p«>m,,<d MoJ ... IOS puicnt •. /'I •• ,.. <S: 261-n , 1997. Noc_ I I. s... ..... e: L,,,,,diseaJ<. Ad v I., MN 00: 69·117.1995. !'t"h... , ... R, 5,..", ... C: The "iad 01 ""'toIoJi<: ...,,".."' .... oI Ly.... d •..,.,.· M."''''~i1.'"''''1 ......nri ••• "" ,.""",1""••,,;.;.. i'i....-olOU l', ,<7·Sl. I98S. I'Khn<,'" R _Duray P. SK.,.· C.""'I .. " ..,.., 'YO- 01.'.... '" "'-._ ,.oded Sot,. ' ''. '00. '''' NEUROSURGERY Coo,,,,': ",cU"i<.,!"".",. " Ill . M".!:..... II; LA : Cu",", .. " .. oIloborao.ooy diolllO.... for Lymo di-. • . Am J Mod 98 ($-0"'). 1G-2S. 199}. I!' . Will« !I.SChe..... C. l'rr:ao:·M."'" V.".." 1." .. 1>"", I PfWLI<1'" 01'1"'<'('" .. uibod ... . I ""'p I>ctT<I.. ~ i. poo ......... ;,n Iymphocy'''' "",tunl'>'Id".I;li . ( !I"' n,.. nh ~ J I .. f, .. Ok 1}1: JOoI·ro . 1986. II}. H... il ......... u.l H.C",. 1>1 ... <>1, 1"""",.,,10""lin t\:InDtm.I li, ... ln "'n:b<o>pOn,1 ~" id or-.! blood ov<r ,,'" «>.or><: of 1,"'f'I>o<:Y'''' ....... ~"'"l"" n""'h~ 'y1Idromo) . ..... i'i ..."' 1O: 1)7·~}. 'f""""'" . la •• " 116. T,..,,,,,,,. d Ly .... _ 117. li S. 119. ,». Il l . Ill. .... Mod lo" ... XI: 65-6. 1988. S/a", "' C: L, ... "' ....... /'I Ene! J Mtd Ill . 58696 . 1919 . Sot.lo I . F....,obedo F. Rodri' .....corbol • • " .1 · T..... py of I'" .",nym.o' ln" ",.'~i1 .,i,n pruiqo.nl<l, I'i Ene! J .\It<! )I~; 1001·1. 1'$-1. $oI<101.Goe'''',. V. 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Iu,"b .. y<n.lnI oWel,,"'rod d, .. A""" .. 0143 ""'" ....'i .... 'U,,"'II ~ ",:>,tdl>"''''''' 1'1 .... ...,.... , 38, 9:!6-1l. 1996. Shl() S.fo~linv 101 0. B"",,!>ou,C H: M.,jiool ..,d ."",col " ' _..... dp~.it: "'" ~ ,..oo4y!o<li.<:i"~ Pw: II, C""'rrnp ~ .... .... ,26(10): I·S.2000 . Itothrnur R H.So- F A.(.....~ Tl>o 0f>In< 3nI «I .• W.8. SOUndc".I'hiIod!IpI1io. 1m. Ki"';"' W s ... , ,toINrcol<hlJaf,M>I..II • ...J,pi"'. I" Nc .... """'. E<to-'ard o\rmld. London. l~. Vol . I:W,7SoSJ . """ ...... R..."",h Coo",,1 Pon~ "" Thbo,_ ""to<.. 01,10< Spi.. ,Coo,,,,~"" .. ,1 ....... .,,00.:_0.:"'" ;" ,II< or"tnolo!ooy ""u· ..... 0'." ...... ' .ut.:.. uro..., R<,.I,. AI (/om: , . ... of .. '0. , o!I:<. 'w. 111 . '" I Jl. 114. Pyop'''' ,... ".1< 17'. 176• "i. ," ""oJ,,, '" 111, A~,..,90)--6.1991 . Be ....... I. WOld ER . M<y« j D." .t.. Epido..1 ......, ... "'" v.... bro'_m)'<,iti. 100Iowi ", .. " .. IIwnbar_",,. •. Podlalries n " 7SoSO. 198) R.. 1... 101<0.-."" I M .Millt'C A.«<>I.: SOfJ'<a1 ""...... , oftbt _ _ .p;.. l cpidurol .... ICUI, S. ", N,.<OI 37. 17<·9. 19n K.. r..... D M. Kop! ... j G. Lio",_ 'II: 1.1«<.,., POll M' 0.5><0.00'""'" ~ M.t! oI.; Oo4oli.i· .",.. nIwI«<I Mil ,•• "',,' nf«''''.J C.... p ~, ....... .... T"""'J' , •. 72'·9. '9!'0. POll M' O.Qoon«. Il M. M,,,... I... B M." "'. Spi'" ,.1«1;,,0' E,·aI ...", ... "h M~ Onol i.,,",,,,,,,",, .Ill,,,,,.nd. Rodioloc1'<fl; 76S·1 ' . 162. Moml'Ol*nlT I . lto><p, H. """",,' a T... oI .. S _ u « O"< .. "",.. of,pi"'<J>~ ,.fo<,ioo1 •. J 1oIn ..... ,'" 2(18·10. 19t'I, 11.0"'1"" WC ....."'" NO.£I .. """ P W. M..... 'it: 01>< "",.",...,i«_... ", o(;pin"<pO<!",.I._, . S ~ ... N_J<l : ~.ll. """""0: 'R i. ",i.," .pid.ri! .......... . Nturolo&l' »: 8"·~.'95(). ' S1. ,~. ,~. "".""",.;<.' ""«>- ,<11" "'0<1<,", "'.. .,,"""'_ NEUROSURGERY ..,<><I, .. Komo,J _J.oi~1 s.,'1 7SB; 100·1. 1991. l SI. SoUl • .., C I. 5,,",,,,,,,,,, _ , n", ..... J",\I" ~ E' o;.k ....«';O"'.owI l"' :65~·S. l !164 . M ol, ~ G M. M<C"""ocI P: M.... ;C ....... or.pin< """ I.......... lnl di'" 'P"" mf..,;o. CO . ..... p Nt .......... 10: ' .(;.19&1 Ill. K. "",Hll S.loc h "" JW .J<f.miolllo. .,t>I" i')'<>.. " .. ;~r« , ,,,,,, oc<u~poimorily Inl d ...... J 80.. Join' SUfi ~l B . 693·1". ''713 , •• . _ .So.o..;.oO.DiNTS,n.ol.: "-of><'" t,.., d,, ~ "" : Do~,,,,""h;'l . .. MM ,,,..,,°1(,od· '"I' 1 dill< !pO«<Il..., ... R..s .. ,"l!)' 11"76)..11.1992 . IS~ . Kop«k y K K.Gilmot II. l.5<0" 1 .... ~141 .. p;,f.l1. ofcr '. ~i",..,.;.or .....i,. "'.........,.....,.11 ~1-«> . 19a5 . 186. Wf...,1 M. w•• ",,~. HNlkt E H: Tul>o"," ",", 112. I. I.,.".,.,"... j, f""" _ ... ,.,.""",>1, .. NEUROSURGERY spon<I)'l;';'''''''k'. J _ JoI •• s..,,61 ... : JOOS· II. I'/I~ . I. ~' J,"I' C E. Willie" III .GoIla II ... . ., Ill" """. .....-..t 1tlle.,....I'1......... ,u'l"l'J' I}; 371-6. 193). 188. 1.." ... E.l'lidoenV ... Il . Il...... LG: """"""' .. pOI/OI><f>lti .. di"'~i ..... ",'_ I~ ...... yof 'I' U1U . ... ct. S<aJod 61: lOS·,. 1m. IS'). o.....Z L .Sc ~ ;_ 1 S.O,/T".., II. H.IIIII" In"Mf' Ubnf d"k·.po<:< ;.f«,'" .1'Ie« h)'...".,.;. ;np:. 'ion • .o.JNII6: 5H. 19a5. 190. Fouquot B.Coup.!" P.lo" ;'" F.,,~I" o.",iti..(I .. I.","" d. ", ....J<>')'. !'<"u.nor -0"'1";'; - ,,'" -.. p''''· ' ...-.Splno 17: JS6-I. 1m 191 Th<1_ U . b...... S,Qu""" ....",orC."""".. l"<I«i. 1e..I, oncI'<ylt..o<)1< "",i_.",... _ of· ." 'pulS! ,",£<,} . SpI ... 11' 0100-0 , 1m. 117 . "I'<'", ...... on""" 12. l nre<:tions d'" ........ 13.1 . Seizure classification Dellnition of II .;el lU",: an abnormtll p$ro~yamal cerebral n~uron81 dischaTge that reauiu; in plu ralion of seMation. motor (undion, behavior or t<>n~jouaneu. Seizu~ Olay be cJa!lSified by type, etiology. and by "pilepti~ ayndromes. C lass ificatio n o f mllj or se izure 1. typ{!. '~ primal")' ge n e ralized: bilaterally symmetrical and synch ronous involving both ""rebral hemispllerea 'I the onHI, no 100:111 onset. ~n9dou.ne&IIOS I from the lta rt. Repre$<'T1ta _ '10% !If all5llilurE!st A. generaliled Wni~-cl(lnk (GTC) (nee: grllnd.mlliaeizuret, ~Ilerali~ &eei. zun! that evol"". from IDnic to donic motor activity . Thi, iSlllpecific type lind dOef tiQl' include plIrtial Hillires thai g<:neralize ~~darily B. donit &eizun!II: fairly symmetric, bilateral synchronous semirhythmic jerk· ing or the UE & LE, usually with elbow I'!u.iOI1 and kilO'" exlwaion C. tonic seiures: sudden allstained increased tone with" ~haraeU!riatie guttural cry or gn.,"~ fI.S air is foreed th rough adduc~ vocal cords o. ab6enCf! ( n~: petit·mlll 'J'Iisure): impai red conaciOllll1'leSS wi th mild or no motor involvam~nl (_ ~Iow) l. typical a~nte'!l 2. a typical ah&"",cea : more heterogeneous with mor~ variable EEG p.~t­ !.I'.m then typical o\lsenct'. Sei~u ..... may Il18 tlonger E . my~)onic seixUTes: .hocklike body je rks( I or more in su~"fon) with gen· eralized EEG dilOChprges F. 1I!'miesei~u re6(AKA ut ~tic $eizu,ret; or "drop attacks").: s udden brieflossof lone that may l'8 un falls 2. partial Inee f~allei •. ure): implies nne hemisph ere involved Ht nnlel. Abou157'i of all sei2uretl. A new onlle.l of partial se;:ure repreent.! II a!Nclura) leiion ulllil proven (otherwise A. simple panial.eilu,.. (no impairment oroon.dousneul I . with motor signs (including Jacksonian ) 2 . with stlnliOry . ymptomli (5peda) sens<>ry or .omatoienaory) 3. with ~utooomic signa or SymptolliS ~. with psychic symptom. (disturbance of higher cerebral func tion l 8. ~mpleJ< pArtial .eizu re (many used to be. dasaified lie psychomotor&eizure, often attributed t o temporallo-l.w but the)" elIn arise from any cortica) area): auy nlUl rntion ofconaciO\lsn~S8. usually LOC ora utomal;smR (inc1udinglip smQclti ng. ch ewing. Or picltirlg ..... ith the linge"' ) ..... ith s " tonomic eUrA (US". aUy nn epig8l!ltric rl.ing s.ensationl I. .im ple. panial 01l6et followed by impllinnen t of eonsciousnel!Jl (may hBve p .... monitory aura ) B. without 8u tomlll;sms b. with autolliatiams 2. with impairment orconsciousnesa Nt onsn a. without automatiSml (impairment ofoon>IC;Ouane&1 only) b. with automatismll c. partJ~l6eixure ",ith secondary gE"rlcralization I. .imple pIlnial evolving to li:en~ ralized 2. complu partial evolving to generalized 3 . simple partial evo],'; ng to compl"" panial evol~ine to generslized 3. unclassified epileptic 6('izures ; ~ 3% ofal1.se'tures ClaSllificlltioD by et io logy (an d so me e pil e ptic ..yndrome9) Thi5 liat t. nnt " lllnclu$;ve ( ~rererenc:e'·ll. 13. Seizures NEUROSURGERY s ymptomllotic {AKA 'secondary1: seiwres of known etiology (e .g. CVA, tumor .. ) A. temporal lobe epilepBies: 1. mesiallemporal .der(lsis: fI'" bfolow 2. id io pathi c (AKA 'primary"): no Wlderlyingeause. Includes: A. juvenile myoclonic epilepsy: Me IH:low 3. c ryptogeni c : Seizures presumed to be Bymptomatic but. with unknown etiology A. West syndrome OnfantHe spasms. BJitz·Nick·Sala3m Krampfe): sl!e below B. Lennox·Gastaut "yndrome: """ bfolow ~ . special syndromes: . ituatico-related seizures A. febrile seizures: u" p<J&t 264 B. seizures occurring only with acut1l metabolic Or to~;c event: e.g. alcohol I. KEY dist inc tions (having thera peutic implications) In generalized tonic-don;c seizures, primary generalized generalization (o ften_le..., l On!let may not be observed)" In ,ta rjllg spells: abJlence VB_ complex partial.. V3. pa rt ial with serondary EPILEPSY ~: '~.~";-~'~~~~~'~'~_~.;.~'~"~m~- leriu-d by recurrent ( 2 01 more). unprovoked A disorder, not a . 'ogle disease. Characseizures. •• ABSENCE SEIZURE Fonnerly called petit-mal sei~ure. Impaired conaciouSJIe8s with mild or no motor involvement (automatislIU occur more commonly .... ith bursl.8lasting > 7 secs).l:'ill post-ictal Ccnfusjon. Aura rare_ May be induced by hyperven tilation x 2-3 mins. EEG shows spike and wave at exaotly 3 pe r sec_ ond. ,. UNCINATE SEIZURES Obsolete term : ' u"cal fol.8". SeilUre50riginati"i in the inferior medial temporal lob<:-. us ually in the hippocamp91 region . May pr(l. duce olfaotol')' halluc'''ations (kakosmi a or cacosmia: ~he perception ofbad odors where none eKistl. ,, M ESIAL TEMPORAL SCLEROSlS'" 'the most comma" cause of intractable lempo rallobe epileptly_Specific pathologic basiA: hippoeampal aclerosi~ (ceU IOS8 in hippoc_ ampus on "ne side). Characteristics are shown in Table 13 -1_For differential diagnosis , Ut pog~ 938. Adult seizures are ini t ially responsive to medicallherapy but become more varied and refractory_ and may respond to seizure our· gary. JUVENILE MYOCLONIC EPILEPSY' Sometime!! called bilateral myoclonus_510% ofcase~ of epilepsy. An idiopathic gener- epilep.y $yndr ome with age-related on_ $et ron5isting of3 seizure types: t. myoclo,,;cjerita: predominantly after waking Z. generalized toni~-donic seizures 3. absellcc EEG -. poJyllpike discharges. Strong family history (IIQ me atudiu showing lin kage to the HI..A region on the short arm of chromOllOme 6). M08t responsive to depakene . ali~ed NEUROSURGERY 13_ Seizures WEST SYNDROME Thi. term II being used JeM frequently as it appe.... ootto be. homogeneous , roup. C]"s.iCIIlly _seizure di sorder th ,u u",'ally appeart in r.rttyur of life, and fIOI:I, i,ts of,.,.. (urTen t , ,ron nexion and occasiona lly e~ten.ion of the trunk and limbt.(maslive myoclo(lua, AKA infantile spum a, AKA salum "ilUTti. AKAjacklO1ife apa,m.). Seizure. tend todiminlah with aile, often aMting by ~ Y"'. Ulually .uocialN with mental retllrd.tion. 501\ may develop eomplex -parti.l seizurN. lome orllle relt may devel~ I..cll1lox-Ga.U"t .yndrome (Ut bt:low). All .uoclattd bra in IHion may be fouod in lome. EEG - the mlljonty ,how either intenda! hyp..rrhythmi . (hIlP.piketwave plu. slow wave re,embling mu.de artifact) or modified hYPIIllrrhythmi. It OfOMe point. Ulually d ra matic 'UpOn.. ohei.u rel and EEC findinp to ACTH orcorticotteroida, LENNC)X-GASTAUT SYNDROME Rare eondition that begintln ~hildhood u atonic "i,uru{"dropalUtC:Iui "). O~ de· velops inw wnic sei~ures wi l h menUlI retanlation . SeizU"'II~ ofttn polymorphic, diffi · cult to treat medk& lIy, aod mllly OCeu r D.I ofttn a, 60 per dilly. May al", preMnl with SlatUI epilepticus. Approximately.sO'Jl of palient.s hay. reduced sei,ul'e"l wi!.h v.lproic acid. Corpus callosotomy may reducelh. number of.tonic seizurft. 7000'5 PARA{. Y515 A post-iclal phenomena in which there i. perti.l or tot.] pIIr.ly.i. ulually in ...... inyolv~ in a partisl sei,u~. More COmmOn in pati" nls with ,tructu ral lesion, u!.he source of !.he seilure. The pllre lyai. uluaUy resolvel.lowlyove r . period of.n hour or 10. Thought \.(l be due to depletion of ""uron, In !.he wake oIthe exten. ive electrical disch.llrJ· ell of a .. hun. Other limilar phenomena indude post-itt.al aphuia.nd hemlanop.i • . 13.1.1. Factors that lower the seizure threshold Factors that lower !.he seizure !.hreshold li.e. make iteu i"r to provoke a .... iture) in in dividual. with or without II prior seizure hiawry include many itema li.ted under £Ii. ologier of New onset Huun, (5ft boolow) aa well U: L sleep deprivation 2. hyperventilation 3. photic stimulation (in some) 4. infeclion; aY' t.emic (fellrile 8I"i1U,,". sec ~ 2(4), CNS .. 5. metabolic disturbances: electrolyte imbalance (especially profound hypoglyce· mia ), pH disturbance (especially alkalllOlli,), drugs ... (sn bool()&:J) 6. had Ino urn.: dosed head i!\iul')', penetrating t rauma (_ page 260) 7 . cerebral ilChemilll: CVA 15ft bt:low) 8. "k.indlina": II concept th.t repeated seitu r" may facilitate !.he developmentoflater leilu"'l 13.2. Special types of seizures 13.2.1. New on set seizures n.e 1Igf! .djulte(! i.M.i!1tntt ofne... onlel se11UTft in RochnUr, :'>linne.ata wu 44 per 100.000 penon yean'. E tl oloai"' In ~tienta pretet>tifl( wltb a firtHi ...... ltu re. etiologiell incl1.lde (modified'): ]. following IWurolOJic luult: .i!.her acutely HA. < I week) or remotely I> I week • • nd ulually < 3 ~ from illfull) A. cenbrcrvQCu lar .ecidenI ICVA. or I tl'Ol<e): 4.2'" had. leilUre wi thin 14 dllY' of a CVA. IUak incnNed with MYerily of , t rok.'· 8. heed trau.rna: cksed head i!\iul")', penetrat;na trauma Uft ptJIft 260) C. CNS inr~tion: meningiiQ. ce",bra] .b_n•• ubdural empyem& O. febrile .ilUra: _ po,. 264 13. s..i1UI'ft NEUROSURGBRY E. birtb 8!iphyxi<l underlying eNS abnormBlity A. conpnit.al eNS abnor()"lRlilieil B. deg!!n!!rative CNS disea5l! C. CNS tUnlOr. me13sl<ltie or primW")' O. hydrnc:epb"iu l E . AVM 3. acoWi SYltemie metabolic diaturbionoo A. electrolyte di3l!rd~rG: Im!mill. hyponatremia, hypaglycemia tt!$peeially p_ Cound hypogl)'t"elDiaJ, hypel"ClOicellli3 B. drug mlaled, lncluding: I , alcohol.withdrawal : JUprJgt 261 2. roeaine toxicity: _pagt 152 :I. opio;oid s (narcotical. principally a&aociatM with the following: a . propoxyphene (DarVllnill) b, rneperidin('.(Qemero)®l: nlB.Y alw c~use d~leri\lm ~, the Itree! drug comhination -rsand blues" (pentawcil).8 \Tal· wlnill) • the a ntihis tamine tripelennamine) 4 phenothi a1ine antltmeti<5 5 _ with administution of nu!ouenil (Romlllic:onill) 10 lTelll beuzooiaz· epiru= (BDZ) In"erdose(especially wben BOZs al"l! taken with olhers!!i· ~lIre lowering drugs luch as Iricycli~ anlidep re ilSanLs or eocai ne 6. ph,m~ydidine (PCP): originally u!red D.$ an (UlimallTllnqll ilizer 7. cycl""JXIrine: elln affect Mg" leveL. C. eclam/lSia 4. idiopathic 2. In 166 ~ patients presenting loan e.mergency depar1.Olent with either a chief romplai nt of, OT a discha rge diagnosis ofll first·timll5l!izure'! ; 1. no were found 1.0 e~tllall)' hive either 8 ,"""UHent seiz ure or " non ·ida! event 2. of the 51! p3ti""ts actually thuught til hve had a 1in;t.-\imeseizul"I! A. 71 % were fabrile eelruru B. 21 '10 were idiopathic C. 7% wltre "sYn:lptomalk" (hyponatremia, meningitIs. drull intoxiClitiun .>.) In II prospeetive ~tudy of244 patientf with II ne"·~D.~et unprovuked Hi!ure, /IDly 2770 had further ~ei%,," a d uMng follow-up"- ". Recum!nt Hi zUJ eI wera more common In ",th a family $l!"i~u .. lU! tllry. ~ pikl!:-and- .. ave!llln EEG, or . hist.ory ofa eNS poIuentf insul~ (eVA. head iojw:y •.. ). No p•.tfenneizur.... rree for 3 yeaMi h ad a recurrentt'oFollow· ing a second seilure . the risk offurLher seirurM W84 high. EVALUATION Ad ul ts A new-oosel &fIlilllre in an w1Jd.I in the absen ce of obvious cause (e. g. olcQhol with · drawal) ~hllu ld llrompt a search for an u.nderlying bull/ the OnMlt ofldiupat hir ooituru. i.e. ~pileJ.lIY, i. most common bero"! or durinsad ole8cence) . A C1' or MRt (withnul a nd wilb e nhance!oent) ohoold be perfnnned. A sY"t~mi<:."orkup "iIo uld he doo", to identify the pre.en~(lrany faCIQTS tis1.i!d previou aly (~tt abo"'). IfaU this ii" negative, then o.n MRI s h,",ld be per;o""w ifnot already done. Ifth." I' nerst;v •• 1&0. a ~PI'at s tudy (CT or MRI ) s hould be done in - 6 month a and ftl I lU,d PQ6IIibJy 2 yea" to Tule-<>ut a tumor .. Mch rolShl not he e vilienl nn the initiai u udy. Pedi a t r ics Amonr pediatMe patienlll with Ii.Mlt-t;me 8eizul"U. laboratory and rlldiologic evalu· BtionB were "fl.en «ISlIy and not helpful". A detailed history and phyllioa l ~lWJn wert'. more helpful. MANAGEMENr • MpnllgemenLofan aduJt with ~he n\!W OIIMt oridiojlSlhic: l e'z\lr1l.0 e. nn abo"""al • •ty fouod nn CT or MRI , 00 eviden«! nfdrug wi t hdrawal) la oolltl"OYeraial. 10 one s tudy. an EEG WILf perfo""ed. which ifnnrrnBI wa~ followed by 8 sleep deprived EEG with the foUowlng o-beervntioM" : I . there. ill IUbotand91 interohl<l!rver variation in interpret.ing SlIth EEGa 2 ifboth EEGs were normsl , the 2-yr Tf!(:\lrren~ Tille-of lIl'izures was 12% 3. if oneorboth EEGs showed epllepti~dilcha'1res. Ihe 2· )':" recurrence r~(t,waa 113% NEUROSURGERY 13. Sei~ure.'l '" 4. the prelence of nonepileptic abnormalities in one Or bot b EEGI had a 41% 2.yr recur~nc. rIta the I"«urrence rat. with focal epileptic dillChargea(8 7%)waa Ilightly higher than for generaliled epil.pt>C: diachargl!8 (78'J\,) The.:onclu.ion ia thit BEe. thu.obt ained hlva moderate predictive value. and may be factored into the deci.ion of whe!he r or not to t realluch sei!ur" with AED •. 5. . I 13.2.2. Posttraumatic seizures 1 Key pointa 2 categori": ear ly (,. 7 dayl) and lote (> 7 day") alle r head trauma • anti.:onvu laanta (AED.) may be ulled to prevent u.cll pasttraumatie .ehurea (PT5) in patien" a t high riak for Ailurea (fH ~:Itt) • prophyl actic AEDI do NOT reduce the frequency of late PTS • diacontinueAEo. aller 1 week except for caAI meeting.peci roc criteria t.... ,..Itt) Postt ra umatic aeilurH (PTS I are ollen divide-<! (arbi t rarilY) in to: udy (occu mng within I week of injury) a nd late (thernller)" . The~ m~ bejuttilication for a1.hi n:l eat. gory: "immediate". i.e. wi th in minute. to In hour or.o. Ear ly PTS (:0; 7 day. a fte r he ad t r a uma ) 30% incidence in IeVere heed injury ("leve.e" defined .. : ux: > 24 hra, amnHi. > 24 h.-s, focal neurodelieit, documented oontuaion, or in t rlcuni. l hematoma).nd in mild to moderat.e injuri... O«un in 2.6% of children < 15 yr. Ig' with Mid injury cauI;ng at least bri efLOC or amnesia". F..arly PTS may precipitate .dverse evenu . . .. rNult of .I.vation oftCP, .It.e .. tio ... in BP, ch.nge. in oxygenation, .nd U«Aa neurolranamitt.er r.leale". -I" Late o o set PTS (> 7 d a y s afte r bead lra\lma l Estimated incidene.. 10·13'1> within 2 Y"' aner · signif,c.n t" head trauma (includ.. LOC > 2 mini, GCS < 8 on admiuion , epidura l hemat.om •... ) for alL.ge ftO<J(»"" ' . ReL. ative ri . k: 3.6 times control pIl pulation. Incidence in.leYt!ll! head injury» moderat.e > mild". The incidence of early PTS i. higher in children than adulu, but lat.e "';&urea are much Ie.. frequent in children (in children who have PI'S, 94.adevelop them within 2~ h ... oftha injury"). Most patieou who have not had a seizure within 3 yr. ofpenetrltinc head injury will not develop leizures"'. Risk of lat.e PTS in children don not appear related to the occurrence of earl,. PTS (in adulta: only true for mild injunea). Riak of devel· oping late PTS mly be higher after repeated head injurie •. PeDe trating tra uma The incidence ofPl'S;1 higher herewith penet ra t ing head injuries than with closed head injuri" (occura in ~ ofpenet rating trauma C86e5 follo.... ed 15 )""Sf'). T AEATMENT A prosPfICI.ivedouble blind . tudy ofpal~nlS at high risk ofPTS(exduding penetratinc trau ma llbowed a 731110 reduction ofriskofu.w PI'S byadministerinc 20 mglkg load· ingdoseofPHTwilhin Z. hraonnjury and mainlaininghigh lhe .... pel::tic level.; but aner 1 wef:k there wn no benelit in continuing the dT\1g {bued on in"'ntion to treat)2". Car· bamazepine (T~to~) hn also been ahown to be effective in mucing the risk of urly PTS, . nd yalproic acid i, currently bei"i Itudied '·. PhenytOin ha . advene cognitive effectl when given long''''= as prophyluia &(ail\.lt~. TAEArMENr CWIOELINES Bated on .vailabla inforTl\.ltion It« obouel it appeara that: I . no treatDlent lIudied effectiyely impede. epilep~nes;1 2. in hilh·ri,k patienta!He' Toblf 13·2), AEOS mUCH the incidence ofurl:t PTS 3. however. no .. tudy h.. ,hown thlt reducing early PTS lmpro-.·es outcome 4. on« epi!e!»y h .. developed , continued AED. re<lucea recurnnce mlUr" The following •• e ther.ro... offered II &\IidelinN. NEUROSURGERY I ni tiat ion o f AEDII AEDs may beCOnBidered for ~hortterm U$~ Table 13·2 H igh r isk criteria for PTS e!~ially if a «izure could be detrimental A . I . 8ClJ1lI subl::u13l, epidural. 01 intracerebral Early posttraumatic seizures were effectively reduced when phenyt<'lm wD8 u&l'd for 2 ... eekl! 2. ope!"K1epte$sed skul ltaClWfI wilh pllfe .... following head injury ,.-ith no significant in· dl)fnal lnjury creased mk ofadvel"M effecta". 3. seizura wilrin !he flrsI2' In aIIer injloll Option: begin AEDa (usuaUy phenytOin or , . Glasgow Coma Seale score ( 10 oarhamazepine) within 24 htll of injury in the S. p&ne\Iatlng brain;,jury presence of any of the high risk criteria shown 6. "'15I0I'l of Ii:p~icant alcohol abuse in Table 13·2 (modified' .. ' .. ... .. ). When using 7. • COIIicaI (tlamor!hagic) CO'11usion on CT PH1', load with 20 mglkg and maintain high therapeutic levels (s« page 271). Swit.ch 1.0 phenobarbital if PH1' not t<'llera~. -- ~~ri1~: ~iij;.~~;i·;::~::'::::~:i~".":h'::r'~Il:owin~ ~ following head trauma ) ':~~~~~;~:~~;:;!\~f.1~:r~~;::i~;'~\~",~:~::;:,,,, after 1 week (aee obo~): mOJl of therapeutic AF.D levels A~· 2. for i _ 6-12 B. recommend EEG to rule-out pre!len~ofa seizure focus before discontinuing AEDs (predictive value) for the following: I. repeated seizures 2. pre8ence of high risk criteria shown in Tobie 13-2. 13.2.3. Alcohol withdrawal seizures Al90. see Alcohol wilil.drawol syrnJT"f)rM, page 149. The withdrawal syndrome may begin hours after t he EtOH peak (8U page 150 for prevention and treatment). Ethanol withdn wal sei~u res are da9.5ically 5*n in up 1.0 83% of habituated drink"," within 7·30 hour! ofwSl5atioo or reductionofethanoJ inta ke. They typicalll' coosistofl·6 tonic-clonic geoeralized ~;~ ures without fowhty within a 6 hour period" . Sei~u""5 us ually octur be· fore delerium develops. Tbey may a l90 occur during inl.oxication (without withdrawal!. The sei~u re risk penista for 48 htll (risk of deleriurn treTD.ens (DT. ) con t in""" be. yond t hat ), thUll a single loading dose of PHT is frequently adequate for prophylaxis. H ow~ver, ,ince mOllt EtOH withdrawal ""izures Dre single, brief, and self·limited, PHT has 1121. been shown to be of benefit in UIlcoroplicated cases and is thua .IIjJ,!ally not jndj. ~. Chlordiazepoxide (l.ibrium®) or other benzodiazepinea adminiBtered during detoxification reduces th~ risk withdrawal seizures" (....e pogo 150). Eval u ation The follOw ing patients should have a CT lI(an of the brain, and should be admi tted for fwther evaluatioD as well as for observation for additiona l sei7,ures or for rrr.: 1. those with their first EtO H wi thdrawal .... izure 2. lh""" with fOCllI findi ngs 3. those having mOre than 6 seizures ill 6 hrs 4. those with evid ence of traum a Other causes of seitun! ahould al90 be considered, e.g. a febrile patient may require an LP to RIO men ingitJ.s. Treatm e n t A briefsingie ""i~"re may not warTant t rea tment. except as outlined below. A sei. zure that cont inu"ll bel'ond 3-4 minutes may be treated with d iazepam o r lorntepam, with fl.lJ"t.her meaSureS used as in stat us epilepticu! 18<'t page 264) if seizurea perSist. Loading with phenytoin ( 18 m&fkg" 1200 mgl70 kg,""",, pa£e 271) and long·tenn treatment is indicated for: I . a history of previous alcohol withdrawa l seizures 2. reculTent seizures after admission A. •• ~,.Iy . ..1,u reI OIly . I"".,. rcp . • <><1 OIay ad.e_ly . ff«'l>!ooc! P"-U,"" Ind ""Yl" n deh.e<y . • nd ""'Y'"Oroen o,b. r injuri • • (e ... . pin. 1cord injury in t ho .."i",or e n u .. labl. oetvi .. r . pinel" NEUROSURGERY 13. Seizures '" 3. history of a prior sei zure disorder unrelated to alC<lhol 4. presence of other risk factors for seiz ...... e (e.g. aubdural hematoma ) 13.2.4. Nonepileptic seizures AKA pseudoseizures (although IIOme prefer oot to UM: thi s tenn since it may con· note voluntary feigning of seizures), with the term psychogenic I!<!izures being preferred for nonepileptic eei,ures (NES) ....jth a psycho· logic etiology {psychogenic se;,u«", are real even13 and may not be under \"olunlary con· troll"". In a major medical referral center. 20% of patienta with intractable seIzure. have NES. Up to 5O%ofthese may have legitimate seizures at $Orne timeaa well". The hazard of NES is that patient.ll may end up needlessly tak.ing AEDa, whicb in some ClOseS may wors· en NES . Posaible etiologies orNES are given i..o TobIe 13·3. Most NES are p"ychogenic. Table 13-3 Olfferentlal dlagnOll1 01 nonepUeptle seizures" c. o. c , ... ,"'" G. DIFFERENTIATING NES FROM EPILEPTIC SEIZURES Distinguisbing between epileptic seizures (ES) and NES is a common clinical di · lemma. There are unusual ~ei~uru that may fool experU". S<lme frontallobeaod temporal lobe complex partial seizun!S may produce bi_ UrTe behaviors that do not correspond to eiQllic ES findings WId may not produce dis· cernible abnonnalities with scalp-electrode EEG {and therefore may be mtsdiagn05ed even with video-EEG monitoring, although this is more lik.ely with partial seizures than witb generalized ). A multidisciplinary team approach may be required. , B. c. D. H.istOI")': Attelllpt to documen t: prodromal symptoOlS. precipitating factors, tiroe and en· vironment ofSz, mode and duration of pro> gT"ession, ictal and polItictal even\.6, frequency llI\d stereotypy of manifestations. Determine ifpatient has history of psychiatric condi· tions , WId ifthey are acquainted with individuals who have ES. Suggestive ofpos$ible NES: mulUple or variahle oei.u .... typea (whereu ES ill. "3""lIy ste!"eQtypical), fluctuating level of OOTl$Ciousness. denial of correlat ion ofS. with stress. Psycbological testing: May help. Differences occur in ES a nd NES on the Minnesota Multiphasic Personality Inventory (MMPI) scales in ria, aed schiz.ophrenia". , bypochondriasi~, •.. depres.9ion hyste· Tabk 13·4 COlltra$\.6 some features of true $l!izuTe!l VlI. NES. and Toblf 13·5 lis13 some features often associated with NES. however, nocharscteristics s re defInitively diagnostic ofNES since a number of them mpy also occur with ES. 1. 2. 3. "" Ifany two of the following are demonstrsted, 96% of time this will be NES : out-of·phase clonic UE movement out-of·pbase clonic LE movement no vocalization or vocaJiution at start of event Features COmmon to both true seizurfs and NES: verbal unresponsiveness. rarityot 13. Seizures NEUROSURGERY au"'matiam •• nd whole-body f1.ttidi ty. rarity of urinary inc:olItine.-. Pro lacti n le vels after eei zUl"elll Tran.ient ele"al.ioa, in hum811 aerum prolactin (lIS P ) leve l' Ottu r followi ng 80110 of general ized mo"' •. 45'11 of compleJC pa rtial , ond only 15'1. of simple partia l .eilures" . Peak level l are reached in 15·20 minu,," •• nd gradually retu rn to baseline over the lublequent hou~ " . It hu been I UgcHt.ed that d raw. in, . serum prolactin Ievellhor1Jy I fler I q Ueliition.ble _ilure may be helpful in dilferent iltil'lj' NES (wh ich may hive elevated cortisol levell but normal HSP level .... ). " .... ..... ..... ,,. F'I!~ Epilepllc HIlu,. cIenie UE movemenl '" ---- ............ ... OOA..oI·~ 0 dorJie----cE"""_ 0 ,, I!M 01 ~llJ' .- "'. ..., .... 6(l'4"epilep!lccr( !ilde-lO-siQe NEUROSURGERY 'ES '" "" SO. , ..... . so. ~ .--0 mic: 01 donie: It$- .....~"" ga\1911'9. 'eIdin;. .....,.. "ilOty JruSde !riIltIJi Repetitive seilUres an Issoci· eted with progreslively I maller HSP elev.tions" •• nd no riM followl IbHnalaeilures or IUtUS e pilepticu. (whether tOIlvuiJive or IbRnoe)"". Greater than twofGJd HSP elevuion$ con! iBtently foHow aeilllTft th.t pro-duoe intense widespread high frequency mesial temporal lobe di scharges: whereas .uc h elevation s do not OCCur in sei lW't1 not involving t hese limbic I tructUTK<O. Furthermore. the ... may be high. ItT bawl!ne HSP level. In C.MS with n,htoilided inte.xUI EOO discharges c:ompared to t.hOH with kn-lided". I nd the pr esence of ~ych<lpatholOC' may s/feet pooitirtal HS P elev.tion.... ",,",,,ro. e. the ,,~nal of HSP peolul may be BtI"onll:ly indicative of troe seilures. but the abaenal mlly be due to. variety of com plu phenomen.··. The over. lI c1.&Sifica· tion accuracy io _ 7~ ,. Table 13-4 Faat ,... 01 ES a NES'" ... --.. , 8'fo (sIooo. 1ow am- 36%!'IIOIerl. hi£tI pMude) .mplitllde) nble 1W Fealuru often as.aoeliled wUh NES" 13. Seitures Febrile seizures 13.2.5. DefiDiti o o'" IetIIie ~,-- ~r.1n irIIIms 01 e/IIIOren a$SCIdII:eQ with I"'e' I'Iliii no dtl'lI'II!d taU58 _ ~nIId by IItUIe IMRiiogle ~ NIMH rll"ducln cumo ~'-1) .0IIIIWIsiCln NIHIl; Iongii'""... 15 rnmtes.1S lOCi crll'AJll!plll {mole 1hII~ _~ptr~oIlew!) ...""'" n'IOfe ""'" _ fpiscde 01 \e'N .~- wI!h semw. EpidemioloJY" febril.l'On¥ullion. I~ th, moel ronllllDnlype of •• jure. E~dudlllg chi ldren with pr. w.tm, Mut'Ol",", nr dev.lopmenllllibnormilitlu, Ihe pre¥lle~e of reb rile ..i· LIIrn;' _ 2.7<rt (I"II nse: 2·$" ill U.S. (hild"n llied 6 ~·6 yrI). The risk for developing epil.pt'y .fter I simp!. febrile ",bul'll iII - \ .., I nd for I comple>: febril. "",ilure i. 6""(9'.1. for pl"Olo~ teilUl1!, 2!Mo Ibr i'oo:el wtlurel. An underl)'ln, nNroloPU16r developmen. t.l1.bMnn.lity or. r.ml", I'Il.tory of epilep.y inc~ the ri,k of developing e9iltplly. T rt'.Rtm e nt In ollliludy, the IQ in !.he ,",up t",.led with phenobllrb.ital Wle 8.4 painu lower (95"ronndCl~ lnW'rY'U lhlP! the plaeebo /!:TOup,.nd t~rt remRinad •• iKDific,nt dlf· ioeyenllllOnlhs .notrdilCOntlnuing ~ oinIlI"'. fUrlhnmo.e. there WIH no.ignif· kant radIKtion in AilUrei in the phenobarbital group. And yet. noc-th~r drull' l"IIally . ppeal"l well ... il<P;d to lre.ti"" thi, enlity: earblmnepinl and phenyt.oin II ppes. ineff"" Live, vllprOl-\e mlY be ,!fen!"e b ... t h..... n OUl rilb in the<:Z yr. sgecroup. Given the low i.>cidena! (1$) orhavin, c{dvUe ~ZJJ'" (i.l . • pilejnY) ~' ali!Julk febril. seizu.e and the raelthal AEo. pmbllbly do not p""ventlhil ~velopmenl, thue ialltll.! ... pporl I"or p1l!5<1ibingllflticonvul'lInUl in these tun. "". re(:Urn"1lCI rtlle.offebri1e seizure- in drild ..;m WIU, I hi.cory of one or n\Oft! febril. HizUI"!! can be mlt>C:ed by administering diaz&pam 3.3 mglkg PO q 8 h ... dunn&. rebriillepiaode ltemp >38.1 "C).nd continuing until 24 hN th e r. .....r lu\)sided" f_""" .n... 13.3. Status epilepticus Derio!tion: More than 30 min ... t" onUtontin~ se.z ... re aeu"';ty , or (:&) multiple se.. ~uros without full _ery oftonscioulneK beI."Weetl H1"luree" Types of atatu s e pile pli c u 5 gene ra lized SliltU. clHlvulsive, geMTIliud conv ... lei_ toni~lonic statu. epileptu:Ul lSE) i. lbe moe! frequent type". A medical .""''VIllCy I. 2. lIh$ence" 3. 8etcUldllrily ge ne"li;u,d: accounts fOf _ 75'1> ofgenerelized SE 4. myoclonit ~. ltonie (drop lIl .... ck): Npeeiaily in l#.nllOl(-G ......... t Iyndrome (In" ~ 2581 partlaIIUlt .... (""","Lly relllled t.o In /IIlllwmic abnormill ty) 1. simple (AKA e pil e pl)' pl rt l.li, cont ln u RII.) 2. compJu A: mo.!. often from frocllllllobe foo:ua. Urpnt t~.tnwnl" r.q ... ,red 3. .;econd. rily leneraliu-d Ep id e miology Incidenc. il _ 100,000 Ciau/yNr In the U.S. Most ea_ ooeur 1n)'O\itIII ehildtcm (amon« ehlldNn, 7S'Ao were < $ 'J"I"I old" ), th e nlllt n_t a rrtcted rrOJp il pauenla over Ige 60 yr!. In " 5O'Jo OrCl\it'Il, SE t. the !)flUent'. lil"$t aei . ... reM. EUo lo gl ea 1. febrrle ¥ellUl'll': ' rorr.nwn pT~iplUto.in youn« I"'tlenlil. o5-&'lIo IIf palrenla pre- 13. Se;z". .. NltUROSURG£Rt' teoling with S[ ha~ a hi¥tory of prior febrile M'izures 2. ~erebrovJ;lJculu accideot.t: the m Olll~ commonly identified c8uIIe in the elderly 3. e NS infection : in children, mo.! Ire bacterial , the rnOtit <:ommoo Qrgan is rn . were H. irl/llO(lnZll and S. pfU!~moni~ ~. 8. 9. 10. idiopathic: aCCOIInU for ~ one-thin:! (io cbi ldren , usu a ll y aasocia(.ed with fewr) epiJepiI)I! i. plft",nt Or il .ublleq .. ,",n tly di agno»ed in _ 5[)%ofpatienu presenting with SE. About 1(We of .d ult.. ultimately diagnosed as having epiJepll)/ will pruent in SE lubtherapeutlc !\EO, in patient with D known a",iure dilJ(lrder electrolyu imbalance: hyponatremia (moct common in children, usually due to w.~r [ntollie.lion"), hypoglycemia. hypocalcemia, uremi a d rug intoxication (elpeelatil' cocaine) . Icohol withd rawal traumatic brain injury II. aoo~il 5. 6. 7. 12. tumor In children < I yt age, 7S'JIO had In I~UU eau1le: 289& were te<"Ondlry to CNS ,n fee:' tion , 309& due to electro~yte d i80rders, 199& 6IlI«ilted with fevu". In adul1.l, I Un.octu ... 1 lelion ,I more lik ely. In an Idult, t.ll e m08t common ~au.. ofSE I, lubthe'lpeutic AEO level s in I patient with. known leinore di80rder. FeHtures MOlt common eauae iI. patient with I known .eizu... dilOrder hlvin, low ABO!ev· ell for IIny ...,llIOn (noo-c(lmplilO.te, inte",ummt infection prevlnting PO inLllke of medl). One out of .ix patieoUi pre_enting with I flNt timl ..izure will pretent in l1.I tUI epilept icu. (SE) . In IDO$t inatances. SE il' manifest.at;on of In !lCU!,.e inault to the lH".in . MO$t Clse1l of convulsive .ta tU I in adul1.lI1.lrt • • partia l telzur. t~t ,ene,.IiM. Morbidity a nd mortality from S E Mean durat ion ofSE in patientl without neurolocic lequelae i.I I.e; hrs (therefore, proceed to pentobarbital anH theaia before _ I hour oCSE). &nnt mortality; < lD-IN (only - 29& of deaths .re directly a ttributable to SE 0. i1.l eomplieat ionl: the rat.re due to the underlying procea producing the SEl. Mortality in lowu t .moo p t children (_ 6'Ao"), patien1.l with SE retaled to subtbe rlpeutic AEo., and pl t ientl with unprovoked SE>O. The high..t mortality occur. in elderly patien1.land th_ with SE .-ulting from a noxia Or CVA". 19& of patientl die during the epi.ooe i~lf. Morbidity and mortality is due to": 1 . CNS injury from repetitive electric di K hargea: irreversible ch.... ges begin to IJ)' pea. in neurona .ner IS little as 20 minutft of convul,ive activity. <:'11 d... th i, vlry common afto. r 60 mina 2. ly51emic at rtali from the se izu relcard iac:, retpil'3tory, ""nal, metabolic) 3. CNS damage by the acute inault that provoko:d the SE 13.3.1. General treatment measures for status epllepticus Treatment i. directed .tltabilizing the patie nt, stopping the IIIizure. and identify. ing the Clu.se (deurmilOin, if there". n ac:ute iruult to the brain) and if possible liso t .... ting the unde r1,; n, prote:U. Although SF; ill defioo:d fOl" sehu,""" lasting". 30 mins , IggTeMive lo ticonv"laan l therapy i. indicated for any sei zul'fllasting:> 10 mins. Treat, m~ntoften mult be inlti.led prior to the avsilsbi lity oftatl to confino the diagnOlli$. CPR ifneeded .Uend .i ....... y: onlli ...... ly Iffe6lible. Ot by n .... 1~.nnula or bag·v alve· mask. Con· l ide, intubation if respirations compromised or if aeiture pel"8i8t1!". 30 min IV (2 if pouible: 1 for pM-nytoin (PHT) (Oi lanti~), not neeeMary iffOlphenytoln is .~.lI'ble): IU.rt wit h NS monitor: EKG,. frequent blood p reasu, e check. bloodwork: electrolyt.es (including glucose), Mg", C ... , phi nytoin level, ABG. SE due to elKttolyte imballnce reapondl more read ily to eorrection than to AEOs" ,f CNS infection it. m~r eon,id... t;on, p.erform I..P forCSF a naly ai.(eapeciaiJ), in f, bri le childrtn) unl ... contrli ndicl led . wec pleocytOll i. u p to 80 ~ 10'/1. can occu , following S E (benill'll ~tictll pleocylOolil). and th_ pltien Wllhould be truted with a ntibiotics IIntil ,nfKtion can be ruled out by neestiv, cultu rea NEUROSURGERY 13. Sebu rea US ~ew rueds for unknown pstient: glucose: A. for adults: thiamine &0· 100 mg IV should precede gluCOIie bolus (in tllS~ of thiamine deficiency, e.g. in EtOH abuse ]. NB: CIIn precip;t./Ite Wernicke's entephal opathy in akvholic patienl.$ (Uf pag<! 151) B. iffingerstick ghu:ose can be ObUlined immediately and it s hows hypoglyce· mia, Or ifno fingerstiek glucO$f! can be done, give 25-50 ml of 050 IV push for adulls (2 mVkg of25% glucose for peds), Be aure blood has been sent for definitive Rerum g lucose first 2. naloxone (Narcan®) 0.4 mg IVP (in case ofnarcotics) 3. :t bicarbonate to counte r acidosis ( 1·2 amps depending on lengt.h of seizu re I administer .p~dfic ant iconv ul$1lnts for seiwres lasti ng:> 10 millS (""" ""low) EEG monitor if possible if paralytics sre used (e.g. to intubate), use short aeti ng agents and be aware that muscle paralysis alone may $lOP visible seilu re man ifel;tations, but does not stop the electrical seizure activity in the brain, which Can lead to permanent damage 1. 13.3.2. Medications for generalized convulsive status epilepticus Table 13·6 shows a summary of medications for 8t8tus epilepticuJI that are outlined in further detail be- Table 13-6 Summary of medications for 6tatul eplleptlcusln average size Il.l!.Y.!t low (modifIed management scheme"· (see IMIo< ~tails) ..... ). Items below in boxes are(on8~· A. lorazepam (Ativan ) 4 mg IV slowly OVer 2 ered treatment of rnoice. · Peds· reo mlM, may repeal ancr 5 mini fel"$ to patients" 16 )'fa of age. Dru gs should be given IV (do not use 1M B. simultaneously loa with phenytoin' rou te). If IV aroeS!! is impossible, di· 1200 mg ifnot slready On phenytoin uepam solution (not suppository] 500 mg if on phenytoin (check levell can be given rectally. C. phenobarbital rv (@<I00IOg/mi n) until sei. zures stop (up to 1400 mgl (watch BP) Protoc o l L D. ifseilures continue> 30 miM, intubaUl and begin pentobarbital (Ut tut) "",,",m...., rat, tor pMnytOin IV i. $0 mcPnIn ; t", lot· p/"ItnyIOin ~ ~ t5() mg PEImIn 1_~2'2) diazepam (Valium®) 0.2 mglk,g (10 mg aversge adult dose) IV @Smg/min, repeat ,fineffective q 5 mins up to 3 additional d08e$. Pfds: 0.2·0.5 mglkgldose with max 6 mg if < 5 )'fS, max 10 mg if .. 5 y/1!. Diazepam should routinely be followed by phenytoin to pnvent recurrenee. Rectal dOile is 0.5 mglkg of diazepam solution up to 20 mg max, and is usu' ally absorbed in ~]O mins OR 2. in pediatric patients with freq uent seizures or prophylaxis of reb rile sei. zures and no IV al:Ce!;S, vaJproic acid is well absorbed ....,tally, a nd is admi n· istered at 20 mgfkg d iluted in water or vegetable oil" simultaneously W with phenytoin (Dilantifi®) (P HT ) as fol!ows (do not won)' about acutely overoosing, follow dosing.rJlJ.tl, monitor BP for hypotension and EKG for arrhythrniaa). Conven t ional phenytoin must be given only in NS to pre· ven t precipitation. ~r giving the following loading dose, start on maintenan~'1 (lfffpagt 271) '" 13. Seizures NEUROSURGERY 3. for 70 kC adult) (use 15 mg/kl for elderly pat.ien~). maximum rau tor phenytOio < 50 mglmin (max rate for rOllphenyt(l' n ia 150 rna PE/min), P~.: 20 mgI'II.g, ral.e < 1·3 mw'klVmin B. ifoo fliT and ...... nt levI' i. known: a rule ofthu.mb il (ivinS 0.74 mglka: to an adult .... i.es the Iflvel by ~ 1 .. glm] C. if Oil PHT and 1eVi!1 Im known: -, ... It: (ivI500 mtO < 5(1 m"mln pnxeed to each :oIlowin,ltep iC seiturft continue: A. PHT.dditional ~or5 mg!ka O< 60 mg/min up to_ toul of SO mglkg 8 either" .< phe~~~~I,:_ up to 20 m~ ~~. ( 1400 lTIJ fw 70 kg) (start in uaing 100 '"&'min vntil ..ituret atop), takes 15·20 min to work, ""atd! BP (e myocardia l depres .. nt). Ped.: 6·10 <n&:IkaIdo.e q 20-30 min to mUIOU130-40 mglkg. Phenobarbital may be pn!fernd to PHT in pauanu with PHT hyperMn.itivity. card,,,,, eonductioll abnonnaJity, and in neon.WiII aDd younr children. Maintenance phenobarbital therapy should be inlU_ tut.ed with 24 hOll" of tht 1000dini do$e (xc~ 275 ) OR diat.~ eva1iutr4) drip: 100 III( diazepAm io 600 ml D5W. 40 mVmm (_ Icvl!! ofO.Z-O.& ""'mlJ. Ra,..ly u~ , levels hard to dleck C . Prtp8r.! to init.iata reneral anuthelia, lidoc:.ine may be med to temporill! a.ihown hert (ulually oDlitted ) lidocallle 2-3 mslkg IVP .25-60 mg/min, ifeR'eetive follow with drip o(51).IOO mg in 250 cc D5W . 1-2 DIg/rain D. ifeei,urel continue > 30 mInutes. intubate and i,...t.ituu."generalllIle$th... ti a" by any of th.e following: pent0b3r?~ta : load witb 15 mWVJf (range: 5-20 n:gr).g) IV at a rate of25 mg/mln , tbe .. place on "'Iinttnance IUrting It 2.5 mgIkghr, follow EtG and t.itrat.e while maintaining burilluppression..··' hometimes up to 3 m8/kglhrl. Monitor SP. i/hypoteR.lion OCCUl"lllgive fluid. and dopamine<utpog, 662 lOr addit.ional meuu res IUch as PA eath.eted. For bmokthrough sei~urell, Jive additional SO mg pent.<lbarbiul and iner-ease maintenalJ(:l! rate by 0.5 m8/kglh OR benzo(liazepinu: high-d06e IV loraupam {He ~I"",l or midatolam (VO'~): adult: 5·10 mgbol u. at < 4 ""'min. followed by 0 .05-0.4 Dl8/kgrhr drip. DaLa is limited, and use . hould bI rel tricted to refractory SE" OR call anesthetiologist to ioit.iate general inhalat.ion anO'.thO'!ia: isoflurane (Foran/!4D) i, the pref...reo;I agent (M avoid enflurane (Ethrane®),$UpafJt 1). NS : this requirtttn &neath'!'"ia machine and usually tran. port lei the O.R... and eannot be mainuined indefinitely. Rar.!ly. neuromuscular junction blodung agenta are required (NS : paralyzing thO' pat.ient and thu. halt.ing the motor activity without slelppin, the epilO'ptk: act.ivil), i. in!ufficient a. continued oeizure act.ivlty in It&elf ia harm ful , . . ~ 265 ) OR propofolanellthellia: Dau. i,limited. and use Ihould be rest.rict.ed to refroctory SE". May have weak intrinsic e pileptogenic pro]M!rtiM Efficacy Diazepam .IeIp. "izuret within 3 n'i.n.t in 33111>. within 5 min. in So-.. PHT .topol.el· 2urel in 30$ aner ~OO 109 has been given. 63~ ofgeneraliud lonic'clonic SE r espond to benwdiuepine • PHT. PHT is . Iower to control . U.lul than d,azepam, but lutllonger. Lor ne pam Not FDA approved for seiwrH (m.y , t.ill be used U ·off .... bel· indleat.ion ). Among "- ... in.1>o>th phtnoborbi"ta1 on<! • bonood" .. pine (•.•. di • ..,.m ) I. di_"',od b«. u.. oI i ....... tod rilk 01 '""1» "'10,), dep....i... NEUROSURGERY '" benzoc!iazepines.lora,.epam (LZP) is preferred (diazepam (DZP ) ~istribute5 rapidly in fatty ti" ues~, and sei~ure. may recur within 10·20 minutcll), but ~a\lses longer sedation. LZP aborts SE in 97% of cases, " •. 68% for OZI"". Abo. leSli respiratory depre.osion than with OZP. As with all benu.>diazepines: 1. respiratory depression and hypoumsi on are exacerbated when used with other depressants (including barbitu rates ... ) 2. effectiveness in SE is reduced by prior maintenance on other benzodiuepines (e ,g. dona>.epam), but.s not affected by the presence of other anticonvulsants 3. tachyphylaxis may deVl;!lop 10 that .ubsequent d<)$eS are less effecti"e'" High-dose IV lorazepam: LZP may also be a leSll toxic alternati"e to Table 13-7 pentobarbital bUT1:lt supp re""ion «"na" because. among other things_ LZ P does not produce systemic hypotension (this may beartifactual since in this study_ bUNtsuppression was MI an endpoint with LZ P 88 it ill with most barbiturnte protocols). It may be given as II contin uou s infu_ sion Of as frequent intcnnittent boluses. The continuous infUSion protocol used by LIIba"" is shown in Table 13·7. , ,, Me di ca tio n s to a vo id in .statu s ep ile pti_ ou, I. 2. nareotice phenothiazine.' includ ing promethazine (Phenergan®) 3. neuromuscular blocking agentli in the ab.sence of AEO thempy : seizures may con ti nue and cause neurologic injury but would not be clinically evident (.f('t page "" 13.3.3. Miscellaneous status epilepticus MYOCLONIC STATUS Treatment: valproic acid (drug of choiC<)l. Place NO, give 20 mglkg per NO loading dose. Maintenance: 40 mglkgld divided (.f('e ptJIJc 274). Can add lornepam (Ativ.n®) Or c10nazepam (KlcInGpin®) to help with acutccontrol. ABSENCE STATUS EPILEPT/CUS Almost always responds co diazepam 13.4. Antiepileptic drugs The gGBI GfllJltiepileptic drugs (AEDs) is seizure contrGI (a contentiGus term, U!Ually taken 8.R red uction of seizure frequeocy and se"erity to the point to pennit the patient to live a nonn.r lifestyle withGu( epilepsy-related limitations) ... ith minimal or no drug toxicity. _ 75% of epileptics ca n achieve satisfactory sei zure control with medical therapY" . 13.4.1. Classifi cation of AEOs AEDs tan be grouped as sho wn in Table 13-8. 13. Seizures NEUROSURGERY Tabr.13-B ClassltJca lion at AEDs OIfl., "OM. • .g. le, CN"""""",") FOil. .1'.M1c.>1"'" _ a ' In p'."" ,.,., IM.,_ let ..... <Jr8typ8S ~_ IlOl ~ p<QYe<j irrdl<:a""'S .-e ., _ . oII~or..J II.bIIt. , lOtbOns: II.BS . aD,""""". a(Ij "'adj~e ll!erap\< . CP ", comp!e. po!InIAi, GTe . gMtrit~ed lct>k>-elOnic, PHT ", ~fl'rIOIn. Sz . "",.~"'. "tlttU¥"' .Ial"" ~p~ onmediale ' .... a .. oooage 10111> 13.4.2. Choice of antiepileptlc drug Autie pileptic drugs (AED ) for various seil;U r e type» 8o!dfa~ drup 8~ druC of choice (DOC). I. prima ry gtl neraJiUld A. G'I'C (gene ralized I.oni.,...,lonic), 1. val prole acid (VA): if no evidence cf foc.lity sollie I tudiel fthow fewer .idi! effecta and belter control than PHT (5<!~ poge21~) 2. CII rb" rnaupin~ rte pogt 273 3. phanytoin (PI-tT); Off pas. 27/ 4. phenobarbital (PB): Mr past 275 S. primidone (PRM): 6« PfJIJ~ 275 B. ~b~""e: NEUR OSURGERY 13. Sti%u r~ '" 1. 2. etholux imide val proie acid (VA) 3. cJonazepllm 4. methsuximide: I a page 276 C. myoclonic _ benzodiazepines D. (.Onic or atonic : 1. benzodiazepines 2. (eJoomate:!Ie;> po.8~ 276 3. 2. vigabe.trio,seefHllIe279 portial (aimple Or complex , with Or without secondary generalization)" (VA may compare fav"nhly with CBZ for secondarily GTC, but is less tiredive forcompiex partial se izures"): A. carbamuep ine (CBZ) most eHeetive, leaS! slde efteets B. phenytoin (PHT) C. phenobarbital (PB) D. p!imidone (PRM) 3. I slightly less elfeclive. more slde eHects se<Xlnd line drugs for anJ of the above seizure types: A. valprOllte B. lamotrigineA: lMe p~t 278 C. topiramate': _ pllf;e 279 13.4.3. Anticonvulsant pharmacology.. G ENERAL GUIDELINES Monother a p y versu s polyth e rapy 1. in~rease a given medication until !!eiuTes are controlled or side elTeets he<XIme in2. 3. tolerahle(do notrely$Olelyon theTal)eutic levels, wh.ich is only the ran8fin which most pa.lients have seizu re control without side effect$) try tno!lQtherapy with a dlfferent drugs befwe resorting to two drugs together. 8O'l& of epileptics can be colltrolled on monotherapy, however, failure of monotherapy indicates an 8O'l&chan~ that the seizures will not he controllahle phermae<>logically . Only. 109'0 hellefit significantly fTom the addition of. second drog". When> 2 AED. are requ.i.red, conaider nonepileptic seizures fXJ8~ 262) ",ben first evaluating patients on multiple drugs, withdraw the most sedating ones first (usually barbiturates MId donnepam) <- Gf!nerally, dosing intervals should be less than One half-life. Withoutl08ding dose, it takee about 5 half-liyes to reach steady $tate, Many AEDs affect liver fu nction tests (LFTI), however, only rarely do the drugs caUBeenough hepllticdysfunction to walTll.ntd iscontinua!.ion . Guideline: discontinue an AEO if the GeT exceeds twice normal. SPECIFIC ANTICONVULSANTS Table 13-11 AbbrellraUon. AED .. antie~~I_~ptic drog; ADS . ab5en~; EC '" enteric cooted; DIV '" divided; DOC "drug of choice: GTe" generalized tonic-.:lonic seizure; SIC-P ", s imple or complex partial. P h annaoolUnetioa: Unless otherwise specified, numbers are given for.onL dosing form. t m m half· life; tp£.oU( " time to peak serom level; tss .. time to steady state (approximately 5 ~ tm); I OIC" time to discontinue (re<:ommended withdrawal period OVer which drug should be tapered); n-IDF " minimum dosing frequency. "Therapeutic levelis the average therapeutic range. A. • ffi!<t.iv. for monr tl'P"" ofVnoroli..d '10 ~.u,..,., 13. Seizure, ""t •.-enal rnA opprovod fa, Uti. ,ndi"'''n NeUROSURGERY ~ phenytoin (PHT) (Dilan tin®l ___~_oo_._ro_ \~-,-I _ \ -"-~ INDICA TIONS GTC, SlCP, occasi(lRally in ABS. PHARMACOKINETICS Phannacokinetics a~ complicated; at low concentrations, ltir>etics are 1st order (elimination proporti(lRal tQ concentration), metabolism saturates near the therapeutic leYel resulting in uro-orde r kinetics (e limination at a constant rate). ~ 90% ofl<lt.al d rug is protein boun d . OralbioBvailability is _ 90% wherl'3e TV bioBvoiJability;s _ 95%; this small difference may bto significant when patient.s are nea r limit1l of therapeutic rang<) (due to ulO-orde r kinetics). Ivt ' tii£.t.K- - _.- !"!',~~ __.J10(~•. suspenso<:w1 ~'!~'~"~3c . . ,.. -~, ,"~\range. ~140hrs)t <>[$ j,egularcapsules; 1.:"3h'5 extende<l_~~SII~: 4-12 hrs IherapoeubC _ u """,sured in _laba: l().20jI9ImI (NB. ~ Is lIMo Ila PHT Ihal is "'" impcrlarll !Nliel)': 9>1$ 1$ USUAlly _ , .,. 0/ 1O~ PHl. !/Iu. IMr"l*'tic 1," P HT l""otIS ... ,·2 /IgII'm: $Orl'WIl8bs at. able to rneaWr. j,,", PHl dired",). pn~ oe~. on ... rum """'*'lIrltlOn and melat>olic IIIIOlndoction I'I:! lot Ren a l fa il u r e: dosage adjustment not needed . lIowever, serum protein binding may be altered in urem ia which can obfuscate interpretation ofserum phe nytoin le~18. F:q 13·1 may be used to convert. serum PHT concentration in a uremic patient C (obse rved), to the expected PHT level in non uremic patients C (nonuremic). C (nonu'~mic).. C (obse,",,~d) 0.1 ~ .lburnin Eq 13·1 .. O.J ORAL DOSE Rx Adult, u3ual maintenance dO!!e= 3O{I ·600 mgld divided BID orTID (MDF z q d , for single daily dosing, either t he phe oytoin-sodiWD ca]lfiulel Or the extended release fnrm should be used). O ral ~ dose, 300 mg PO Q 4 h" uotil 17 mgtkg are given . Ped e: oral maintenance; 4-7 mglkgld (MD F .. BID). StlPPI.IJW: (oral forffill ): 100 mg tabJets of phenytoin·sodium ($Odium·salt); 30 &: 100 mg KapsealS® (utended release); 50 mg chewable lofatabS® (phenytoin·add); oral sUlipension 125 mgl5·ml in 8 oz (240 ml) bottl .... or individualS ml unit dose p3cks; pediatric suspension 30 mgf5· ml. P henytek® 200 &: 300 mg cap!lule• . Dos a g e c bang es Because ofzero-order kineti<:8. at near · therapeutic Table 13-10 G ... I~lIne" or levela a small dosage change can caw.e large level chang- chang ing p henytO in dosage tIJ. Although (ompu\.er models are ne«.ssary for a high Presen1Ie~1 eMnge 10 mak, degree of accu racy, the dnaing cha nge guidelines in Table (mold) /3-10 or the nomogram in Figure may be u~ as a l00mwday quick approximation . GJ abaorption of phenytoin suspen sioo Or capsules S. 5O~day may be decreased by up to 70% when given with ns""llU· tric feedings ofOsmolyte® or Jsocal®"· " , and the suspen 6ion h as been reported to have e rratic absorption . Hold NG feeding for 2 111"3 before and I hour a~r phenytoin dose. ,:i.," " >. PARENTERAL DOSE Phenytoin is a nesative iDotropl' and Can cause hypo\.ension. Conventional phe nytoin may be given slow fVP or by TV drip (Ut below) . The 1M route should NOT be used (unreliable absorption, crystalliza t;nn and sterile ab!ICe&&es may develop). TV rnlUlt be given ,lowly to reduce risk ofarrhythmia~ and hypotension, viz. Adult: < SO rnglmi.n , Ped s: < 1·3 wg/kglmin . The ooiycorr,pRtible solution is NS, in· ject at s i\.e neares t vein to avoid precipitation. Rx ~. Adult: 18 mWki s low TV. Peds: 2Q rnglkg slow TV. NEUROSURGERY 18. Seizures no R;c m~'l.«. Adult 200·500 mg/d (MDF = q d). Most adulu have therapeutic levels on 100 mg 1'0 TID. Ped s: 4·7 mg/kgld (MDF ~ BID). Drip loading method : Requires cardiac monitoring. and SP check q 5 minutes. R;c Add SOO mg P HT to SO ml NS to yield 10 mg/ml , run at 2 mUmin (20 mg/min) long enough to give 18 mglkg (for 70 kg patie nt: 120(1 mg over 60 mins). For more rapid administration, up to 40 mglmin may be usOO , Or use foophenyt(lin (_ b.!/ow). Decrease rate ifhypou-nsion occurs. Dlr&ellonl for ullng nomogram " " " I "" • ,~ 30 ~ ~ , "" draw line connec:r.ing serum ~ 00 line A with currenl flDseon me B B. marl< point whete lhis I'im il· lefSeCIS line C c. (;I)tIIl«;I poirIt 00 C 10 Ihe desired serum level on A O. read new dosage 00 lire 8 . ., I 600 500 'SO 3SO 9 B ~ (SSWIIIIIS Sleady state) 300 ,SO "" 6 'SO . 5 - ,., - R.p«odocw r""", ""'' '11<"'' ~ M,",itori " 8··l"r<4ict;"~ Phony'oin Dooc • " R<Yil«ll'lo- 3 A 50 B C ~m·.R.mbe<kB ....I.\loI. t. W. l2S·J). 1979. ",th p<m,. .. ion FIgure 13-1 Nomogram 101 adlushng phenyIoin dose F OBpb e nytoin sodium injection Foephenyt(lin sodium (FOS) ifl.iection (Cerebyx®) is II newer formulation for admin. istering IV phenytoin. and is indicated for sbort term use (0: 5 days) when the enteral route i. not usable. It i8 completely converted in vivo to phenytoin by organ and blood phosphatases with a conversion half·life of 10 minutes . Product labeling is given in terms of phenytoin equivalents (PE,. Safety in pediatric patients has not been established. SUPpuw: SO mg PElml in 2 & 10 ml vials (l00 mg PE and 500 mg PE respectively). Advantages of FOS (over conventional IV phenytoin ): I. leu venOIL!l irritation (due to lower pH ora.6·9 compared to 12 for phenytoin) resulting In 1~B8 pain and rv extra vall88 ti Qn 2. FOS is wster soluble and therefore may be infused with dextrose or saline 3. tolerated by 1M injoction (1M route should UOJ. be usOO for atlt tus epilepticu.) 4. dQell not come cotnbine<\ with propylene glycoL (which can caU8e cardiac arrhythmias sndlor hypotension itself) S. th e maximum admini.tration rate it 3 X as fast (i.e. 150 mg PElmin) S!DE EFFECTS OF PHENYTOiN May interfere with cogni tive function. May produce SLB·li ke ~yndrome, hepati~ granulomas. megaloblastic anemia. oe rebellar degeneration (c hronic doses), hirsutism, gingival hypertrophy, hemorrhage in newborn ifmother on PHT, tmae epidermal nectol· Y8is (St.even8.John90n varian c.). PHT antagoniU8 vitamin D - osteomalacia and rickets. Most hypersensitivity reactions occur within 2 monthsofiniliating therapy" . In e58'" of tnaculopspulsr erythematous ruh, the drug may be stopped and the patient may be reo challenged; often the ruh will not recur the second time. ~ (fetal hydantoin 8yndrome'"). Sign s of phenytoin to~icity may develop at concentrstions above 20 I'g/ml (toxicity l 3. Seizurea NEUROSURGERY is more common at levels> 30 pglml) and inc lude nystagmus (may a lso ocCU r at therap'!Iltic levelsl, diplopia, ataxia, aSlerixis, slurred spee<:h, confusion, and CNS depre.\!~ion. Drug-drug inte ractions; Ouo~etine (ProzaC®) results in elevated phenytoin levela (ave: 161~ above baseline)". Phenytoin may impair the efficacy of; CQrticosleroids. war_ rllrin, digoxin. doxycycline, estrogens. rurosemide. oral contra<eptivel, quinidine. rifllmpin. theophylline, vitamin D. ~carbamazePine (CBZ) (Tegretol®) \c~/,--- __~_"'_~ ___\,,-, INDICA TIONS Partial seizures with Or without secondary generalization. Trigeminal neuralgia . An rv form fo r use in e.g. status epilepticu$ is in developmen t. Dos. &: ora l route . Ad ult ra nge: 600'2QOO mgld . Ped. : 20-30 mgl'kgld. MO P .. BID. Before starti ng, cl>eck: CBC &. platelet count (consider retku )ocyle count) & Mrum Pe. Package insert &ay. · recl"leck at frequent inte rvals, perha!'S q week I( 3 mos, then q month I( 3 yrs." Do not sur!. CBZ (or diseont inue it if patient already on CBZ) if: WBC < 4K . RBC < 3 x 10'. Hct < 32%. platelets < lOO K. reticulocyte. < 0.3%, Pe > ISO pg%. SUrt Inw and increment slowly: 200 mg PO q d I( I wk. BID I( 1 wk, 'I'ID It 1 wk . ..u an inpatient, d(>Sage changes lI"lay be made every 3 days, munitoring for signs of side ef· fects. As. an outpatient, changes should be made unly _ weekI)', with levels after each change. SlIPPLtEo: oral fonn . Scored tabs 200 mg. Chewable scored tabs 100 mg. Su~pension 100 tnglS-ml. IV form' Dot ava ilable in t he U.s. at the time oftNs writing. Carbohy_ dra te (exte nded releu1! CBZ): 200 & 300 mg tablets. Caveats with oral fonns: oral abso'lltion i$erra ti~, and smaJJermorefrequent dose$ are preferred". Oral suspension is ab~rbed more readily , and also lit should JJ.l!l be ad ministered simulta neously with othe r liquid medicinal agents as it may resull in the precipitation ofa rubbery, orange mass. lit May aggravate hyponatremia by SlAD H·Jike effect. PHARMACOKINETICS l,l'i (ha~.fiIe) single do:l$e: 20-55 '"" alte! cIIIoruc therapy: 10-30 h's (&duIts), ~.~ ~~ (peds) may be mi_rng """"'" lhe _ ""'tabOide Clllbem<l.Zepine-1 0.1 ' -epcx;,je moy c.ouse 10XOcity and musl beassayed_al~ ISS ""'y :Ml.eq"",,,Uy!oI due 10 auooin(luClion wt.O(:h plateau. $I . ·6 wks eBZ induce$ hepa tic enzymes that res ult in increased metabolism ofitliClf(autoin_ duction) as well as other drugs over a period of 3·4 weeka. H $IOE EFFECTS lit Drug-drug interaction; caution, propoxyphene (Darvon®), dmetidine. erytlUomycin and isoniazid may cause dramatic elevation ofCBZ levels due to inhibition ofhepBtic cytochrome oxidallO! t hat degrades CBZ"'. Side effects include: 1. dtowsiness and GI upset: minimized by IIl0w dose esca lation 2. relative leukope nia in many: usually dou not require disconti nuing drug 3. t ransient diplopia 4. auwa S. 1e$ll effe<:t on cognitive fu nct ion than PH'I' 6. hematoiogicaitoltitily: rare . May be serious - agranUlocytosis & a plastic anemia 1. St.evens.Johnaon syndrome 8. SLAO H 9. hepatitis (occasionally fatal) reported NeUROSURGERY 13. Seizure! ~ oxc:arbazepine (Trileptal®) \c.,../,::,--:-~--::"":.,--"'__\-'~ Ver, . imi.a . efficacy profile 10 carbamueplnlP. with Ih~roUowing differe neu: I thare il no lIutoi oducl ;on (C. P~ 50 i. not involvM In ,,, at.ftbulilln) and Ih enl! rore m;rumal dmg-d' ''11 ;nkrlldiofll 2. fI<I bll'lOd !.tIling if ~ulr1!d ';1'1«: A. lhl,.. ia no Ii..., «Iudt)' B. lite,.. i. nn hematoLogic wx ici l.)' C. there i. no netd 14 check drug 1, ,,,,,1, 3. do.i nl iI BID • . ki r>elic. ... Iinea r !i. mOllle" pelllli..e 005E R.r. tUrti ng d_ for ptIIin con t rol iI 1)() ms PO BID, fo r ",~urat It i, 300 mg PO 810. Muimwn dOle 2400 mlP'day lOUt . !Jt..'I'I'UM: \50, 300 &.600 1111 Kored ta ble"., 300 ms/5 m! anol UlptllIlIion. ~ •• 1"",.. \,-~/ ,-_ _""'_"_'_ _ \>-.., A•• ilabl. . . valpmic .dd IDepa\umfl'ill) and dinlproex sodium ([)@pakote\lll), """'nom Effective in primary GTC. Abo uw l\.o\ in ASS with GTC, jllvenile myoc]onicepilep..y, and PIInial ~izu r. (not FDA appf'O'led for 1Mtel'). AJiCI FDA IPPI"O""'" for migr.>ine propbylu iL Note; 1e"1"" GI upset and shOf'\ halrlife ~kl " .Iproit acid much leas useful than Oe~kot<llll (di "a1prou sodium), DosE Adult rang'" 600-3000 meld. Ped. TIlIIJr. 15-60 mw1<gfd . MOP ", q d. Rx Suu't a~ 15 m&'kgfd, i rocremMl al I \\Ik in~rvals by 5-10 mclkgld. Max recom· mended &dul ~ dose; 60 mi/'kg/ol. Ir daily dOH" 250 mg iuequired , it should be divided. 9U1'f"UIW- Oral; UI*UlilS 250 "'I. Syrup 250 mgl5-ml. Depakold(enleric _ud) tabs: 12!i. 250.& 500 "", 5prinkle ClIp5u lesl25 me. IV: Depacon®for I V• •!\i..:tion 500 mg/5 mt vial. SlOE EFFFCts s..rious ,ideeff.,w ..... I"IU"8.. f'Mq1:ll1ilil hal ~n repo~ F.UllU.er failure IuIII occurred especially if IIge < 2 ynand in combination \\I,th other AEDs. Tbtppntc 1_ Conlroindil:ali..". btlow), Oro....mna ~lI'mpOr..,.), minimal coenlt.ve dt6~ita, NN (mln1roJ1ed with Depil kotl'),livet dy. f"oetion, h~ramm_mia (tven w.thout l i~rdy:lfulK' tion), weight lain , mild hairlou.l.remOl' (dose related. l imila rto ~ip !'amma] tremor: If'eo<er. and vlliproic lleid i. 1'Molutl'ly ntcuNf)', tbe tnulor m1l,)l be lrutftl with beta blllCkeno/. May ;,Hetfen witb platelet fllnction, ealltion with aufJef)' on theK pII t;en". COloffRAINDICATIONS " Pregnancy: CIU_ n""1111 tu be def.,1.1 (NTO) in _ 1· 2110 of,.l1l n"", Sinee II cOl"rtl,tlon bet\\lO!en ptllk VA l,vl lI .nd Ih' ri, k orNTOs h .. been fouod, ir VA mll. l 11ft wwd , -.>me ol'''-peru recommt:nd dtangi nalmm BI.o w TID d.:..in" " Pltiol'nts s 2yrs 'I'! (n. k of hepel.OlmrJcityl, la , ~jlUIU NEUROSURGeRY \ I phenobarbital \ INDICA T/ONS Uled u .Uemllt;Vi! in GTC a nd partl.ll nol DOC). Had b,e.en DOC fill' febrile tel· ures, dub.ioUIIlH!neCil" . About 41 en'clive I.-' PHT, but very &&datinl' AI.'IQ lI~ed fll~ sUo· I", "pilllpl;(U' (Me Pf18t 2611, DoSE &1m" do8e PO, TV, or 1M. MDP . q d" " . Start .Iowly 1.0 minim it. tedation . Nor AduJt lOlldini: 20 m"" ~ IV (.dmini,ter at rate < 100 ,""min), Ma.iuk: .nlIJltt; 3()'250 mgld (ullulillyd;vidM BID·TID) Pcdlll!adin&; 1!>·2{j mg/llg. 1!'I..wt.tlW1r/l! 2·61t1i/'kg/d (uIU$1I)' divided BID}. 8U1"I...:0: Uoba 15 ml, 30 mi, 60 mil. 100 mr. Mi.w;ir '20 mKf5.-mt PHARMACOKINeTICS ~~ l (pHiI""') ISIH!1f5lll.) 1m (h.itII-ife) iiiilf5C1 (fBI'9&: SO::160 tnf IN rnr:f:'6 (~) f&:2raiYi1/i11, IiQ F '!! PIds:~':7onca ~ 11M! &:a-..¥{,ecII.a 1s.30 iijmI iDe up 10 3OdI'I!) - 25,;,perWMll} _ Phel'lobllrbital i& II potent induee. ofhepahe In:qmu that rfletaboli .. ollier.u:o.. SIDE EFFECTS Coen ,live impairment (mill' be . ubtle .nd ltUIy oull ... 1 ..tmintstn.tioo ofo.e drug by It leul several m(lnlhr'), o.ua Rvmd in ~!; &&dlhOn: pa..-wal hypuac:tlV;ty I~ dllUy In ped!l; may CIlUM! Mmorrhage m newborn ifmother primidone (Mysoline®) ~ on phenobarb.tal. \ I \ IND~T/ONS Sime a! phenobartJital (not DOC). NB: when II&ed in combination therlp"lowda.es{50·125 mg/dayl ma,lld d $igniliant6\lin"'\I! conlTollOthe pnInllry AED with rew,ide elfec:"'. DosE R.r Adult: 2S().lOOO mgId P ed.: tli-30 Inf/kgld; MUf' '" BID. Start.L 121i meld II" I wk . and inc. , !owl, to "'(Iid -u.tion. SUl'I'UEIr. (()f1I1 oru,l: lOOTed t.I~ &0 rug. 250 mil:; IUlpelUlion 2IiO mg/5· ... I. PHARMACOKINETICS Mtllbolilell include pho!nyletbylmllonomide (PEMA) and ph .. noba rbital Thln!fore alwly! dltc::!..Pt'enob.ttlit.t.1 1....I.t ..ml ti.,.. .. Primldon",.C"'~'~I.",. ."".... -_ _ 1117 +~. WAIl IIsIS ""IiiC" IIifiiIiIO*IiViI /!IIIt·We) 1PNt1Mal(tltadr1lall} (~) (jqIrIj j ~: Cmlli" ciIfWt!I D/lIfICIbIibltII: 500 1!iC M 11"-5111 SlOE EFFECTS S.me .. ph<llnoM.bilAtl , plu~: 1 ~1ii3D1IiYI ~. """ . . . IJI'TiibIi: H5 ~ dIMd ~ If)-'O I oflibido. rare ..."crocylit: .nemill. ethosuximide (Zaroo tin®) \ I \ INDICA rlONS OOCinABS NEUROSURGERY 13. SeiturN '" DosE Rx Adul ~: ~p .... lel 2~ 500-1llOO mWd. POO l : 1().<40 mglkgld ; MDr . q d. SuPPU£D: oraJ only; mg; 'YTV P ~O mW5.m l. Its Therapeutic Ia'IIII (SItIft1 "'t.) (IiVII'i) acOt: uplOf4Oii)'l 4().1!):1 ptds: up 10 1 dal' SiDe EFFECTS NN; lethargy; hiC<:'Ough.; HI... ; ra~ly : eotinophilil, leukopi!ni •• erytheml multi· forme. S tev'M·JohnSOn syndrome, SI.E·lllca Iyndrome . Toxi c level. - pl)'1:hotic ~hav· jor. methsuximide (Cetontin®) \ / . ,,., """, \ INOICA TIONS l "di~llt.ed for ab$~nce seiz,,~. refractory to other drop. DosE Rx optimum dOM! must be de~rmined by trial , Start with 300 "" PO q d, ine~'M by 300 mg lit weekly intervall PRN to a maximum 0(1200 mgld. Suppuro: ISO&: 300 rnl cap$ule., ,-/ felbamate (Felbatol®) \ / tRJOlNFQ \ , • CAlITlON: Due to an unllC<:eptilbly high nlU "f '))Iut;" llnem;1I and nepoltk fail. felbamate (FBM) 5h ..... Jd nol ~ ~ e~cept in those cin:u1n6tanca w~n the ben· efit clearly outweighs the risk; then., hematologic con.ultation;. recommended by the manufacturer. ~e Sick t!ful. below (also for drug.<,lrug interacti.ons). ~. rBM i. efficacioUII {or monotherapy IUId adjunctive lherapy lOr pIlrti.l .eizW'ft (complex and HOOndary gene. a1intion). and reduces the r~uency of atonic.nd GTC ",izures in ~nno,,·Gastaul syndrome. PHAflMACOKINEnCS "~) I 20-23 fA I1(pe·kleYebj .... 1·31n· DosE R.r. CAUTION I « QI>oot. hbl.I3-11 Effect ollelbemale on olller AEO level.a Felbamale ia~ 10 be used as I lint-liM! drug. Palientor cu"dian . hould sign informed content rele'l\!. S\.IIrt with l200mwddivided 8ID. TID.or QID, and deerUI\! o!.her AEDS by one third . IncruM relbama\.ll biwHkly in 600 m, inue. rMnU to ulual doN of 16003600 mWd (m ...: 45 mg/l<gId ). Slow down ina.!menUo and/or reduoe other AEOt further if,ide etf\!Cu ~me ~en. Admini.l.er at upper end ofr."(\! when used .. monothe r. apy. 9uPPuu>: (onol only) 400 &: 600 "" acored lIbleu; .u_pension 600 mg/5-m l. SlOE EFFECTS Felbamat8 has bHcn auoc:iated with aplastic anemia (ulually diacovered afte r ~30 ...·ks 'ftherapy) in _ 2·5 caSOl' per million person, per yr, , nd hep3lic raau", (..-me falal. nt«IIIiUlling b..eline and serial I..I"I'1 every ]-2 wki). Other .ide effeda: inaomnia. anore",;a, NN, IVA. Felbamate i. a potent tn\!Ulbolic inhibitor. thus it i. necellaryto redUCf! '" 13. Seizure. NEUROSURGERY the dQ~1! or phenytoIn, vllipronle Or C8rb8maz .. p;n~ wlln \l&ed w.11I relbamllte '" (see 'rabi, /3 · / J! (geoeral rule: drop dOlle by ooe l hirdl \ I leveliraceLam (KeppraQ9) \ INOICATIONS AdjUnctive therapy for part ial 0080\ Sz. in &dults. DOSE IU st.art. with. 600 mg PO BlD. [ntroment by 1000 mgld II 2 w«kI P"RN 10 II maxi· mum IIf3000 mgfd. SIIT'Pu ao: 250. 600 & 750 ms Salrl!d rdm-<:Ollied Ulbl . SlOE EFFfX:TS Somnolence and ratigue in 15'>\-. Dininr.ss [0 Sot-. \ ! clonazepam (lGonopin®) \ A \lenzodiucpme derhr~liVL'. INOICA TIONS • tilI.~ I r<!COmmended drug for l<!i1.UMlt (SI!f! btlew ). lIRed for mJOClonie, awoic, Dnd absent(! &eizur~s (in pbs" .. """ leas "lfacl lve Iloilo valproale Or ethosuximide. and tol~ranC\: m~y deve!o-p). Nl1: clona2epam u~uaUy work$ very wQII for $evenl mortlns, and thcrt tendg to ""eomo l"55 ~rrC'Ctive. l~aV\ng ol\ly th .. ~~'CIatingflrr~'(!to . Aillo, many casu have been ...,port.. ed or patien ts having sclwres dunng withdraw"l, induding AlII!U!I epilcplicU!I (even in p$tiento with no hi~tory Of&l.II.luS). Thus. may nef'd to taper th)$ drug Over 3·6 month!! . DoSE 1U Adult: IIUlrt eL I .!i mgld OIVTID, incrclIIIC. by 0.5-1 mg '13 d. u6ual dosage range is 1·12 mgld (max 20 109/d); MOF ~ 'I d . Pew.: Bt.arlat 0.01·0.03 mglkgld OIV BID or11D. irn:rea9e.byO.2S-0.6 mglltwd q 3 d; u9U111 dDMge. range,~ 0.01·0.02 mg/kgld; MnF '" 'I d, suP!'uHu: <IJ'el onl:.'; S«)rcd !.lib,: 0.5 mg, 1 mg, 2 mg. PHARMACOKINCTICS 1'<1 tss I!'WI (hIIII-liIe) (pNk Mis) (siOOtly (.late) , ~""T,!1n , - TlierIlQellllc level lQ( (1lisoonIkot] (PI¥rnI) ~"i:"4:.aa~3-6~: -O.lI"i3=O.on- CAUTlON. ~awal""U/"""~' _"""1tbove SIDE EFFECTS Ataxia: drowl incU; behavior d>llnR"C!. \ I zonisftmide (Zonegran®) \ INOICA TlONS AJijunctiVl! therapy for JWlrtlaJ Sl in ndulu.. ~ \ ! acelazol8l11ide (D iamoX®) DfIUOItlFO \ , Tho anli~pilcptie errC'Cl mfty Ire e.iUu:r due to dln:.d iMibltfon ofCNS carboni~ 1111hydraS\! (.J~ l1!duces CSF production) o r due. to thc ~ light CNS acidosis that T1!sull!l. INDICA noNS CentrkephaHe cpileps;~'S (ebsence, non focal NEUROSURGERY &ei~u r"g). 13. & ilurea Best ,"""u)u. are in ab<sen~ m aeizuru : how_ r benefit h""ellKl b!!en obllcrved In GTC. myocloni,jerk. SIOEEF~CJS Do no~ UII in fi"'t lrime$:er of prfllUan cy 11I111y btl ~rll~nk). n,e diu r.tic ~fTect Ul ullU ,,!nallo... t>fHCO~ which mllY lead to lW .ddotic I\.III.!! with lon,-I.!!nn Ihe •• py , A aulfonamld., Ih,,,,fo", eny typi~lI.l reAClion \0 \hI , clll61 mlly OC'C ur (anaphylaxii, fevi!r, ruh. Stevens.JohnlIOn syndrome, \o~;c ~pi di':rmal n8Croly~il .. ,l. P. . . thui": medica· tion should be. diMOntlnufld. DosE Rx Adult; 8·30 I1Ilt1'kgfd In divided dOJt!alma.x I amid, hiKher dlllla donot Il1Ijlf'OVI control). When given with another lIED, theluggelted lurtingdOlllll250 mgoocedaily. lin d thi! ilJTld uolly Inere.aeC.. 8IJ1'PULD: t.ableu 125. 2SO",.. Dilmo:~ ilf!qudalll ..... au.· tainl'd reJea'e 500 I1Igcapolulet. Ste rile cryodeN;csted powd~r ;,alllO ..... il.ble in 600 mg viala for p...... nle •• 1 frv) use. ,---/ gabapentin (N eurontin®) I \ IlfIUOII'FQ \ , Although developed w be. GABA .coru&t, ildoes nllt inlll rlol:t.t .ny known GASA Em""cioul far pril1lary generaliuod sellUl"e1 and P/lrtlallei.uru (with 0. with· out ~onclal')' generalization). Ineffective for 'WoeI1C<l ..i IU~. Very low incidtnoe 0( know n tide·effect..o.. No known dr uc interadiona (probably beqr, UiIe it i, ..... nlllly excrel<ld). ~ptor. DosE It:.: Adult; 300 11111: PO II( 1 day 1; 300 Illg BID day 2; 300 o:o,gTID dayS; thell irw:rea.. rapidly up l.o u.ual doIIe. of ~ 800-1800 m&" per day. 00$eI of 1800-3600 .... y be netdi!!l in intracLabln pati~nt.s. no.a~ mUlt be redured;n ""l~ta with ~.I intufficiOlney III'" 011 dialrs\;!, 8m'I'um: 100. 800."00 109 Cllpeulu. PHARMACOKINETICS Gabapelltin i. no~ l1Ietaboli~d •• nd 9a~ile~creled unchanged renallywi\h pla.ln. du rance direetly Ptllpnrtiona~ to crntinine deal"lllnct:". Ooea nat affect ~patic micrn&om.1 "nlymeB, and doe.. not .ffect fUelJlbohsm llrother AEU.. Ant.acid. decUQe bioavailablUtv by _ 20%. thererore <'ive ,abe"""t;n > 211,.. the anl.ldd" ilin: ~ '"""'¥W --I1r$ ="- nw-~ .ne. llhaII-lilel $-,IVi' (pNk __j (s1llldy$IIII6J f.3fiiS f.laiys _ . ......... SIDE EFFECTS Somnolence. diulnea., . Iui l, raligl)l!, nystagmus; IU redu.:. .1'-.....,-2-8 weeb of drug lhenpy. lncre.1ed appetil.e.. Nat known to be terat.llp.n>c. ,---/ laffiot rigine (Lamit:ta~) \ I ~ I!*O \ , A.ntleonyultant effect .... y t,. dw.1.o prayn.ptic. inhibition ofllu tUUlte relealJe". E1fiCicioua.1 .dlu!)I:Uyt thenpy for pnrtiallCizuretl (with 01" without seoond.ry gener.hJ.aUnnla nd .... nnox·O.. taul IyridroOle. Pnlim;ruory daUl I"'llBul it mly IllIo be us.ru! In .~ltRct (/)r refractlit)' lellenl lized KizUIU. or n IIIOllIIthe .. py for newly di.",~ part ial or ¥t'nl!flj li Uld aeizum .... Alia fDA Ipp«I¥ed for bipolar clillllm r. a. SlOE EFFECrS Somnol.noe, d.iazlllQl:, diplopi • • II Serio..- .... b" requirillC hOll~itaJiElltion and di. cnnunuation O(WOIpy hllye been reported I,...h ....,ally bt!gi1Ul2 week. afte r inili.ling therapy and lilly t,. HVete and potenUllly lire-tb,,,,t'!lung, inclw\lnC Stewcna·JohlUOn l)'I1drome lmore of, concern " 'ith ~muJtaneou. UM o1valp. oale),'rod 'Irely. tolUf epi· deMl"l.1 necTOlyllia ITEN )). lncideru:. or'icni1kanlep;dennal rNction may bot dec:reBted by. alow ramping-u p lI( dataCe, MIY increaH MilU'" (requenQ' in severe myoclonic epileplly orin/"allcy"". Metabolilm or lamolri"ne ;1 arrec:t.ed by Q\her ABO.. 13. SeI1.U,et NEUROSURGERY DosE Rx Adu lt : In aduJta receiving enzyme-inducing ABOs (PET. caz, or phenobarbi tal). start. wjth 5(1 mg PDq d lI 2 ",lui, then 50 mg BID 1 2 WQ, then I b.l' 100 mgldq "'...,1< until the UlIual maintenance dose of2oo· 700 m(id (divided 'nt.:- 2 dose,) is reached. For patients on .... lproic acid (VA) oJone, the maintenance dO&e Will! 1(1()-2oo mgld (divided into 2 dOlI". ), Rnd VA level. drop by _ 25'1> wilhin II faw weeks ofsLilrtinlllamolrigina. Por patien ts on both enQrne-inducing AEDs.a.rul VA. the starting dO&<! iii 25 mg PO qod • '2 \liD, then 25 IIlK qd • 2 \Ilks. then I by 25-5{lIllg/d q j-2 Wk3 up to a maintenance of 100-150 mgld (divided into '2 do&e.). Instruct pati"ots that f8~h. rever ()r Iymphadenopath .... may herald .. serious reaction and !.halll phYllidan .hould be contacted immi!djately, Ped~: not indicated fbr Ulie in patients < 16 yrs old due to high(!r inciden<'e of potentially life-th reatening rash in the ped iatric populat io n". S\II'Pt.II:U. 25, 100, lfi.O &. 200 mg tablets. 2. 5 & 25 mg chewable dispe1'8iblc tabJ~ts, PHARMACOKINETICS'" ilPW. llotl j(pta~ 1eYeIII) (hIIII·li!ej ~iv!.' 1I.5-5r..s naw·I~';s <t1OI!&nI(llO _ _ 1ss 1staad1 stale) 4·1 dayi ~ IiVii! niifiiIililiiIi IS 1>15 II)' f'HT .".,. CBZ, _ •• VIIIproo< or'()r.asea ~ 10 5'i 1'111 \ ! vignbaLrin \ INDIO. nONS EtTective in treuting pEll"I.iaJ DoSE R." Adul ~; ,-/ sei~t1res. Le5~ aa far ge"emli~ ~i~"r". 1.500..;>000 mgfd . wpiramatfl (Topama¥®) \! DflIJO fIFO \ 1 Mal' block vo!tage-serlJiiuv ... sodium channels- and enh~nce GABA activity at GABi\\ reeeptors and attenuate !;Om'" gJut.amate r..ceptor~" IND~TIONS" All 8n (lml Bdjuru:t to (llher drop in t .... at ing refl'8cl.Ijry plll'tiHI ~ ... i~U""8. DOSE Rx Adul t.: start .... ith 50 mgld and increlile ~Iowly up to 20().400 mgld", with no s'gmficllnt ben~fit noted al dQS.a~a > 600 mgld i '. SIII"''''" ;II: 25. 100, &: 200 mg !.!llls PHARMACOi<INITICS 30'16 il md8boli~~d in !.he liver. the I'tiIt ill excret.e<i "ncha nKed in the "rine. -'" --TI'iiI~ {han.i1e) (~SIale) !ill - l (9-251irs 5-1 days ~ estabiStIeii SIDE- EFFECTS May in«re8JIe phenytoin concentration by up to 25%. Level s oftopirllmateare reduced by other AEDs Cphl'a.ytoin. carbamaze pine, valproic IIcid and possibly olheral. Cognitive ill1p,&irmenll ..... ord fmding difficulty . problems ... jth C<)n""ntrllti,;m •.. ), weigtn loss. dininess. ataxia . diplopia. pareathesias, nervousness .nd conrU~;Of\ ba ~ been troubleMIme. ~ I.S'A\- incidence of renol stones ..... hich WI"ally pan lpo ntaneously" Otigohidrosis (redoced eweatingJ pnd hype.rthenn.ia. prima r ily in child ...m in Iluodution with el~Y8t.ed enviroomenl8l te.n'peT~tU1'8S and/or Yigol'O\.Is plly sicsl a.divity NEUROSURGERY 13. &iZUTes '" ~ tiagabinc (G!lbitril®) \ I OfIUO~O \ , A GABA ... pt/lke inhibitor, with eogni~iye problems ora sim ilar l'T equl!ncy to thet witll topirsmate"". Ri' Ad u lt, sla .... willl ~ mgld , ,,,creaM wukb by 4·8 mg to II maximum of32-56 mg (divid....J BIO to QID). SU'I'PlJtD: 4, 12, 16 Ie 20 mg teblel.5. 13.4.3.1. Most se!%U~ Withdrawal 01 antiepileptlc drugs recurrences d/)vejop during the r;ru6 montha aile. AED withdrawal" , INDICATIONS FOR AED Wlm!1RAWAl Then! is no agreemel'\l on bow long a patient should be seiru re-frel! befQI"<! with. drawal of lIntiC<loyuluRUI, nOt i. there agrllement on Lhe progTl0<5tie _allle of EEGt lind on the but time IMriod ~er whicll to withdraw AEDa . The FoLlow;n!!:;" based aD a study of92 patient!! w;UJ jd joDithil: epi leJl'lY, who had bt!en rreeofsei~urea for two )'Par.... Gt.neraliwLion, e.g. til polIltrnumatic stizu.es, may not be appro pri ate. Taper WQ3 by I "llJ\it" Q 2 W"ka (when! a unit UI deflnoo till 200 rng for CBZ or valproie acid. or 100 mg for PHT). Follow-u p: IMAn ~ 26 11I0B (r lrlgf: 6-62). 3) pa~ientJi (8491,) reIDp>led. wiUl Ule 8V1!rsgt' lime to I"I!lapse beL~g 8 m(>ll (ranh"': i· 36). Usi ng act~rill l me thods. t he rigk for ncummce i. 5.9 \IIJmonth for 3 month •. then 2..7'WmonLh for 3 mon th!. then O.SlI<Imonth for 3 months. Fa.d.onl found to affect the likelihood of rel~p$e include: i . ",,;wre Iyl"': 37"" rel"1"'1I rale for g:~nerIlJizl'd seizur",, : i6% fo?r«lmpiu or ~imple partial; 54'1 for oompln part;"1 witb sec:ondary generalhalion 2. num ber of oelzl1UlI bl!fol't'_ w nLrollluained : thOllt' with '"' 100 seizure! b~fore C\ln· trol hlld slawt;cally lIignificaM higher ~Iapse rate 3. the number of drugs thai hlld to bo1 Lried before 5i",le drug therapy t~S9r~uy contro lled seizuret: 29% if llIldrug worked. 40% if 8 change to a 2nd drug "'as needed.Wld 80% ifa cl>ange to II 3rd drug WIlS required ~. EW cias. (Ie<! Thl>le J3.12 j: cl81~ ~ had wo rst progn08;1 for reiap!ll!. Epileptiform discharges on EEG se rv" to di/ICoursge AED withdrawal"' In" larger random;~ed ewdy·. the.m06t ;'<lporUlat factors identified to prfldicLfreedom from recurr~nL seizu "-'"II were: I . longe r seiz ure-free period Table 13-13 Recommend ed AED withdrawal Umea 2. useofoni)·<Jne AED ('..... multiple AEDft) 3. !lei~ull" ol.iler than to .. rc·c!on ie seizures Wl r HDRAWAL TIMES 'I'he rerummended withdrawal times in TQilh: J3- J3 shO\lld be used (01)1 118 gu ide. lin.... 13.4.3.2. Pregnancy and antlepUeptic drugs W01)1 en of thildl;)e"ring potenti al with ing pregnancy"". "" 1.3. Se izu'l!li epile~ ahou l d und e'l'l "",unuling rqnrd - NEUROSURGERY BIRTH CONTROL AED~ that induce liver micro~o",al cytOChrome p.!>,> enzymes (su Table 13- /01 ) increase the failure rate of"ral oontrateptive~ up to fourfold". Patientll desiring to uSe BCPa should employ barrier contraceptive me8lu res un_ til ovulation i, consistently suppressed, and they should watch for breakthrough bleeding which may iodicate a need for a change in the hormone dosag ..... Noo-oral hor. monal contraceptives (e.g. levooorgel lrel implant (Nar · plaot®» circumventll first paM liver degradation but should combined with a barrier method because afde<:lin· ing effe<:tiveness with time . Te b le13-14 Et1eetol AEDs On liver cy1oc hrome p. 50 " COMPUCATIONS DURING PREGNANCY Women with epilepsy have mOre complications with pregnancy than mothers ... ith· out epilepsy. but,. 90% of pregnancies have a favorable outcome". There is an increalile in the number of gravid seizuTe$ in _ 17%( reported range: 17-30%)0(epilepticwon,en, which may Table 13-15 Changel be due to noncompliance or to changes of free drug levels of In Ires AED level s d urAED~ during pregnancy t.:Hoe To1:tl~ 13· 15). l solalfd seizures Ing pregnancY'" can oceasionally be deleterious. but usually cause no problem. Drug Chlnge Statu, epilepticus pose. serious ruk to mother and fetus during pregnancy and should be treated aggressively . There is 01." a slightly increased risk of toxemia (HTN of pregnancy) and fetal loss. BIRTH DEFECTS The incidence of fetal malformations in offspring of pnient.s with a known seizure disorder is . 4·5%. or approximately double tha~oftM- general population*'. The degree to which this is due to the use of AEDs vs. genetic and environmental fact.o.s is unknown. All AEDs have tbe potential to eftuse deleterious "ffe<:t.s on the infanL Polytherapy is as· sociated witb an increased risk over monotherapy in a more than additive manner. Generally. the risk of seizures (witb possible concomitant maternal and fetal by· pollia and acidO'ilis) is felt l.Oou t weigb the teratogenic risk of most AEDs, but this must be evaluated on a cllse.by-case M sia. Oc<:a.iooally patienUl n,ay be weaned off AEDs. S pecific drugs Carbamazepine (CBZ) produced an increased incidence of "minor" malformations (but notof "major" malformation s) in one studY" (t his study m'y bave had methodologic prable",,). and may increase the inddenceofneuraJ tube defects {NTD)*'. In utero exposure to phenyl.(lin may lead to tbe fetal hydantoin syndrom .....·" and a child with an tQ lower by ~ 10 points"'. Phenobarbital produced tbe highest incidence of major malforma_ tions (9.1%) in one prospective studt" and wa.o slw associated ... ith mOllt of the increllse in fetal death or anomalies in anotb"r . tudy". Volproote (VA) causes the bighest incidence of mD (1-2%"), which can bedetected with a mniocentesis and allow an abortion ifdesired. TID dOlling may reduce the risk ofNTD (see poge 274). Benzodiuepines given ahortty before delivery ~an produce the "noppy infant syndrome''''''. Similar e(Tect./! may QC<:ur ... itb other seda ting AEDs l uch lUI phenobarbit.aL Dru g r ecomm e nd a tion s A general consensus is that (or most Wamen of cbildbearing potentia! who require AEDs. that monotherapy with the lowest dOlle o{CaZ tha t is effective is the method af choice if the seizu.re disorder is Te$ponsive to itt". tfineffective, then monothe rapy with valproic acid (with TID dosing) is currently tbe recommended Se<:ond choice. Folate supplementa tion (a fter confirming oonnal B" levels, lee poge 904/.i>ould be used in all . 13.5. Seizure surgery 20% ofpatienta rontinue I.Q have seizures even with AED •. Many of the" patients may be candidates for .urgie81 proceduTe$ to control their , eizures'. NI';UROSUROERY 13. Seizure/l '" INDICATI ONS Seizure diaorder must ~ s~ere, medkally refractory with I13ti. fa cl.ory tri,la ofto1uable medication for It least ~ 1 yea r, and disabling 1.0 the patient. Med italty n!h-actory i. ul ually con.idered two attem ptaofhigh .dolle monotherapy with two di , tinrt AEOa, end one attempt at polythuapy , The thlll. ¥tneral categoriH ofpatienta . uilable fOT .ei~ulllaurgery h", . ...: I. pa rtiBl ltiz u.e. A. te mporal origi n: th e larpal gf')\Ip of surgical undidatea (HJ)KiaJly me, iaJ temporal epilepsy whlell iI ofie n medically Illmdory) B. ex tratempor. l orifin 2. seconde rily generalized It;Iu.ea: e,g, Lennox-Cntaut 3. unilate ral , multi focal epilep. y afloOClated wit h infantile hemipl egia . yndrome E VALUATION All patients ,1I0uld undel'll'l Imaging atooy to ru le out neopla. m, AVM. etc. Nonin· "asi"e techniques aUow locali ution in the majority of cl _ . N ONINVASIVE TECHNIQUES MRI Tile imaging modal ity of choice. E~tremely good for detectinghippoc.ampaluymmetry ormesial te mporal sderosia t hat may produce f;Omplex partial..,iwrtl (CPS) .... CATSCAN A $e izu .... focus may enhanze with IV contrast I hortly following a seizure. Subtle enhancement may be present on the . ide of the focus on interietal CT kiln .... VloEO-EEG MONITORING Most cente.. periOTUl pre-openoti"e long-tenu inp. tient ,'ideo-~EG monitoring t.o correlate the c1inicaUy diaabli ng ""ilUre with appropriate elN:triuol abnormali ties and possi bly to identify the sei~ure focus. PET SCAN (POSfT1'ION EMISSION TC»/OGRAPHrJ lnterictal PET sc. n uoing nuori nl!· 18 deoxyglu ..... (IIFOG) shows hxlmmetabolism lat(lra li zed to thel id.oftempol'8llo~ focus in 70'11>oI'pstimts ... ith med ically refractory CPS (dOH not t how actu , 1 W of origin). u""rul whl!n MRI and EEC uonnot localize. SPEcr SCAN ($INOI.£ PHOTON EMISSION TC)t,f()OIW'HYJ U~ t.o demonstrate increased blood now during a Itilure to help localize lite of on· !Jet. 199m) Technetiu m (Te) hexam.l.byl· propy~ne·amine-oEime (HMPAO) ;. u~ually ad . mini.te~ immediately a~r O:l!Jet Or lei~ r• • and thoe lean may be obcaiJled within "-'Tal hou ....., WADA TES7'AKA intTliurotid .mytal toeSt. Loca lizea dominant hemisphere (aide of language fu nction l .nd _ _ ability orhemi. phere witl\out Ie, ion 1.0 mainttin memory when ;aolstad. U. ua lly rHeT'Yed for candidate, for large resectionl'"'. Start witlla!1fiocr1m (m.)' uH IV digittl . ulXraetion angiotrrt-m (DSA» t.o as_ frOQ now ud to RIO persiltent trige minalartery. Signi licantcTOQ·n .... ia a re!ativeeontraindiuo tion to anelth.tiling ttl. lide or dominan t supply (patient roe' t.o I leep). Wilda Uat may be r - i y matc:unol4l with hip flow AVM , Alao, poTtiOlll of hippoCampUl may be aupplied by po.tenor circulation (not anestheti1ed by lCA injection ). EEe monil.orina: it uau.llr perfonned durine the teat wlltn it i. bein, done for Iti. zure I u.ra:ery , Pat",nl will lllO"N deltt "'''_ duri", deepen I."el or anesthesia. T echn iq ue inl truct palient as to what it opectad tatheteri1e ICA: ul u. lI)" l tart on aide of lei ion '" NE.UROSURGERY have patient hGI':: contralateral ann in air, and instruct them to hGld it there inject 100·125 mS"sodium amGbarbjtaJ (Amytal®) rapidly into internal carotid ar· tery (effect start8 almost instantanl!<lusly, begins to subside afl.er_ 8 minutes (may subside in _ 2 minutes with AVM where now rates are high» detennine adequacy Gfil\jectiGn by asseasiog mGtor functiGn in elevat.ed arm (shGuld be _ flaccid) assess language skills by showing patient picturu Gf Gbjects and ask them to name each Gne out loud and remember each Gne assess memGry functiGn by asking patient to name a8 many Gf the pictures as they can _ 15 mi.nuUll afte r test: if they have difficulty. ask them to pick out pictures from a grGUp tha t contams additiGnal Gnell nat shown to patient repeat prac~ure Gn Gther side (use lower Amytal dGses '... lth nch subsequen t in· jecticm) INVASIVE TECHNIQUES EEG OBTAINED WITH INVASIVE ELECTRODES Risk Gf infectiGa wi ,h depth electrodes'"': 2-10%. Surface strip electrodes may be placed through a bUrT hGle. Depth electrodes m:lY be plac~ stereGtactically. Temporal depth electrodes may be helpful fOlr CPS, usually tG determine the laterali ty Gf the mesintemporal SOUT(:o:' nfseizure , Frontal depth electrodes a re also aometimes used . 2-3% risk Gfintrac~bral hemorrhage'·'. Subdural grid electrodes aC<l placed with a craniGtGmy. Thellf' SGmetime$ may allnw su.mcient mapping to permilsurgery under general anesthesia ..... ithGut need fGr intraGp' era tive mapping under local anesthesia (helpful in clUldren Gr in the mentally retarded). SURGICAL CONSIDERATI ONS Twn basic type8 nfpraceduC<l' ~sectiGns and disconnectiGns": 1. rellf'ctiGns A. resectiGn of epileptic focuB: higher chance Gf completely CGntrolling seizures. PerfGrm~ ; 1I nGneloquent brain. Seizures must have focal Gnset (resectioo nGt encouraged ifmultifocal Olnset) . lnc1udea: I. IUlterinr temporallobec:tomy: su twtGW 2. amygdalo-hippocampedomy 3. neocortical ~sectiGn8: especially with neurGnal migratiGn abnGrmllli· ties B. resectiOln Gf lesiGn in secondary epilepay (e.g. tumCtr, AVM, (8vecoous malfnrmatiOln'''" .. .). In mOllt cases the seiture focus is in Gr nea:r the leBinn, but $Gme structuraJ lesiGns aC<l nOlt responsible fOlrthe seizUC<l$. FOlr seizure foci within me temporaJ IGbe, sei~uC<l control i, better when JesiGnectomy ill accompanied byamygdalo-hippocampectomy'''" 2. disconoectinns: used when eloquent brain is lnvOllved, nrto sep8:rllte t he electrical activity nfthe twG «!C<lbral hemispherell A. ocetion Gf """,,"3 ."lIosu .... (o"ll0e0tomy): when d .... p Pt""O"," pre the ", .... t disabling seizure type Gr fGr multiple bilateral foci (.«< fwlow) B. hemispherectomy: fnr unilateral seizure.s with wic.esprelld hemispheric Ie· siGns and profOlu nd contralateral neurologic deficit. FunctiGnal hemi· spherectom y isolates the abnGrmallide with _ 80"" seizure control rate (similar to anatomiC hemispherectomy with pres<>l"Vatinn Gf the baBal glln· gl ia, but with lower compliClltiGn rate) C. multiple subpial transectiGn"': fGr partial sei~ure Griginating in elOQuent CGrtical areaS. ThecGrteK is transacted at 5 mm intervals, thus intelTUpting tbe hOlrizGntal spread nfthe seizu re while spa ri", the vertically Olriented functiGnal fibers ANESTHETIC CONSIDEPATIONS If intraOlperative electrocorticography is to be perfGrmed: NEUROSURGERY 13. Sei~ures '" uDder local anesthesia: theoDly anesthetic agents that may be used are narcotics (usually fen!.anyll and droperidol (the components oflnn(IVBr®) under genersl anesthesia: ~ benzooioupines and barbiturates INTRAOPERATIVE ELECmcx;ORTICOGRAPHY (ECoG) May be pe,;orroed with , urfa"" maw that includes superior temporal gyn>s and inferior frontal gyn>s. Depth electrode.! in the amygdala (3 cm from temporal tip) and hippoo:ampus (5 cm (rom temporal tip) may also be used. Methohexital {Brevitol@)maybegiven:observeforJ fast activity io s uapected focus. INTRAOPERA nVE CORTICAL SnlofUlATION For Icx:oting motor strip, sensory cortex, Or speech ""nters intraoperatively. Deter· mination bas...! On visible ana lomy is unreliab le. For 8J11l"ch center. stimulate cortex while patient names objects shown on picture cards (automatic verb3.1i~atiOll> such as counting, is robust and may p<'rsist ). Observe for effect/! ranging from lo!.al speech arnlSt to paraphuic errors. Typical settings for a cons!.ant current generator using 0 bipolar electrode ore shown in TOlI>J~ 13· 16. If Tsble 13-16 Senlngs lor cona voltage based unit is used , start at I vOllt and in · . Ienl CUfTenlge n&ralor crease. CORPUS CALL OSOTOMY Psrtialor total section may be most elTective for gene raljzed mitior moto r seizures. or little benl'fit for simple or complex seizures. Benefit has been supported for: L frequent episodes of~.lI..WI ("drop at· tacu") where loss ofpr;>sturallone - falls and injuries '" (70% reduction with callosotomy) 2, jlO:Ssibly for generalized seizure disorder with unilate ral hemisphere da mage (e.g, iD fantile hemiplegia syndrome): hemicortical resection may be better for this type, whereas callosotomy may promote partial sei zures. Note: Q "functional hemispherectomy" i8 recommend...! OVl'r "anatomically complete- hem;~ pherectomy to reduce morbidity ond mortali ty'" S. some patients with geoeralized seizures without identifiable. resectable focu! Division of the anterior two thirds of the corpus callosum (CC) (minimize. the risk of disconnection syndrome. su b«low) may be advsntageous over complete collosotomy (controversial). Some advocate sectioning the CC with intraoperative EEG un t il the typical bisynchronous discharges that are usually ~n become asynchrOIlous "'. No need to """tion anterior oom misure. Can u.ually be pe rformed via a bi fronta l craniotomy utiliz_ ing a bicoronal skin incision. May produce post-op I v.. rbalization or akinet ic mutism that usua lly resolves in w~u. ~ Contraindication: major behaviora l andlo r language deficits may occur even with partial division in patients with speech and dominant handedness located in .Qjlj& W hemispheres ("crossed dominance"l. Thus. Wada test i$ reeonlmended in aU len handed patients. MRI sagitta l cuts are superb for assessing extent ofdhtlsion of the CC''', ,, DISCONNECTION SYNDROME In a patient with a dominant left hemisphere, conaisl8 orlen tactile anomia , left sid ed dys prax.ia (may resemble hemiparesis). pseudohemianopais, right sided anomia for smell, impaired spatial synthosis of right hand resulting in difJicultytopyingcomplex lig· ures. decreased spontaneity of speech, incontinence , More COmmon with larger surgical """tions oftbe CC. Risk is le~s if the anterior commisure is spared. Patients usually adapt af\er2-3 DloDths, with final function normsl for most daily activities (deficits may show up on neuropsychologicsl testing). TeMPORAL LOBECTOMV 80% or patients with medically intractable sei~ures with demoTl6trsble (ocus have foci in anterior temporal lobe. Most patients have neuronal 1088 a nd gliosis of mesial temporal struot ures. Thus, a standard resect io n of temporal ti p (often wi th Bmygdalo- hippoc_ 13. Sei1ure$ .VEUROSURGERY ampectomy) may be performed. Limi ts of re"ootion (without aia-nificllnt oe urologic deficit) Not.:! tbat th~e valu" an! generally con.idered .afe, howe'>'e., variat ion. occur from patient to pIItient and only inll'tloperlltive mapping can reliably determine the location oflanguas-e «nle .."'. Some ~ot.:! rt .pare the superior tempore.llQ'ruI"·, Tlte following measure menta aN! made along the m.illlI.lt. temporal gyrol dQmioan1 temporal lobe: up to 4·6 em may be removed , Ove"'n!OJe(:!ion may injUn! ,peec h ~n t.:!ra. which caOOOI be reHably loc:ali1ed vilually non.dominant t.:!mpo.el lobe: 6·7 em mey be rue<:ted . Slip! ove r.resection may - partial eonlralate... 1uppe r !lund ... n! hornonymoua htmienopsia; l'U<!dion of89 cm - complete !luad... ntllnopyia Alternatively, intraoperelive electrorortico,,"l'aphy may be ulled to guide reaection of el\lCtricaUy abnorma l areu . RelICti on .hould b. performed in .ubpial plane ttl prevent il\iuT}' to MCA bTanchM. AM VGOALD-HIPPQCAMPECTOMV The amygdala liea in the roof of the ant.:!rior t4!mporal hom of~he lat4!ral ventricle. two buic approachea: I . t'8II.cortical: ima~ guidance i. very helpful A. Niemeyer approach "': 2-3 em longitudinal cortic&1 incision through the middle temporal gyrus centered . t a point _" em JIOIt4!rior to the tempo.."l tip B. approach through the anterior superior tempo.."l cyrus 2. transylvian: approach advocated by V.sargil. More ""'tfictive and great4!r ri. k of injury to Ml portion of MCA within . yMan fiMure Complications: va...,ular injury i, the most significant rilk, RISKS OF SEIZURE SURGERY Major riil<l; are related to' '': 1. removal of e!lSlmLial areas ofcorteJ: 2 , injury to meduUary core underlying cortieal resection (projection fibera, 855 001 , lion fibers. and/or commi8sura! fiber'): the ITI06t common deficit after tempo..,,1 lobectomy il a contralateral (homonymoul) . uperior !luadrantanoplil (1CKII1led ·pit·in·the-9ki'defect, due to an injuT)' to Meyera loop .... herein the fibe .. for the superior vis ual field of the optic .."d;ation t.akoe a slight rostral "detour" I.owaro. the tempo..,,1 tip) 3. injury to vtasoels in area of mection - ischemM: damagoo to areu supplied: "p"d ally sylv;8II branches durin( tempo<1lllobectomy or ACA branches with corpus callosotomy 4 . injuT}' to nearby c.."n'al ""rv,,: especially third ""~ during hippocampectomy whre it liea medial to tentorium PERIOPERATIVE MANAGEMENT FOR SEIZURE SURGERY Mlna,oemoent dun", eva lualion: During period when A.EDl l n! beingt.lpered, pa!ient . hou!d beobserved 9t.1I times (for paLitnta not in ICU. a 201 hour·a-day aitter i. required ). PRE-(JP ORD£RS (EPN.EPrIC SURGEflY) I . taper antkonvu:... ota. completely ])IC 1 day before surgery 2. 10 ml Decadron® PO h! bero", , uT(lry .•epeat PO or TV On AM of l urgery 3. ilKi&.um drytlpp: phenob.ri;,it.al 130 ml TV (. < 100 IIlwmin) PosT-QP OROERS (EPfLEPTIC SURGERY) I . ror ",i1u r" in the immediate po.tt-op period ("honeym«ln tei~UI'ea;·), not n"",· . ary to treat only one brier genel'tll iled lIilU"'. otherwise load appropriately with phenytoin or phenobarbital; 2. continue 4 mg dnameth"l0~ ( Decadr0r4) PO !I 6 hfl k ~, then taper over nut week (eatential to maintain for full ....eek) NEUROSURGERY 13. Seizu ... '" 3. 4. anticanvulsants aTe continued X 1·2 years even ifno po8t-<>p sei zures OCCur before discharge: A. neuropsychia tric evaluation B. serum anticonvulsant level C. EEG OUTCOME (VYrrn A£S;;:CTION OF SEIZUf'lE fOCUS) The greatest effect of seizure surgery is adJ.ltli9n o(lICi= frt'9uency'''. however. any surgical procedure way fai l to have a beneficial effect. Sf.izure con trol is usually assessed at 1.3 & 6 most post ap. and then annually. A POSt..OP MRI i$ usually obtained at 3 most post..op to assess extent oflurgical resection. Most patien ts take anti-epileptie dru gs (AEDa) far 2 years post-op, and then may be dis· con tinu ed in those free ofsazurea. Recurrent seizures: although late seizures may occur, 90% of sei1u re8 that recu r da sa within 2 yearll. 2yeano post-ap in patients maintained on AEDs: 5O'Ji> are seizur .... froo, and 80% have ove r 50% reduction ofiaz"re frequency . Far temporallobectomies ,n the dom inant hemisphere without intrllaperat;ve mon· itoring, there is a 6% risk af mild dysphasis. Significant memory deficits occur in ~ 2%. References 13.6. c.""...."'" "" CI."if",..... ..., Tcmli .. ",,~ of II>< I.,."..,,,,,,,", Lel , ,,,, A""o" Ep;k",~ , Prop<><oL Il . r", .....;>«Icli nkolond ."",u<><"""p"""",pI<i< 1. f"'t""" Com ..." ...... CI .... and T<rminolon of IlIc l"",mMl"". , W, .. AI'''''' Epo1c1"7' Ovj,jo· l. 6. I.... 'nt<,io;:IOI .fMl i<tal ",.Ipo""'"",,,,,,,pbo~. 11, '""""oJ ""v",ps)'<""Io;;':ol ''''' ",. neoroi"", ,,,,. rc"" .... "" P"""Iof', N.~rol l<l· 781 ·1 . 19113. EOld lJ. S""",, ro.- ,.1,"1'<' . N toll J Mod )}4, 641·)2. '996. R A. POll')'''"!"",,,", C P. I.""nolo .. y. ""0 On"""••", S. 9. 10. II, OC:IO,,,oep".PSY. A '''''' ... A"'. """"")I/: )90041. 19\13. !I ...... W A.A .... ,. ... IF. K ~ancllT: I ...... _ 01 'fIl"'psy"" ~od ..... "'" •• Iloch<"<f. Mi • ....,. •• 19)1· 19S4 . EpI"'Pl-b ",. 453·68. '993 Hou""W A.A""....,. V E.Lo< ......... R 8 . <lDI Se ...... r« ...... _ . fI< •• r. ..., .ni"<'voI.od .. i.. ~ N... [old J ~ t . d J(\1: Sll·'.19n. 11.<,,11 I. Icv;..... n HS. NaJ" .~.m. H."al, Seizv .... >In>ke: Prodi<toB.nd ~no.". "lO;ro· ;n ""_. Tho: COp<nJI,&< n ~""'. "o<IT. 15; 'S'S·S9.1m. Landr."' N.O .. ..,..· ~ """." M . W .ib1cyR E. <lol_ Now ",,10' childhood 1<.. "" " Eme,.... ) "'1II"l. """"'11<';'..0. J Fl. M<d ....... 79: 697·7((1. "".1< Sir"". ,m. 12 Ha .... W A. Ro<IIS S, 10«>11, r.t P. ~"'I. : Pu""" po''''.'' oI><;~_""" ....:l""'"rr.-0u4 •• ",ilb ... " Iy d"JnOOO<!'pi I<PSI". Epllq><Io 2a: S ' 6-1, '" ,. Ii ... f", .po<Iem.oIo,o< _ .. , "" <p.kps, . ~ pl ltp . "' lO, J89·9II,19S9. Mo«.. ,,~ R ~ .So EL- A<I""., _ _ h '011>0: d.".~ "o. or >e> .. f<, """ <p;kpI:< .,,.,,.,,,,.., M. ",ctI~ ...... ,1 : ~5·1 •. I9%. F","""J A. W.III" ...... P D.ThoGao; v 101, <lDI" a.....:''''''0CI 0( • •• ,1i0/ «mpenllObo: <pikp" . 1. Ro"l .. oI tH'''''JI_p~,''nl .>omi_, Aon Ncurol :14: n ..lIO. \993 Willi.m30n P D, F,.."h I A. Thad •• i V M .<la/, Cban<t<ri" . :< of m«IlOl,ompen llobl: opd<poy. ll. •• •. 1S. Seilures >du', ,diopo'"'' • ,.. "r", ..1oo 0( <plkp"" .. i....".. EpUopol. 11; 4S9 ·~1. 19S1 . 1913 (t b"""'). • ... 000",,.,, C. Sehim"""""" R.J. G«IU A T." "'" V.1v.cf 'h<.I<ct .... "'<pho~m '0 po • tI.n" "ith .'"reotod r"" ..." ..... A.... _<Ot4~ : 1ll-7.1m. Y"",,&O .Row RP.N_ n JA.,,"'.: F,,' ... of ~rb:,i<;al1, o<I""oill.,od p""nY'O.n '" I... po<I"................... J N...,.... " l IS. P"''''''' ~ 2J6. 41.1\18). A_tenJ F.Or.bo.d D co--.:. R V. o,"'.: Se,· •• '"" . 1Ier _ "'vmo; A Nn· <oIof.J XI. 683-'1. I990. B.lk>: ~ R.a...n" R M.CI;I'\oo(; • .,..,.; (;.ioIe11... 1.. 'ht "'t ".rt""" 01 ....... ~...:IIQj.'l' . The 0", .. r",um' f ou""",ion(l'/<w YM.,l. Tho: A... of 1«"""",ic:0/ S.'r<"'" IPorI! R",,. . llIinoi,). orIIl The Join, Soc,i,., of 1'1< •• ""..."" oM Oi'o<.'Catc, 19111 . M<Que<. I K. B100:~_ DH R.Horri, P. <la/ ' Low riol<ol 10.. poII"'u",,,,, "',vm I"U"".. , ... PDI'I'i""'" ,,0<1,. nc'. ,,,,,,,,,i..;,,., , ... I,..d 'nJUlY. J Ne.,01 Ne.!'$01l: ~y<bl'h" y 06: 3911·9001. l'IIIl . II. y""", O. R.pp R P. Non<" 1 A... o/.: F.II ... 01 ","""yla:,ic:. lIy od ..... ph<O)'lOin '" "" .. '" ...~~ 19. 20. 2 1, ..,.tod _"....... ,>0: ..,...... J ............... >3: n, · '.I98J. H..... y S.fIoOI>. S, A..---yA M, .,<IIo F.. <O<J;n· n..."""" """",""",,'0; .. <h;I<I.... Nn..... •..,rtcy 1); SM·l. ' 9l!8 W.i.. O H.sa.... A M. V-. SC.""" I'I--.o\i<,. '" I <pikp<, io P< ~.I _ i.jo· 'Y. ""h Ncurol 4): ?1 1 ·~. 1986, T.mI<inN R. D,l.meoSS . Winn H R: I'oo!n. .... 'I< C~G Non llA..... 1, .lS-J5. Lt."" ... poo,,,,,u.,.." .. ....... 1'.",....." ,~, 11 . Tom~i.N R.Di~""nS S. W;kn>l<, A 1.<101,: A m""...I.«I, _ k .bllnd "od)' ofpno:ny,,"" ro.- .... poi'' '.....1ic ..i....,.. N Er>zI J M..t 321. 4<n·lOl.199O. pn: .... ioo of 1) 1'. O;~ .... S $, T<"",I.1< Il .Millet B... IfI.: I«.tOOoIuo • ...., .rr""" of ph<"J'<oin pmpII,l .. " of pool' ,," ...... ic:"''''k$, JAMA 1M: 1171 ·7.19\1. HoIri..... A M . N .~I D W. Tcml.l.NIl.<lal, Sid< ;"'EUROSURGERY ">o<",cd ..;u, ... 0( "","y. 1"""'".....'" wi.... propIoyl>,I, J orr""", """ ......m!I'y 1<1;" f ... mly ". ~6 . ". " N. <. " " ". " ". ". ". " " ~. " N... reo." 91: n8·91. I'M Yob"", SA' I'O>'lao.... "' •.,'.... " «h Phy> Med II."".,;) 70, 91)· 1001, 1991 Nonn) B. J'cl,h. 1I It K. H,.,"" 1< ... uI.' """"ylOi. jlO>~"" <1'11<,..1: I< _1o·~I,"" >ludy.J N.u ...... " sa, 61l-l. IWI Ooorn... M E.S;""",1t P'~'JOA : EliIMIoI """ " .... "'''''' .y ..... . " Eo\~1 J Mod lll. 44l·~ •• ,"" 19~ . L..oc""n!>cfJ R. Womc,T 101: Sol,.", ""~ .... ,,,,... • • mnl .1coh<>I oxlO,irlC.. ...., . Arch ..... f"OI 41' ~)s.s. 1990. C'haboI I, I) R. Krahn I. E. s.o EI, "", . ,,"ydlOl"i< f101"I<~Itp1'" ,,1,",.<, .\1.yo CII. I"r<>< 7" .9J· ~.I9\16 0 .... I It . It......, V. Wh . ~n 5 . .,4L 10111 clu_ .. ,,";.-. of p><u~",,,• •. A«h lII ... roI.2. III)· 7.1985. Kin. D W.G>II>.Vo: ' II II. M_In AI. ,,"'" 1'><,. _ " , .... 0" , _ ,,, •• , ''''''' . N''''oIocrll, 18·2).1'182. 1I.."'luT F.T..,l.,OM. F"", I, ,,~I,' MMPI io· dice< In ,he i<1c .. lf""'...., of PO'''"'' .. ltIc"''"~ p....k,,,,I,,,,,,. Epl!.poIo ~9' I SO·7. ''lS8 Wyll" F.. I.ud<r1 H, M",Millo. I p, "41,: Sorum pr<>I><"n 10,,1•• flcr <piJe",1c "'ltUm, N,.roIov ).0. 1001 .... 198-< . DoN·t!acft J. Trimbl< M R. o.l.y l : Prol""' ,n and ,_",,"n.~on v. ro111:"',n'8<""""i-, ~ pulill ..1..,«, J ..... ""' ""' ........ 111 1'» 'chI • .,y 06: lll · S.I 9i ) . 'rid,,,,, P 8. W,._or II a.s"" , J."QI_ So· "'''' P<Oloc'i' 00'I<I _,001 ...... " ," .,..luu"'" of .,.._pltp''' "l,ureo. A.... Nturol "'17·9. ~, K D. M.llooly I P.H..-II 6; P>o'.cIln wnll<' ,~" .. ,"' .... ,!> .. ,fo«! by EE(; mooi' ...• i",. N• .....,...,.. )S, 11·~. 19S~. Abbon RJ . 8",""",C MC K, 00 __ Ol W. So· """ proI>cIl. >till CO!1i .... concrnu .. lo,,, Ir... . ...... mol .. I•• _ . J N,_ N< ....... -,: "'y<lllo,..,. "1, 16)·1, 1980. J><l<1 R A. MIl .......". O. TnY(ldl R. If <rI.: R<do<· 1"",0( "IJ>O'I~ ,."h "pc,;,;", " I,.m . ~e p,1o U ' SIS. '931. T"",,,,"T. I ~_ U. 8 Y.trQI_ SoNM do';", ",,",.p;Icp1i<u •. J " ... tQI .... y .... ...... Psy,~ ... 'l" 52 . 1 4l~"1 . ' 989. SpMinl M R, Pru,h¥<!' ,. """I J. " "'" FroIo<. ,io ;. ",n,,1 ,p;I<f'>Y: An ood«" '" <)fl,mtr« 1<,. ......... ". r<... roI :!II: 71(,,21. 1\>36, M... ~O<d U .~ S.LICbll"'.S . .rQl,oeomI*i_ of "" efl«:1"" lre"101 """ .. _ I lob< ""n .. I .. ; ..... .., ic.vel . . ..... b 1'1 ... ,.1.9' proI""". ,.l._ p<OJ.,,,,,, JPIOI""" ". 1hN·l1ocIlJ. Trimbl< M k ' """"'". and"....,... ,up;. '100' .... (ull........ " I" .pik ....po,Otnu,..I'h and owi_ F'Y<hopoIhololl' 8io1 P,y.hI01'l" 19, )Z9-l6. I9&-<. H,,,,,, AG . _ , n: QIKI ,rodi. , ... rdI ~,01 49. n1 .... 1991 (ed ,torl.l) V.n'yC M .Cold'",J ' Ri •• of <pll'pol,r.. , f<tnle _,ol,i..,,, A owionol «>lIOn >lwy. 1I.\1J JOl 1)1l.(,. 1991 , r ....... IIJ ~. La Y l.I1"" 00 ... 1>1" F't><oobutial for ft"b<il ...;'"" •. <II"«" 00 ,",,11;11<_ """ on .. I,." «<u"""".N F.dJlJ M.d lU- J601·9.1990 R.,."",nN P.CoI, .. T.l..lbO.",J . .. 0), A <Oft.. IJOliod ",.1 old,,,,,,,,," lId"'i";"''''' donn, f<brilo i"...." '0 i>«vetr1 ... unu<:< of fdonl< .... i..... . N F.r>;IJ .'1«1 l29' 19·84. '99) . \\''''',nl G""'P" S,at •• Epil<p"'''' Tre",mcm of """" I.i.. """<pil'plco"J" MA no; BSoO·9. 4. H," .. , W A' SUlu. ,p;ltplicoo: Ep,o\<m,oIoc'" """. ~. " ~. ~. " " B "B. • " ". " W 'ID. n~·lO.I99~ . " ". ... ,_ion>. 1""'' '' ........ ,W; NEUROSURGERY ". • " o. N... """",.'HSoppi 2t. 9-1). 1990. I'I"I)I,..S A,ShaUIIM R I. EI>oJocyond ...,.,,111)" of ..... , ,pikpoi<us ;" ,,,IIII,en, "I"<h N... NI~ : 1'-6.I!I89. It J.'dloc~ I M.T"...", A 1t.... aI" Ep. Idcmiolo&y or JIr. •• <P'I<j>Ii<., . J Cti. N....... pII.)"IIoI' I: 112·U. I99S. FoonW' N 8. E w, P.. lIOpIIy''''loIy or ""."pilo",;"",.J Clio Ne. n>pby<lolll: )16-. l. I99S, O'lpdo-I'.Icuc ..... V, W.... ,I.,.C.T......... OM. "4/' Man.og"""" of _., cpll<",Ic\l" N t.>gI J .'>'I«IJ06: 1))1-0.1982 8 . _ E.F ...",..J M: S.-.uupil<p'ic",. F<d, In R.,I.", • • la ~. 19112. CU"tOO e 0 , C. ...-.JI'-«I """ ...1...... >I""' 'pd<f'" '''u •• M.,., CU& Fr0<11: "1117·91. 19\16. .....y It J. K,.11 It I" T".,m<ftl of " . '" ,p,lcpol"" 1O<uo~ , .. ...,h III... , "~! ' 005-11.191)01 \..oW,n,,,,lnl) H.... ",lnoIfMJ.S,mooR P' B. tto, •. ...'" ......,~.".'n:l>< U,,,',,,,OI of" .. ", <plJep1"." C!i.",.I .. pcn,. ",. ... ,,~ I. "'''' ''''''11 1': J95·oI()(I.l'1U. 0....;.,1._ R CO T"""..... of,.r_1OO)' .h"'" ",no:-<"",,, "',u, .pH<p1i'., ... ,," II<noobor. b,lIl fI.,. ~iJlr _ pheJrylOln. F.pll,poio 1O, 006< ·7 1. 1989 . 01&0,1). M,II,"", M: Lon.!'pam ""., dim""" for III< '<u""'", of .to'u> 'p1Icp<1c • •. hd ..... III",· ",I 4' ljl·61. 1918 AppIc<orr It, S_"'1 ". 0I0arr .... I, <1.0/, Lot"'"l"m ....... di.... pom ;" u... ""'" "eatme,,, of <J>llcp<ie .. i,." • ..., " " ••• piltpicu •. 0 .. M", C ~1 1d N.. f"OI )7. 68H.lm. C...... f<Jr<lTO.Mi'chcli We. 5 R. I.o<' .. ",m ,.<~ IIoJ_ " . '"" <fI'I<p""''''' ",,,.1 .. i...... m«u ................ ""hypl'ly\o.oi•. N...,oIoII1l 7.19Q.5.19f7, Ub>r 0 R. .-....hm .... R_ J, Hi .... _ ,",,,,,, _.1000 ..1"" roo "" ~,,,••crllor .. f"""'l' ... 'LK <PI1op11""'.N<wt>IoU.wo '..:)).1.1_. Brod,. M J. Oi<l,." M A: An",,,,I.poiclirlll,. 1II l~ J :I'I«I )4' 1M-1$. 19901. M"""" R H . ~J A.Coll""l COM' pori>ot> of C"Mbomo:>q>i"'. pt><_I. phcoy"," In . ...t pri't'"d",,, ;., p"'iol''''' orawbrily 1<",,,11«>1 ",""..,1001< ..1...... III F.... 'I J 101«1 lll' 1.~5'. I'lSS. M.. _R H.C- I A.CoIIi ... ' F. .. _ _ of'll_"'''~<_''p1'''' r...,~ ........ '" of «)nIpI<. """1. 1...,.,,,. """ _ Iy 11<",,,,1,..., I" ..s..1 ... 1'1 ~ J M.d )17' 7(o}.71. 1991 Oruf. (""pilop'r· M«I 1.<,,« l3, 91 .). 1936 R ._ ~ 8.8o<.i", H E, ~nlop " . .. .0/, """",,,'"l phc")'1Oln_. I< ......... """""""', Tl>t, ~ M""H I: )!S.)). 1919. SoLI"') I.G" ... R H,SIwp W P.I""""'ionof ,..iI . ....... 1..-di,~.,J r ...... E., Null 1(1' In·). 1986. w""",.J P. WoodC A, W"",,,...,C H' """n)'\WI .nd _ C'>I,I< foodlnl" NeuJ"Olov}oO: 132. 19S00 0._""" L<l1",...., ...i," po'''.'' 1'''''' _"he.... So"""... f.""" "'""'ooon- 101',""''''''''' "'''''''' •" ". o. ". ro " " " " ". "........'''''n (1<,,,,). 8 .... 1.. I! A. 0.,,",,", O. v,n War. M. " aI .. "". n,..1 of "'~ of "" I.,", hJdloIHOi" . y... ..... 111< N E~JhI«I Jll: 1$(07.72.1990. 1'U~i< H" "1r So"'i«: FIuo> .. ""cphclrytOlll ,.. " . "","o... . fl)A M~ Bulltrltl 200, 3-<. '990 Winltlo,S R.I_M S' ... ",,,,,,il<p1I<~"" ....... PorI I. 1II...,..,a _9: 449·S2. ,m Ole! K S. w"'1>t M.I'..,l' J 1\ : C.'O$''''I'"I< ...... kif" ' il"' a", '" d"" I........ '....,: Toyotol ,nd Oorv .. , So ... N... ,01 31, I"'·! I. 1!I89 , CIak ..hou P. H... 0 M: V.I""", •• rId ""., bind•. II. M«I J 198, 1m-I . 1m. W,""i<w:ok; B ... C ... in W H: ()r,ce.dal ly rodmlni.· I'" '''' of pocoob.>rtoi"l I. odul", Clinical <lr"*'1 ptoll"'"'" s.. ... SeillJJ'eS '" ". • " ..•• ~ ". • n • ocI bt""r" . Arcb N<urol .l . /MI· 700. 1981 . 0. ... " Q.Muo:h .. K O. ~""'J II . • "tI.: On«·(\O,ly oIo<,nl .. ,1Jo ph<"""".".,I • • Mdt<n .. "h """, .. di_". PtdI "rI.. 68. 12.·). 1981 . Felhom ... . Mod "',.... )S, 10J ·~ . llI'Jl . Wiol./<, 5 M.l .. , M $.A!IO,.,iiopo'" w.,. .......... Pon 2 Su'1i " ..,..., 4<1. X>6-1. 1m, (lol:>ap<n"n.A_>lIti<on,.,..., Mcd 1.<11<, )6, ~, I 99-l ,m ~""",;" .. 1<lf<pil<f"J, ~'cd l.ri'" 37. 21.3• u.-",,,, C ..""" R. /)Lt ... , C.C • . - p • ., .'. oI,..j 'i"" ,. ',,,.:rr "')'00""';'; .pilep. ' y. [pu.poI. l~ : ~·Il. 1998. r opi,..". .. I", <II'lq»y . Mtd 1.<:I .. e )9. SI·l . '99), E. W,lda 8 I. R.m .. y R i . .. I>I. Top, ..• "'... pI_",",,,,,k<I_'''.,;''llnol in ..I ..... IO<y ~.i.1 <1"l<9>y •• i.1 200 •• 4(1). •• nd 6OI).m; d.ill~ . N ... """,,06' 1/>1:4·90. 1996. Pr....... M,FiDCh""'It.~')' J. ... MI · Topi ....... pl .. doO-<omrolk4 _·".Ii.,..-Iol in ... f..c,Ot)' .pik".1 ",inl 0\00., soo..>nd I JXIO."" d.i· 11 -...." . NtUTO!otD "". 167S-13, 1996. Ti ....i.. l",opil<p>Y. Me.d L<1 .. e40, .S-6. 1991 Sm._, E 1\, Epil.poy i. _ . , M.y. 11 9'11 ·9.1996. C.II •• ~", ,.,. C.~" A. Cocci. T , W,LM ...... ' ~f • ",i«>...'"., dru,. ,. Ir« of for J Mod lIS' 9-lH,. ,9$1. 1\-.0. T. 6 ... ,,,..C.I'<,,_A,,,,,'., II ."",. "..i>oo ..,,_._.001 Ill ... .~ "'_."i_.".I<".~: A P!O>PK'"'' " ""y. 1I The EEG .. p!<d...."or .."'o.... I", ..."", .....1of ,.....' ...... . ;";1.,.... ll: 22S-J2 . • 9\17. Mo4i<.'I1 ...""h C.... ill\.'i.,;l ...... Otul Wi'h· d, . .... , S''"'1 C,,",p. R _ .... """1 of ..... p;. 10",1< (In., ...;tMo. .. oI"'~" Lo . .. , Jl7 (I1S1t. 117S-!IO . 1991, D"'~&O: .. " II. I.,,, D: eoru. ..... I.id.I, ... , """ ..... ,. _ _ n.. I' ~'._ ....... or:! ..... oI oh< ·"h <pil<".,. 1'1", ,,,,,,,,'1 (S.ppl S~ 149-60.1991. 101",..,.. R H.C .. ...,. I A.n.rn.y P D." at · UIe"" 1 ............ i'~ <II,lepl1 Jo\MA m . 1JS.<1O. 19S~ . Po"", .. E. H<dJeO A.I,UH, K A. •" .. """1 of 111< ",I." ... en" ... i"'''"in5 proper. , ... of ",tI<oo .. ~ ... dIU" in 'pile", .. pot.."" . Be J ClIo I ' I L _ /I' 401·10. '''''. V,~ M S. F.. ,I P N. McCorm,O! K: 1\""1"1<1"" dlUl d""",,,,,," durinl "',ur%p" '1 (S.ppi SJ. 11-6. 1m Di ... M S.5<.." .. L N: 1"_,,..;,) fLo""""",,, I""" ..."')' .... oI,..j _r"'''''''''' moll....-Ion. ~iO£ "',"""'1'ocI II,. _"",n"", N........ ......"" 1l.ljS·66. 1990. I""", K L. 1.0<", R V.JoILn_ K 11.,,1>1.. P."."" oJ ,..11.",...,-. in ,flo </.;"",. of _ . "."cd ... ;,h ••"" ..... duno, PfCI'-<I. N "".' J Mcd )1(10 1661·6. 1919 , Rw.o F w · Spin. tor.,. i. ,., ..... .,.....,.... ' ....cd ..,'h<ut.",..... pi .. duLinIP"'I...-.:l N EnJlJ M«I Jl': 61' .1 . 1991 Han._ J W. Smidt D W: The fetal hydo."';' d ....... . J PftIO" 17. 28$·90. 19~' . S<oI.ok D, Nul", •• I, Roo<! J. '" N.Lll<U1'01op..... 01 <hi"'« ...1">'«1 ,n"""" to""")1Oin .nd st""'" .".... F,."" .. 1'0."" ~. U. " ... .. ~. " " " eu.. """, '''''')'UN. '" .:.." ),<-,1>"""""''' ", ... ", ,."n;"",... 1""'.'" "'''''''... ....,"""''"''''pU..... .. " • • ";"n:' 1"''''''' .,.1_" __ 1"""""'" ,..v: 'Y" .1. .>tbam>t<pi"" "''''''''hrnpy. JA.\lA 211 . 167·70 • • • "" '" 101. ,~ . NIok_ V.Ok.m.r. TilL"'."" M... ~I' M uk,~ ... "i"H;."w ..O<l, Q/",h< ..... """"rtl and r"., 00';" joy of 00'''1';101''0: dnol' 0(. <011.1>< ...",< "udy 1""'1' ,n ,..,..... f.1'i"p5Ia 11, 66)·80. 1980. W"""C 11.8<1'; V.G><, P$,.,.," OUIOl)fl"l<'l Gf ,.... ..."'1 .._,...., ... iLh "".. p,I<po;,,,,,,,,,I\,,,' r«oocol II, I»-J. 199-' K' noo J II: U.. 0( 1)0,,<0</;_1"'" d"'., p"'ln'.· <y. lobo<. _I..,...;"". ',",Ill 1'>""'"'" ",I'rr«< ,0 pII><m><oI;, .. D<vp lJ: lSO·IQ , 11."'_ ,L< _,........ ,m S _ " M: r:p,kp>y L< """",n 0( .h,IOI"",,,., . : 11 ...,itton •• I,."" ..""", bt . _ •• sc .". t>am><'p'n<. 8, M.d J 199: S81. 1989. N.i".,oI ln,uM•• oI!l,.hh C_nlO. 0."'''1'" .... , Conl.retI«: Su,1C'l' lor .,0101", . J I\MA 260: 129·)).1990. 8orwYI<I<A I. Rowl., H A,I\_""", F' MR in ,..",oJ.",kl"l" V.""of ~"';.", ""', ..... rio: L«~.iqu<' . A./NR 16: 139-4l. I99S. O&/i./ey I. OJ<LnI •• C A, 0 _... l M, "MI. /drn. oly,", .";Iopt;'; f""i on :ooon .. _ CI\T o< •••• l\rd N... ,.06:669·1I . 1~79 . H..... y AS.H'pl.i .. 'I . Bow< I M. .. MI. F""",I lob< 'p,lq»),: O,ni .. , .. i.u<echOiX' ..... "".ocI "'illl "".1 \99mfl"o·HMPI\O SPECT ",.. t%c.J. 1%(,·10 !993. w..;. I. ~ ........... T'. In"..,,..,,, loJO"'1coo 01 ""JU! for"" I... "!i"~",, of .... ~.p«<h 00 .. • in_•. J N.~, ... " 11: J66·81. 1960 Qtoc< ..... 1 v.c.m..no l 101: IId.""",'.,f>< ........ .u'II<.1..... J<"I<l" 01 _I, <IIikP'Y, Con! ... p N.u ......... ,~(l6) : 1-6.1991• Coh<. 0 S. Zulooy C P. Good ..... R R' Soi..,,_· I<,oonc<<<>"'j fox •• """""" ma'f""",,· '''''''. J N........"83: 2l1 ..02. 19'15 . _ R . V.h !l·S.I'I, .... IO"" 0,,,01,: """Y ..,,'" .k<'rophy. ,o"'ll<o1ly I UiOod ...... .,. I", .. """"., lob< ,,,""" ... nil... ,"1 ",i,,, c"'"pk. N....... '1i13: lll-6. 1m. Mcrn:1I F. W W. 6 1«k T P: M.I'iplo,"" pi.1 """...,i",,· 1\ .... ~ 10 ,he ..",<01 off.nl <pile ... ,. J "'...... '1i 70. lJI·~. 1919, (l .... J R."'pp,~ I E. hpl. "at .. eo.-p •••• Il00010"'1: Cli";';.1o<Ld .Ic<'rn<n«pI>oIoJrl.p/Ii< .fI..... ~piI<,... .I~, 3(l8.16.linI . M .n",,~ . R"uzo PC In tpil<pty and ,be ...... PI<' .&lIOIum. ~ .."'. 1\ C.'«I.f. Pie •• ", ,.,. ... Now Vmt. 19S5: pp 181..J()1 80$•• I E•.'kh.l" D H..... oi., P I: Ccmpl ..... Hof al""""'my ......·• by MRI ""fLo 1ao, ,,,,,, . l\rdL N........ 5: 11Ol.$. 198t. 0;."'""" C A: ' n SUrp-., ' .... 'm ... ' oI"b< <pI1,,,. ..... F"I<I 1 .'«I.) . R.I'~" p,. ... Ne ... V", ~ . 1981. .. 10l. , lOS. 1<>:.';"';,0 ,~ '" ,~ """" .n., ,~. 11(1, 1..0:.-.. "",,,,,,,,'."'.J WM",,, ,<UO""'., III . II~, '" '" pp6J5,q . liS . 0;."'""" C A: S." ... I ""'''py I", mod""" y ",. ..... 111< ''';101''1. J 1'1.."""" 66: .89-911. 1917 116. Ni<nl<y<f p. wlric.I., ."'Jrd«iQ.hOp. po<Q"P«'_l iw I<" 'p<;roi _ .pil<!'". I. T..... por.1obe 8...,.... ILl o<Ld 80iky p. IM.f. a..,,,,, C Thom», Sprin.r"kl. 19$8, PI' 461·12. C,andaU P H: C"'......,,,""',,.,..,. I. S. ...... , " ..""..., of 110. <pliO,,*,. F.n1'1J. (<<I.). R.... n Pfe>o. N.... Vort. . 1981. PI' 377-4(>1. 7Jo.,,.,.... qijo,.,. '" NEUROSURGERY 14.1. Low back pain and radiculopathy TKey points' law block pain is comm"". and in _ SSilomc:ues, no 'pe<:ific dillgIlOllil can be tnIIde ,niti.I ....nmenl iag•• red \.I) de~tinM"red fl.~~ (indiCliting pnl.entially aeri(>u5 paU\oloi)'l. and in the abHl'K'e oflheM!.lmaging ""diu and further tellin g of pa· li'nll; i, u..... Ul' not helpful dllrinr lhe f'"'t 4 W"U of low batk .ym ptom. relieJofdiKorur"rt un be bqlacllieved wilh nonpre&Uiption pain meds and/or 'pinal manipulauOl\ while K tivi tieol .... ay n«d lO he modified, bo!d rel t br.yond 4 de.yl may be more hlnnful than helpful. and patients .,,*enco\lr8~ \.I) r8\\Ull t(lwork or their nOrmal da ily aclivit.n a • ....m .. ponibl .. 89-~ ofplltientl with low block problems will impl"O'o'iII withi" I month even without tr.. c.m.nt wilh Or wilhoutlurgt''Y. ~ ofpe t ief)ta with .cia ti"" ""enLually rem"cr Low back paIn (LOP) !sexlnmel, preyalent.1U>d ;,lhe_ond mourommon rftSOn for people to seek medic,,1 att,elltioo' , LaP aa:ounts for . J M~ofaU lick lea ... from work, and q the ......tcomrnon QUleDf disability fOl' peI'Ons <"45 )'TIl sge". EU.imatu ortifel ime p~lencenn(l! from EO·~ •• nd the .nn ....1 ;ncid~nce" 5"'" Only l ~ ofpllti~n u will have nerve·rooI.8ymptoms.~d only J -3'.fJhllvf Lumbar diac: hemiaLion. The progl>OIIis for n'><llt ~ DfLBP i. load . a nd improvement "s"a Uy IIttUn with Little or no medical in· lervenlkm. • D EFlNITIONs/CLASSIFlCATlONS ,~ rtysbn:lCon rA'!IfI.-.e roaI [~ItId~may iIIc:t.Ior:pM'Il'iiieiii.... l/'itUOIIrA ....1 _ roo:, dem>iI!IwnaI sensory disIurtancH. ~ rA IIIUiSdn n-o.rv.lfo) 171' Il8MI roo., and ~ III\JSIX ~1dI reII!.- 01 lie umalll.lKlesl ~1 N<A "!Io.I!CIlIoW!",$bae\ ~ (boll ~ 1em'IS) iht 0II!!Wiif.niliiTIDi low loW ~ ~ bid pa!II. May rftlM IrtJffI $II.., rA !hi . ,. . . ~ igImenIs. ~ ot !~ joonIi .•• E.td\.des ~~ ~ C&IIi8S te.g. bID. d!l: 1lefTU!1OII... ) ""*''"'* "'I NoMENCUtTURE FOR DISC PATHOLOGY Ki.torically. the to>:rminolac h.. been conl.erlt.io". and n"".Ulndardised . Many diagnOllt ic Jabel. a re II.ed inoollli.len\.ly le.l . IpondyLo.i • • • pr.;r.. ' t rain . mUICU)OIkeltW p.tIl/l. ,"YeNaKial pain .. •). A l ubM:t ofnomenelature proPQlld by a task {orca" i. alIown in Tobl. 14·1. which il IIHful pri ma rily fDt oonai&lent "'-rrninolOO related to radiocn>phl<: reports. re.."" h .. Oejtc ocr al.ed dllle: ..me repDfU indiQle thaI Ih_ ca .. QUM radk\dar "" in poi.iblj by." in!htmmatoty mec:hMi~m·. bill th" ill oot. univ. naLly ~pled. Du lg:iDg d' ae: taay 01' may not be I ymptom.tic. Vacuum di e<: ' imarina lind>np orCas In t he d;te 'pKe, \&aulLly i l\Clical,~a nf d llc deceneulion. Non-St llDdllrn terme TI, elM! i<!1"IJ1!" art! inel"dat for QllnpLet.en«4 but are WIJ. rKOOlmended becauie th~ may be co nru .ina or inllccunt.e' Co ntaIned h e mhtti n n~: dilplaced disc tiuue en l;"'11 I:OnUlined ...,thin an "nin· tel"T\lpt.;!d ( bu~ po4Iiibly d iotended ) .nul .... or atp"ule (lin' ~301 fo r d.!:finil.lon rump- Nf.'UROSURGERY 'U/f'). Ilmay be difficu lt t.o distin(Uish thi. on currenuy av.ilabl e imaging . Iudies from an unconll ined he rn iation wllieh i. undern",alh Ihe pO$lerior longitudinal lig.menl. Ruptured di..,: coJloquiallerm uaua lly in tended to be equivalent to herniated dille. Table 14-1 """'" Reco mm en ded classifies- tion Table 14-2 AHCPR classification It i, I'fl<'(Immended' that acule bock problem. be cl sssir~d into OIIe of lhe 3 eatcgon C/i shown in Tablf' U ·2b!1.ed on the ~ and phui<;al euOl (tee 1";liaJ I,. ..... nunl o{lM palif'nt wdll bocApain below), Further evaluation, lrealment, and eveo 1I000e inform a, tion !'Igarding prognosis esn bo bated on Ihi •• im pla elull li"" tlon . A m-.ioT 1!NI1 is to delcet -red nap' that may ind icate potantially sen ousspinal Or nonspinal pathology (1ft P"'8f' 292), ....'''' .. , Table 14-J Modic', ciasslUcatlon NoMENCUoTURE FOR SPINE PATHOI.00 Y OUTSIDE THE DISC Ve .-u.brai body ma.....,w c hanles: ""-iated with depnentivcor in na mm"ory changes. Modic'. c:l aMi fic:a tion' orMRl characteristic. ilshown in T"bI., l4.J. lnCeMIty ch..... ~ I n .. I I 2 I *,Of , 3 I I OeKrip~on -- DOnt marrow edeflll 8&SOciIled vriIh IMe Of ~ ..,...intJa~ '4 , Sp,na and aponar cord It ... bent mlrl'l1W by III fIIt'tNt OSI~ NEUROSURGER Y DIFFERENnA L DIAGNOSI S The differential diagnosis arlaw back pain (so,oe Low bee. {XI;", page 907) overlaps wit h that af myelapalhy . 10 . 85% of ~ases of l.BP no sp""ific diagnru;is Clln be mad"-, INmAL AS5 E5 SMEtfl' OF THE PATIENT WITH BACK PAIN Initial assessmeot:onsists ofa history and physical exam focused an identifyingserious underlying renditions such as: fracture, lumnr, in{eelian or cauda equina 8yn. drome. Seriaull condiliotlS presenting a8 1nw back problems are relatively rare. HISTORY The fnllnwing jnfnnnation has been rQund to be helpful in identifying patients with serious ullderlyingcam!itiaos such 118 cancer and spinal infection'. Tobie 14·4 shows the sensi t ivity alld specif,ci ty. I. age 2. history Gf callCer (especially ma lig· Table 14-4 ,I na""ies that are prooe to skeletsl metas(aSe9: pr()litate, breast, kidlIey, thyroid. hl1lgl il 3. W'lexplained weight loss 4. immullosuppre.sion: from steroids, organ transplant medica· lion , orHrv 5, prolanged use af steroids 6. duratiall of symptgms 7. responsiveness to previau s thers · , 8. 9. " at "histarythatohk..in infection: especially pai n is wone "'$1 furuncle 10. history ofrv drug abuse II. UTI arother infectian 12. pain radiating OOlgw the knee 13. persistent numbness or "'eaweS!; in the legs 14 . history of significant trauma. In a young patient: M"VA, a fall from a height. or a direct blow tothe back. In an older patient: millOr falls. heavy lifting or even severe cough. ing can cause a fracture especially in the presellCf! ar GS\.e(lporosi s 15. findin~ C(ln. is Umt witb cauda equina syndrome (see page 305): A. bladder dysfunctinn (usually urinary retentinn , or ave rnow inoonlinen.:e)o r fecal in · con t inence B. saddl e anesthe9ia: _ pagt '" C. unilateral or bilateral leg , estilna'e weakness or pain 16. psycholGgical and socioeconomic factars may lnnuence the patient's report af symptoms (also see {XIgt 296), and one should inquire aoout: A. work. sta tus B, typiealjob tasks C. educaliana llevel D. pending Li~igat ion 1::. worker's compensatian Or disability issues F. failed previou s treatments G. s ubstance abuse Ii . depression NE:URQSURGERY 14 . Spine and spinal cord '" PHYSICAL EXAMINATION I.~&a helpful tha.n the history i.n identifyillg patients who may be harboring mndi· tiona such as c'''lcer. but may be more helpful in detecti.ng spinoli.nfections. I . spinal infection ($fe ~ 240): finding!! that suggest thi a as a possibility (but are also common in patients without infection) A. fever: common in epidural abiICe8/! and vertebral osteoml'elitis.lesscommon in di.~dti5 B. vertebral tenderness C. very limited range of a pinal motion 2. findings of jXl6Sible oeurologic compromise: the following physical findings will identify most ca~es ofdinically significant nerve root compromise due to U -5 Or L5-51 HLD which comprise:> 9O%ofcases ofradicu)opathy due to HLO (limiting the exam to the following might not detect the much le811 common upper lumbar dis<: herniations, which TUay be difficult to detect on PE.1tt P'l8" 310) A. dorsiflexion atren~h of ankle aod great toe: weakness luggests L5 and some U dysfunction B. achilles refle~ : d iminished reflu suggests 51 root dysfIJ nction C. light touch sensation of the foot: \. diminished ove r medial malleolus and medial fOOl: suggests lA 2. diminished over dorsum of foot: suggesta L5 3. dimini.hed over lateral malleolus and lateral foot: suggest.'l SI D. straight leg raising (S LR) {also check for crossed 5LRI: Itt fHlIJe 302 "REO FlAGS" IN THE HISTORY AND PHYSICAL EXAM FOR LOW 8 AO< PR08LEMS Based upon the above history and physical uam . the findings ia Tobl~ 14·5 would suggest the pos.sibility of s seriOU9 underlying condi t ion as the cause of the low back problem_ with FURTHER EVALUATION For over 95% of patients with acute low back problems. no further testing wilh· in the first 4 weeks of symptoms is required '. In the absence of any of:he "red flag" conditions shown in Table 14·5. no further testing is r«ommended (even for patients s uspected. of having a HLO) and the treat!Dent is similar for most patients with an acute episode of low back problems. Si mple laboratory tests including CSC and E5R are sufficiently efficaciou s and in· expensive that they should be obtained when there isa suspicion of hack relsted tumor Dr infection . FURTHER EVALU ATION OF PATIENTS WITH LOW BACK PRODLEMS EKcept for those e><hihiting "red flags" l$fe 000.... ). special diagnostic tests are usu· slly not needed during the fi rst month of l ymptomB !in~ it is not ptI8lIib!e to predict which patients will improve las most do) and which will not. TESTS FOR EVIDENCe OF PHYSIOLOGIC DYSFUNCTION EMG for lo w bac k proble ma: IfthediagnOl!is ofradicuJopathy seems likely on clinical grouod s. electrophyaiologic te$ting i8 not r«ommended'. However. these te9ta may be useful for patients with suspicion ofQlher condi t ions (e.g , neuropat~ y . myopathy. myel. opathy ... l Or wh en the diagnOlSia of radiculopathy is uncertain (e,g. a HLO on MRI is not always symptomatid. 'I'esting is highly operator dependent for a'X'u,""cy. 1. needle EMG : can assess acute and chronic nerve root dysfunction. myelopathy a nd myopathy. Not ind icsted and also Wlrel iab!e when symptoms pre38nt < 34 14. Spine and spinsl coni Nlf.UROSURGI:.'/lY WHU. Over.1I accuracy imprQvn w,th knowledge abou t imagin, studies and clinical intbrmalion'. ,",CCUnlcy in predict;n,]f"!] of involve men I" is _ 84<.10 H-ran ....: me .. u.... HIISOry conduction through nerve I'(l(lUi. U,ed 1II001ly 1.0 u _ _ 51 nldlcu iop.lllhy" 3. SEPI. u ..uas .. ntory neU/'ll1\$ in pl'rip~ ...l nel"'U and spinal c:ord. May be ..... ftll in ... aJuptiIlll81.11pe<:te .pinal.tenosi. or .pinal myelopathy <t. rM!1'Y1 conduction ~t udiu (includill/l NeVa): hell» identify acute and c:hronic tn_ trapmeM neuroplllhiu th'l may mimic radiculop"lhy 6. II ROt reCllmmend<)d fOT uae"' n, A<:UU! low bIIek probl~.' A. P·wav. relpofl.le: me.Illrel mot.or conduction through nervi roou., u.sed to ~. ...eM proKinUl1 ~W"(lpathiu 8 . ,,,note EMO: " uefiHl,CUU! and chronic reo:",ltment pIIuenad"ringltac.Ie or dynamic task, using ... Tface {i1\lJtt!ad ofnHclla} I!leetrOdea Bon e ".,. n (or low bAc k proble m a' De.uiption: injection ofradinlabeled oompnunda (usually technetium-99m) thDt aN uken up by metabolieaJly act ive bon@. A gamma cam _ enl i. then uaed w l(I(:el," region' nfuptllb, Th, tnta! radietinn dGH;' equi"elentto a aet oflumbDr apin.(! lr-nya' . Contnlindicat<':d during prepancy, and b~nt reedifli mUll be sUlpended for /I brief interval fnllow;ng ~ bone Ic:aon due to po-eII!lICI! of udiotrater ;1I the breast milk. A mGd~ra tely leuit;v, ~t whi(h may he u~ in ...."Iuatlng low be<:k JMlin when spina l tum or ", infection", or IH:CUIt fr*,!ura;' 'u'J*~ fTOm"r«t nags' 1_ Tobie 14· 5) 011 history oreKDmilla tion . or ruulUi ofJ.b usta or plain .·nlYI, Not....,.., lpecir,e, but may locat<': occult IH;onl alld help diffu. ntiate thea.. conditioru frQIn def:f!neUl.lve chllnge" A p<»itive bone IlCan I UggolSting one of theM oondi t lona u5ually mult be confirmed by ot her dil'(tlostie t.e$/4; or procedure. (no Mudi.,. h,vfI eomp.rtd bone tcalUI to CTII' MRI ). Low )"leld in patienu with lonpt.anding low beck problema and normal plain . -ray. and labocatllry I.elIta lespecla lly £SRI". Thermograpby for 10.... back proble ... ., N!)t r<!COIIIm.nded' . Did not aa;uulely predict absO!nce Or presenceofnerv. root wmp",..ion seen at su rgery", and may be pOIIitive ;n !lsignilicent percentage of 8S)'mptomlltic I>It;ents". RADIOGRAPHIC EVA LUATION Diagn()l;ing lumb, apinPl ~tenO/iis or t..miated inurverub.-al dise;' ... ually helpful only in pOl.ential,urrieal o:andidaU$'·. Thi& inc:ludes ~ti~o~ with appropriale. dinj· cel.yudroroe5 who have not respOnded satisfactorily to adequall non-au.rrieal treatment over a iufficient pe riod of time. end who have no medical CIHItnlindic:aobon. to IUrger)'. RIIdiologk confirmation of these diagnoaa uluaUy requi res CT, myelography. MRl. or $Orne <:Ombination (... bdow l. N8: mye lograpl\y", CT". or MRI" may also show bulginll or herniated lumbar Wid (HLDl or spinal stenoai, in asymptgmati, patif:f\~ (e.g. 2"'1> of asymptomatic pati",nta bav" hern;8ted diSCI! on MRland have ,pinal 5uDO:!li.; thelM! numbe .... become E6'l1and 21~ ..... pl!Ctivel}' in patienta 60-80 yun old,... Thus, tMtt- IUt . mull be inr..."reted In lilht ofebnieal findinp. and the anatorok level and lide shGUld comispOnd to the hIStory . examination, andlor othu pbysiologic data. Diag· rKNIt;e radioiocy is of limited benriit l1li 1M initial flValu5lion in the majority of spinal dilOmen" . In lhe abte(lCe ofud nap fO/' seriou, condllluu, im.ginl.$hJdie$ sr. rIOt recoinmen,u.d in tbe lint month oflymptoma' For patieo,- ... ho have ~ preyioln bad surgery , MRI with c:ontl"ll&l is probably!be besl tat. Myelography (with "' without CT) i. in~asi~. lUld haslncrealoKl risk of compliatioru, and i. ther..LOre ind icated only in !lilu.tio.... where MNl cannot be donee or il inadequatt. and I Urpry II anticip.a~ . 4' • NEUROSURGERY 14. Spine and spinal corti PlAIN WMBO.SACRAL X-RA YS UnOl!xpeoted findina:S(H:t ur-red in only I in 2500 IIdultt < l\O yea ... ,,"", DilfTlOti. of l urgiuol conditions ofdisc herniation aod apinal stenosis cannot be made from plain f, lma. Va rioul cOR£ilnitalabnormalitiea of uncertain silr"ific,nce rn a, be Identifi ed (a .l _ 'pi na hiM. occ1,l)ta). a nd evidence of dea;eneraUve chanle. (including oeteophyt.esJ are a. frequent in sy mptomatic a. in asymptomatic patients. Gonadal r.diation il , ign;fi· canL Seldom indict. U!d durinr prtlr'lsncy. Recorumeoda tio n Not. recommended for rouline avaluatioo ofJn.tieou with acute low back problem. during the fI ... t monUi oraymj)tomt unleM II "red nag" i, pree.ent(Itt' kll)W). ~rve LS x-rays for plltienta with II Ilkehllood orbavillll' apioal malignancy, infection, innamm_tory 'pondylit;', orcl ini",Uy significant frllCture . ln the" calel, plain x-ray. are o1l.enjust II .tartiJlt point, a nd further study (CT, MRl ,.,) ruay be indicated e ven if the plain x·rlly. I n normal. "Red nags" for thBe conditiolll includ .. the following: I . ~:>70yea ...,or <20y ... 2 •. Iy.wruically ill patienta 3. wmp:> 10000F (or :> 38' C ) 4. hii toryofmaJignlncy .5. reoent infectioo 6. patienta with neurologic def,cita IUResting possible cauda equinasyndrome ( ... eldl .. a nesthesia, urioary iocootioelKe or ~ntion, LE wewess, 6« paNe 30$) 7. I\Hvy alcohol or rv drug a bulen 8. diabet ;'" 9. inunllJ"lo.upp'lIIIIIed patientll( ilKluding prolongd lteat.rnent with corticoste.oids) 10. reoent urinary tract or Ipi nal l urgery 11 . ~1I1 traUIllll : any ...e with significant trauma. 0':>.50 yrs old with mild t.aurua 12. unrek!oling pa in at ~ 13. persisteot pain for more than - 4 weelul U. unexplained weight 10M .....'hen s pine x-rays a re ind icated, AP and lalellll views are usuaOy adequa~. Obl;qua and coned-down L5-$1 .iews more than double the rsdilltion eKpoIIure. and add infon.... t:on in only 4-h of c.llses", a nd can be obtained in specific int tancu where WaT' ranted (<!-!C". to diagnor;e spondylolysis when lpondylolisthesis ill found on the lateral film). MRI MRl hill! supplanted cr and myelography for diagnosing moetdiac herniations and also in most cases of apinalatenoai • . n.e test of choice for patienta who have had previoul badliUrpry. Specificity and ~.iti";ty ror HLO are on the allme order ... CTlruyelOjlTa· phy, which is better than myelography alone,· .. • . Advaotages: I. provides inf(N"mation in ..gittal plane lea n easily eva luate ca uda equina) 2. provides information re,an:iing tissue o utaide ofth•• pinal ca"al (e.g. extreme late..al disc herniation (Me paiJf 311), turno ...... ) 3. non·invasive alld does not in""lve ionizing ."diation Dildyan la,.*, I. plltienu io.evue pIIin or with claustrophobia may have difficul~ holding It,ll '2. d .... not vi.ualiu bone w~1I 3. poor for etudying blood early (e.g . • pm..lepidu,al hematoma) 4 . eJ:J)@IlI'ye(nOl.l:maybemoreCOlte ffl!divethanmyelographyi f pon·myelogram overnipt hospitatiution i. avoided. and especially if a rln complic. tion from myelographyoccun) 5. difficult to inlt'llre t in ct._ ofltQliosi • . Myel~ may be luperior 6. a numberofcontraindi:atiooa: 1M COII lraiiVlieoliOlll to MRI, ~ge 135 Findiogs: In addition todemonltnti", herniated lumber dise 1l{lJ)) outaidaofth, dill<' inta.· Bplleeeompruaing ne ..... root Or thecal J.K. MR.l can demoo'U"IIte .ignal ch'''geI within Ibe inte ...pace Iuggeetlve ofd.ilul.tftllm!.ilw" (Iou of.lgnal intenlity on 1'2WI, lou of dille , pace he ight). LUMBOSACRAL CT Not co",idered i tate ofth. art.lrtac:hnical1y adequate ,marescan beobtained {e.g. '" 14 . Spi". and .pina l cord NEUROSURGERY good quality scanner, images not ob$cured by artifact from patient moveloent Or obesity), CT can demonstrate most spine pathology. For HU l, sensitivity is 8O·95%,!lJld specific· ity is 68·88%"· '". Howe_er. even some large disc herniations will be missed with plain CT. CT studies for HLD tend to be less satisfactory in the elderly. More utility ... ith frac· tures. Disc maUlrial haa density (Hounslield UJ1iu) ~ twice thatorthe thecal eac. AS!IOCiated findings with hern.iaUld disc include: I. loss of epidural fat (normally seen as low density in the snterolateral canal) 2. 10$5 ofnonoal "convexity" of thecal $ac (indentation by herni;lted disc) Advantages: l. images 80ft tissu~ to a d<.'gl"(!e th$t may bI! adequate 2. excellent bony detail 3. non·invasive 4. outpatient evaluation 5. evalustes for extreme lateral disc herniation to SOme degree 6. evaluates paraspinal soft tiuue (e.g. to rule out tumor, paraspinal abscess .. ) 7. advantages over M"RI: fasterscanning(significant in patienu who have difficulty laying still for loog time), less expensive, less claustrophobic, fewer contrllindica· tions (see Contra;ndiallion$ U) /WRl, page 135) Dissdvant.ages: 1. does not evaluate &agittal plane (may be partially ameliorllted by eliminating skip regions and then utilizing computerized sagittal reconstruction.) 2. ev. luates only those levels thals", .scanned: A. higher cuts must be taken through the COnUS medulla ris to avoid missing occasionsl pathology there B. performing cuu only through the disc spaces (a COmmOn practice) may miss pathology t.etween tbe disc $pa(e$ .s. sensitivity is sigqilicantly lower than MRI or myelogramJGT MYELOGRAPHY With water soluble contrast, sensitivity (62·100'Jt,) and specificity (83·94%>-" are similsr toCT for detection ofHLD. When combined with polIt-myelographic CT ~can (my. elogrsmJCT), the sensitivity and ""peelally specificity increase>'. A herniated disk in the large spate between thecal $BC and posterior border of vertebral bodi"" at U·SI (insen· s itive apace) may DOt be seen on myelography (CT Or MRI are usually better at detectingthis). Advantages: I. provides information;o sagittal plaoe (unlike plain CT) 2 evaluaUls cauda equina (unlike routine CT) 3. provides "functiooaJ " ioformation about degree ofswnosis (a high-degree block will allow now of dye only aller certain position changes) Disadvant.ages: I , occuionally requires overnight hospitaliution 2. may mies pathology outside of the dura (including far laterally herniated disc). ~n$i~ivity i$ improved with pOSt·myelogr"phi~ (,'T 3. lIlVaslVe A. dru!1:S e_f(. wanarin must be stopped, and sometin:.es converted to heparin B. with occasional side effects (pOSt LP HlA, NN, raN! seituru) 4 . iodine allergic patients A. requires iodine allergy prep B. may still be risky (especially in severely iodine allergic patients) Findings: HLD produces extradurallilling defect at the level of the inUJrvertebral disc_ Mas· sive disc herniation or severe lumba r stenosis may produce a total or near tot.al block. In some c8Ses ofHLD, the finding may be very subtle and may consist ofa cut-<:>ff of the fill. ing (with controst) of the nerve root sleeve (compared to nOrma I nerve(s) on contralaUJrIIl side or st other levels). Another subtle finding may be a ' dual shadow· on lateral view. BONE SCAN Seepage 293 NEUROSURGERY 14. Spine and spinal cord '" DISCOGRAPHY Injection of water· soluble contrallt agent directly into the nucleus pulposua of the in· tervertebral disc being atudied. Re~ults of the test depend on volume of dye accepted into the disc. tile pressure needed to iQject.the dye. tile configuration of the dye (i ncluding leakage from tile confines of t he disc space) on radiographic imaging (plain x·rays produce the so·called "discOf(ram" , CT scan may also be utilized), a nd reproduction of the pa· tient', pain on injection. Someoft he basis for performing a discogTam is to identify levels that may produce -discogenic pa in" or-painful disc ~yndrome", II CQntro~ersial point (see PRACTICf; PARAMf;Tf;R 14·5. page 300). Critique: Invltsive. Interpretation is equi'·ocal. and complications mayoccur (dillC8pace infection. disc Ilemiation , and significant radiation expo.ure with CT-disCQgr8phy ). May be ahnonnal in asymptomlllic patients""'· (as any of the above tests may be) IIlthougll tile false poaitive rllte may not beq uite this Iligh"'. SeePRACTICf; PARAMETf;R 14·9. page 301 for recommendations. P SYCHOSOCIAL FACTORS Although SOme patienta with chronic LPB (> 3 montha durlltio n) may h9ve started offwith a di agn0$8ble condition. PlIychological and socioeconomic factolll (su~h a8 depression. secondary gain ... ) may come to playa lignificant role in perpetua ting Or amplifying pain. Psychological factolli. especially elevated Ilyateria or hypodiondriasis seal.... on the Minnesota Mult iphasic Personality Inventory (MMPI) were found to be a better predictor ofouk:ome than finding-s on radiographic imaging in one study'. A .creening lICIlle of 5 factors has been proposed'" (positive findings in any 3 suggests psyehological distress): I . pain on simulated axiltllOllding: press on top of head 2. inconsistent performance: e.g. difficulty tole rating $traight leg ra ising (SLR) while supine, hut no diffi culty when silting 3. ove~action during th e physical exam 4. inappropriate tenderness tbat is superficial Or widespread these two items may not be rf!liable. 5. motor o.r sensory abnormaliti"" not the others an potentially reliable'" co~sponding 1.0 anatomic confines However. the usefulness o.fthis info.nnation is limited. and no effective interven· tions have been identified \.0 address tllese factors, Therefore the AHC PR panel was un· able to recommend specific as:senment tool . or intervention.' . I T REATMENT An initial period of nonsurgical management ("conservative" treatment. /IU b<!lowl is indicated except in tile followingd rcumst.smes where urgent surgery is indicated: symptolT\l ofa cauda equina syndrome (urinary retention. saddle anesthesia .... see Cauda equino, S)'ndn:m... page 305). progre5Sive neurologic deficit. or profound motor weak· ness . A relative indication for proceeding to urgery witllout conservative management is seve'" pain that (/Ul not be . ufficiently eontrolled with adequate pain medication (ra",). If specific diagnoses such as Ilemiated intervertebral lumbor disc Or symptomalic lumbar ~ ten05 i e are made. euo'gical tfeMme"t fOj' theoe- conditione Play boo considered if the potient fails to improve satisfactorily. In cases wllere no specific diagnosis can be made. managementconsisUi o.f conservative treatment and following the patient to rule out tile possible develo.pment of symptoms suggestive o.f a mol"(! serious diagnosis that may not have in itially been evidenL "CONSERVA TlVE~ TREATMENT This term has regrett.ably come to be u.sed for non·surgical management. With slightmodilication. simila r spproaches can be used for mechanicsllo ... back pain. as well as for acute radiculepathy from disc herniation . Recommendations (based on AHCPR findings' in the sheen"", of "red Oag-s-A): II . OOm. kty liten"u", <iUl io .... tt it .." h.",. prim.rily lhooo rrom Ih. . heAnn<y forll •• llh C. ... Pol .<), and Re...... h lAHCPRI po...,1 r.r to 8i"", .. aI. ' for MI an.Jj'I;' and li.t ~ref.~n <H ". 14. SpiJle and spinal CQrd bt",,, , tu<!i.. lho• • uppan ~m",.nd •• iona. H.,.....or. re- NEUROSURG~'RY 1. activity modirkationa; nn studies were found thal met the panels review criteria for adequate evidence. However. tbe foUowing information WaS felt to be useful ; A. bed rest; 1. the theoretkal objective is to reduce symptoms by reducing pressure on the nerve roots and/or intradiscal pressu1"l!$ which is lowest in the s upine seOli·Fowler position" , and also 10 reduce movements which are e,,~ienced 88 painful by the patient 2. deactivation from prolonged bed rest (> 4 days) appe8.1""8 to be worse ror patien,", (producing weakneS8, stiffness, and increased pain ) than a gradusl return to O(lnnalactivities" 3. recororoenda tio",,: the majority of patients with low back problems will [lot require bed rest. Bed reat ror 2-4 days may be an option ror thOSl' with severe initial rodU;warsymptoms, however, this may be nO bett.,.. than watchful ....·aiti ng<' and may be hannful" B. adivity modification 1. the goal is to ath.ieve a tolerable level of diM:Omfort while continu ing sufficient physical adivity to minimi~ disruption of daily activities 2. risk factors: although there is rtOt agTffmenton their uact role. the following were identified as having an increLsed incidence oflow back problems. Jobt requiring heavy or repetitive lifting, l<ltal body v;bra. tinn (from vehides or industrial machinery), asymmetric postures, Or JX>Stures sustained for long periods (jndudiog prolonged si tting) 3. n!<XI':IIMndationa; temporarily limit beavy lifting, prolonged sitting, and bending or twisting of the back. E6tabli~h activity goals to h.. lp focus lItU!ntion Oll expected return to full rumtiona1 status C. exercise (may be part of (I pb ysical therapy program), 1. during the 1st month of Sympl<lU18, low-stress aerobic eJ<erdlle can minimize debility due to ina~tivity. In the rorsl2 weeks, utilize exer· cises thal minimally stress the back: walking, bicycling, or .wimming 2. condjtioning ""ercises fOT trunk muscles (especially back extensors, and po88ibly abdominal muscles ) are helpful irsymptoms persist (during the first 2 weeki<, these exercises may aggravate symptoms) 3. the,"", is no evidence to support s!retcbing of ba~k muscles, Or to rec· ommend back·specific exercise machines over traditional exe....,;se 4. recommended e~ercise quotas thal are gradually e5(:8lat.ed resulta in betU!r outcome than having patients simply stop when ptlin QCeur!" 2. analgesiea; A. for the initial short-term perin<!. a~taminophen lAPAP) or NSAJDs (ft"e page 28) may be used stronger analgesiC!! (mnsUyopioids , see page 30) may be requi~ for """ere pain , usuBlly severe radicular pain. For non-specific back pain. there was nOearlier ~etum to rulL activity th8ll with NSAJDs or APAP'. Opioids .hould not be used,. 2·3 weeks , at whi~h time NSAJDs should be instituU!d 3. muscle reluants (set page 34) A. muscle spasms have not been proven to cause pain, and the most commonly used musde retaxants have no peripheral effect en muscle spasm B. probably more effective tban placebo, but heve not been shown 1<1 be more effective than NSAJDs C. potential ror side effeeLl: drowsiness (in UP to 30%). Moat manufacture ... r«(lmmend U$e ror < 2-3 weeks. Agents su~h as ~hlorzoxazone Warafon For1.e® and oth era) may be associated with risk or~erious and potentially fatal hepatotoxicitY" 4. educAtinn; (may be provided aa part ofa pbysical therapy program) A. explana tion of the condition to lhe patient" in understandable terms, and positive rea 88 ur8nCE! that the condition will almost certainly subside" have been show.., to be more effective than many other rnrms of treatment B. proper posture. sleeping positions. lifting teehniqe>e •... should be conveyed to the patient. Formal "back school " seems 1<1 be marginally effective" 5. spinal manipulation therapy (SMT); defined as manual therapy ill which loads are applied to the .pine using long Or short lever methods with the sel«tedjoint beillgtaken 1<1 its end range of voluntary motion, rntlowed by applica~ion of an im· pulse loading (may be part or a pbnica l lberaQY progrnm ) A. may be helpful ror patients with Reule low haek problems wilhout radieulopathy when used in the firat month ofsympl<lrns (efficatY al"l.er 1 month i. unproven ) for a period not to extee<l 1 month a. NEUROSURGERY 14. Spine and .pinal cord 8 . illluffidfn~ .... i.t.ne« to Il'IlOmmend 8 MT in th., p~flCt! oInodi~u\(lp'lh)' C 8MT .hould not be u:M!d in 1111. face ofuvere or progresSM! neuroLogiedef;CII until "!.iou. CQllditionl hllve b<!en , uled Ilut D. • reporta or.~rilll d,ulI'Clion {"lfI'lt;~ Il)' veneb",1 arl.fcry) (let pagt 883) and e VA. myeloplthy" 5ubd"ral hematoma wit h cervical 8MT lind cauda .quina l}'TIdrome wltll lumlmr S MT"'"" a nd t he uncertainty ofbenelita h ....., led to the que,t ionlng oftl\e ulle ofSM'J'II (npecially eervica1) 6. epidural inJeetiona: A epiduul lcortlcoJ.teroid iujtctionl (t';SI); there is no evidence thlt Uti. i.ef· feet iveln treating .eute r.diculop.th,.... ProI~ti". Iwdie. yield ... aried retul ta" , S<.>me improvement It 3 &. 6 w~ may O«:u r (but no function,1 benen t. lind no chunge In lhe need for ,ulVery). with DO bMeli"t 3 month .... The . e."onlf in chronic bock JIIIin iI poor in COlllpllrison t.o aool.e PIIio, ESt ro8y ~ In option ror~ reii,fol'rodi<ulor .,.in ... h~ncon , Iml on 0.. 1 mtdkltioh, i. ina del'tuale or for patlent. wh. are not lurpe.1 alndidalel 8 . there i. no evidenl:e to . upport the ut, of epidur.1 ,.uec:tignl olltel'll,d.,I.,. cal IInnt he tk.. and/or gplo.id . for Lap wilhout ..diC\llopoolhy C. efficacy ... ilh comn lignillueh I . lumbar _pinal ~ tOnnietin," _tcnos,. ... PRAC TICE PA R AMETER 14 1 INJtC"ON ' H ~~AP' .0" ,OW'PACK PAl" OplI0n5" : lumba r epidural ifl,ie.:tionl or t n@r point in,j.etionilrelllll.-n· I!,lend ed for long·tenn relido(chronkL8P. These techniqu.. o. fa~1 il\ject,olUl may be ,,1\I!d to provid e ItIOJIONII)' relief in sel""t pl tientlo DiiiftoiUO DptiDII5 "~ lu",ba r faeel lojecllons may pndict the respllnf;e to ndiDfrequency facet ablltion • nm rewmmende:i ba r (usion 11& a diagn*tic tool to predJtI the n-s,onte to lum· ~Ql. recommended by lhe AHCPR pan .. I' for trealmenl of aeu\.e low back pl'llblems In the a~ of"red nap" (."" TaMs 14·5, page 2921: L medieationl A. or.1 lte roids: 110 dIfference was found alone Wefl: and 1 year Biter .andom· iUtiOn to receive I WNk therapy "'lUI oral den.nwthuone or plMebol" B, wlc:hicln,; <:onflicting evidence. show. el1M. IIOme" or rod" mer.peutic bell' er;~ Side effect. offill\' and diarrh'" C /ln l idepre,na lll medications; UlDSt I t ud;H 0(01_ m4!dicatioru; were for dron;" back pain. S _ meUlodolo(inlly f1a_d studlH fai led to .h",,,, benefit. when compared to placebo for thronit fn~ acute) LBP" 2. ph,..ic.llnaUn~nl.$ A. TENS (u 'Inec:utar.O!OUI eleclncai nerve alimuiation); lll!lo slatiltk:ally aigtill'. icanlb' belter than plaoebo. and . dded no bene!;t toexercise al~ B. tnoc:tion u ncludinJ' po!lvic t raction): not d.llnonllrated to be I!ffectiv~ C phy.kalarenuand mod.lititt inctuding hut (i ntllldin, diathumy), ice, ultrasound. Bendt ill ilUlu(ficienlly pl'O"en , however, ..If·otdmuUste....! home prognlnl for application ofhea~or cold may be COf>Iid~""!. Ulln. lound and dialhenny Ihould nOl be uled in pl'1!gJlanty o IUUl b.r COrMt. In~ IUPport belta: nol pI'O'Itn beneflCi/l1 f(or atut.e bIItk pmb· Ie"",. f>TlIphylldit UM hal been advot't.ed, hut thil l.wn lrovfniwa' E, biofeedback; hOI not beftliludieci for hatk problema, Prim.rily ad".,. fUeci I'or c:hronk LBP, wbere ,ffKlJventSl b mntTOV .....i.Ifo> 3 in,jKl>On ttlenpy A. InAer poin t and Il,amentous lnjKtionr thO! then')' Ih.t l riUt' points c:lUH or perpetu.:e LaP bcontrove,..ialand disputed by "'11I}'1!JIp.ertll, [II' jeetiOl.lI 01 local allHlheue an! of eqwvOC81 emeaty 8 , ranlt jolnl injectiON: theo.-et k.l ba,il i, thai thtl'i! Wit. I "fll<:«1 sy n· dro m.e " pTOCiUClnC LBP ... hlth i, ",grev,ted by _pine ute!Ui ion, willi no ne"" root ten ... on _ignI i _ PGII"302~ No I ludi" hive Idequ,tely i.wel ll· "ted U'\)«'tiooe fOT pain < 3 monr.ha4ur'tiQn. For du'onic LBP, neilher Ih e .,.,nl nor the locat ion ( intrar~oet or p.erieapllulad m~de , S'IIlif.aonl differ. ~ce in outcomes" .. C. epi4un l il1,ifttiml in thl!abaenCO! of ... dltulopoothy: _ a~ .all' '" L4 , Spi ne and ,pilla! cord ,..'EUkOSURGEm' D. .ctlpunclu~. no . t udlu were. f"und thnt evlllUII I~ the. u.. in pcu~ b.ck problema. )JJ nmdomi'ted clin ical lrla l. fOUM we~ for pat ienu w,th chron· k LBP, and ewln th' besl /l.tud'uwert! f'lt to be. mediO(:N!.nd con trndictory , Indl c. t; onto for , urllcry ror bOlnlhlted Jumbar dbe: In p~litl/lt.l with c 4·8 w~bd"rllt;on of symptoms: A tllou wilh "l'I!d nap" thol wMlld II'IIIke.lh~m Mndid.lel flIT urgent tT@al· IDfn t (e .i . c:IIl.lda equina s )'l1drome. proi"UoIIiwe nel.lroioric IN!flcit.. .. ) B. ;",II;Ii lil), \.0 conltol l'/l.in wllh adequate p.ooin medication (uneommun) mill)' ..qui t e. e. t ller rldiographlc eVllWltlon IOMI'On.llderation for I Urce.ry InItie.n ta with ~ 4·8 weeu of.ymptoma of sanies that Irl both .."ere and di. Bblinl: Ind ~rll not ImPTowinli "";th lime, with a I"lIdlogr.phkaU)' identll'il!<labnoromalit.JI thaLc:o.rt!IBtu with lindinp on thl hietOry Il1Id ph),lic.l fun, I. 2. PRACTICE PARAMETER 14 2 MRI & Q,<,.COGIIM'I1' 'O~ PA"tt" S[l re'",,,' 0" LU"B~A ~USIO'" Guidelines"": MRI i. ncoa,mendlld u the mitiel di lgnO&tic te'l norma\lIppearing dillCe on MRI , hollid not be c(msidltel.l for d~­ ph)' ortrntm»:nt lumbltr diKOgTaphy should not be ulld es. tland ·a lOQe telt if dilCOfl'aphy .. ~ : to c_ider • dlec level for l rtatmlnl Ih, ... ahl)Uld be .. concordant paoln raponsllt A a!illOciatad MR I .bnormalitiHl Opt ion s"; diKOlP'l,ph.y I hotJld be rese,.."ed for e.quivoo:al NRJ liodinK*."pedally lit Illvel, adjllC1Hlt to I,Int!qUTYOeIIU)' abnormal 1_" 101, _ _ "" _oI_~._PRA.Cr.cEP~/oAEr£R """"""a8tII PIIoIn _ . '*" IClenlicai O! ..,., ........ ... 1!1I.1IMieN·' oogIa;>ht""'PI'~_.L8P""_ _I'MIOO$(:~"" "'-R I :~'" ' • . I. jIOIQII2M _1*11 ~ INS _ .......... """'~ r2'WI""""'intet>MY. _ _ ~._CNIn\JM.. _~.......,.ItaeIlr'odlrQl_"~oo::ur.,~~ I"dic llli o" a for fUIIloD for chronic LaP without lItl'nMia Or -.>Ondyl olil theal.: PRACTICE PARAME. TER 14·3 LI,I'AB . ~ 'us<or, ~O~ lBP "'<TOmu' SH~OSIS O~ SPO><O'"O,-,~ "'ESIS S l ~nda r ds'": lumt.a.r fusion is rtODmmended for CIIN!rull), Hlected patienu' WI th d,ublin, Lap due to 01111- or lwo-Ie.ve.i dtgenuat;"e d ~ without sleno01' spondylohathQis I i. Options ......: Inlel1l"'e Pl'and cognitIve lh~repy I!I reoommended lUI. option ft:r pllUenla wjth LBP in whom con.-entiooal mediUlI mon.ment h .. failed ;"1M~~~po6.ulwl_L8Pkr~:l-"_I'II1d~~oI <boo~"""""U-u"lS-S I , ,,,-._r..<I"""_INdicIoI~ PRACT CE PARAMETE R 14 4 CHOICE o. <1,15'0" T~CH"'OUE liuldellnU" , ror Ai.I P or AU f'. innrummllltion. the addition ofa posleroI"\.eral r... ion il not recommended" Options" ; either a potr...mlat.l!raJ f ...ion Or In loterbody fUl! in... (PUP', 'fU r 0< AUr) are OptiOfT. lOr pa!.le1llll with LBP dIM to DO D I~ I or 2 J"y~bo an interbod), graft lI.n option to U1Ipl"O\tf! fulion ratn and functionll DII\.COmet III lh~ ua. or multiplJ: approaehfl (anter>Or" pl»t.I!riorl il nOI recommend- ed ... I'OIIt",.oplion ror LBP without deformIty "_" __ .".1T>""o> ..,.. _ ~_""'_. ' III--""IIIme_bk>oa_~ ~ .. ...,...., .... _ _ "'' '' .. IrQ..IId~''''' " ... NEUROSURGBRY ~ ~~. _ __ ... .. lINDOiIO,.., (• .11 a64j' 1IIHTn1 ~fuI5on .~ 101_ Spme Ind .pinal cord '" TYPE OF SURGICAL TREATMENT Th. type of surgical proc. .peeir.c condition ;dentir.ed. Ex· .mplea.re shown in Tobit 14·6. DilCullion options i• dura chosenofi.lOme tailored to the • 1'0 provided below. f~'~b~"~'''''~i~~~~:;;':O~W~b;';':k;;~1 Lum ba r s pi na l fusion Although thtre is no conleWlUSOO the indication."', lwnblr , pinal f"lion (LSF) i, I~pted treatmeot for fracture/di,location or instabili ty relulting from tumor or inre<:_ tion. For degenera t ive apine di5' eUf, practic"" plnunewra IuIve been developed and are indud· ed herein . Options": lumbar fusion i3 DIl1 routinely re-r:omroended following dilC exci.ion in patientl with HLD Or recunent HI.D c....inlj" ... dicu lop'-:hy lumbar fUllion ;. a potenti,ladjund to di lC excision in aolel of a H I.D or Tee"lTent HLD: • with ",idence of preoperative lumbar spinal deformity or inlubil ity • in patients with chronic IUi.1 LBP usadlted with rad.iculoplthy Ins trum e ntation 1111 an IIIdjunct to fu s ion Opllo ns" : pedicle oc,...... !lxllinn i. recommended a. I t.r ntllwm t option for petientl with I.BP ~ated with po!!terolateraJ fusion who Ire It high risk for fu· sian railure~ - . . ...... 0I1*11c1o SC1ews II diSOOU<8ged bK:aoM 01 conIIiaing _ _ ""'_.-.c.oI.......-a>sI ..... 01 -.1IDgeI'* _ ~ Th e u.. ofin.tNmenlilion increa_ the fusion ratel">. Hardwlre used in the It;.. een« affusion will eventually fatigue, especially in the region of the lumbar IordOlis. Therefore , iMlTumenlalion mU$t be viewed ala temporary internalltlbili1inl" mellure while ,waitinl" tha ruaion prooeu to complete. S urgica l fu lion option ! Eerly experien« with midline f .... ion. rel"lted in luroNr ' pinal ltel108il as 8 late complication. Then.foT1!, CUlTftDt fUlion t.echniquel ..... pamro-llteral rusiQI<, Or enteri(ll" or poIten« lumba. inurbody lUlion. POltenor lumbar interbociy hilio n (PUY): Biliterillaminectomy and aggre&Sive di&cectomy followed by the place ..... nt ofbane grsf\a into the decorticated dillc .pace. It h.. been adYOCIIted to redUOl the movement in In abnonna l "motion "gment" (defined .. lhe lrel between twO vertei:>ra). Relatively contreindicated with well PT1!urved dille_ ' pI« height. Mlny PI.I Fa when atudied ~ 1 ,.."Ialolr Ihow re-<:OUlPH of the dis<: apaCl:', which raiu. the qUlllion II to .... hether the PUF has I ny benefit over 'i m~le di8CeCtomy. Sund... lnM PUF. may be _ilted with P'08""!"IIIive lpolldylol i,thesi l ll that leveland Ire usually .... pple ..... nted with pedicle laewtlrodl. PUF i . ..lltively contraindicated when the di,k ' PIOI ia very Iall. An t enor lUJ'lli>ar In t erbody tulioD: Re ll tively contraindicated in male. beclUse of ri,k Qrretro..... dt ~"ulltoon in 1-2iio. JOO 14. Spi .. e and Ipin.' cord NEUROSURCER Y PRACTICE PARAMETER 14·, 801<[ G"MT HI~"UH'S & SUBsr'HlHS St an d a rd s ": auto:ogoul boml or ~mbi nallt humin bone mOrph~Mt ie protein t rhBMP-2) bone grin I ubatitutl iI recommended in Ih, setting of I n AUF in <'OIljunction wilh I th~aded liUlnium clge OpHons": rhBMP·2 i.o conJu.nction with hydn>)(yapa tite and lrio:l!ci wn phOlphate may be lubLtitut.ed fot lutorran;n lOme callet of ~Olterol~ter~1 fU l ion n!cium ph.. phate il recom.men ded AI I bona vanaxtendar, upacia lly when comhined with autoiogoul bone Aase5Ioi n, auryic:&i lumbar fI.Il lo D: See PRACTICE PARAMETER 14·8. PRACTICE :>ARAMETER 14·8 R.. O!()(.R"~M'C ASSfSS"'HH Of fUS'O" StandardS" : It.lIlit ". rays ~lone a .. rua r_mended Guidelines "": in t he illwln£f or riJid inl tn.oml1\tation.lack o/'mOlion between verU· brae on laten' n"".o.vuleo.ion x-raya i. high ly au.ggeltive Or,uCff$$_ rul fu.ion • tedlnetium·99 bone Ka nnin, il DIll recommended Options", radiOfTaphlc techniquel, onen in «Imbination, mlY be used when failed lumbar fuaio:l il IUl pected. including: atalic and nel<ionlexte nsion x· raYI, CTscan NB: t~ il welk «Irrelal ion belween fusion and dinic:a.l ou l«lme. Op tio n s " , tha «I.,...,la l ion belween fu.ion and clinical ou tcome il not s trong, and in given ,it uaLon fusion sLa tus may be .. n,.d(Jf~ to QUtcome CHRONIC LOW BACK PAIN Rarely can an anatomic diagn..il be made in patien ta with chronic: LBP" 3 monthsduralioo" . Abo, lee P~iol r~IOI'" pace 296. Pat ients wi t h chronic pain Iyndn>mel ICPS) ",fer to their problems with af_ fecl iveOl"emotional terma with a higher frequency than th .... with acute pain". The amQUnt of time that a pa· tient hal bHn out of work due to low back problams i, related Ul the ch llncea of the patient getting back to work II.i Bhown in Table 14·7. 14.2. Table 14-7 Chances ot pao lien1a going back to work TlIM out Chancel at gettilT9 at -..:oB bitt to-..:oB < 6 mol 50'4 " "" Intervertebral disc herniation INTERVERTEBRAL DISC The funttion of tile intervertebral dill; is to pennit stable motion of the spine while l upporli.ng an d di stribu t ing loadl under movement. ANATOMY Aoul ua fibl'Otlua (IInulu l may alte rnatively be lpelled ann ulUl, but r,b rotul it the only correct "pe ll ing and II distinct /'rom!ib,.,,'-,'!': the mu ltit.. minsted I.,a"",nl that en· rom pa .."" the periphert of the di$e apace. AtLach"" \.0 the end·plate ca rtas"" and ring opophYllul bone, Bland s ce ntrally .... itb th e nueleul pulJlOlU.l. Nu c:le ull pu lpo.u l : the centra l portion of the disc. A remnant ofUlI! notocord. C ap. w e': combined fibers ofthe anulul fibror;Ullllld the po5terior longitudina l li(. ament \th is term i, useful b«au~ th ese 2 stn.oetur"" may not be diltlnguilhable on im' ft,; ng st ud'''''l. NEUROSURGERY 14 . Spine lind I pinal «Ird '" 14.2.1. Lumbar disc herniation C LlN!CAL ASPECTS The posterior longitudinal ligament is atro~at in the midline, and the posterolateral annulus may bear II disproportionate portion of the load . The .... rore , most hemi. at.ed lumbar disca (HLD) OCCur posterior ly. slightly "ffto one aide, compressing a nerve root, characteri~tically c81l3ing .""".e radicula r poin . (j.{,<lt of rrea fragmentll that miI!T8te move superiorly. Characteristie fmdings on the history often indude: \ . symptoms may start ofT with back pain, which aft.er days or weeks gradually Or sometimes suddenly yields to radicula r pain oneil with reduction of the bac k poin 2. precipitating f/lctors: varioWl factors are ollen bl amed, but an! rarely identi fied" with «,rtainty S. pain retiefupon nuing the knee and tlligh 4. patients generally 8void e~C<:!$I!i"e movements, however , remaining in anyone po. sit ion (sitting •• t.anding, or lying) t.oo long may also exaceroot.e the pain, some· times necessitating position changes at interval. that range from every few minutes to 10.20 minutes. This i. di.tinct from constant writhing in pa in e.g. with ureteral obstruction 5. eXlIoerbation with ooughing, ~noezing, or straining at the 5t.ool : t hi, positive ' cough etfeet" OCCUCT~ in 87% in one eeries" 6. bl adder sym ptoms: the incidence of voiding dyafunction is 1·18<J&13'.-. Most oonsist ofdi fficulty VOIding, s training , or urinary retention . Reduced bladder $/.'n· satinn may be the earliest finding. Later itis not unusual to !lee "irritat ive" symptoms including urinary urgency, frequency (i ncluding nocturia). increased po8tvoid residual . Less oommonly enuresis, and dribbling incontinence is reported in radkulopath~ (note: frank urinary retention may be see n in cauda equina syn· drome, ut be/ow). Occasiona lly a HLD may present only with bladde r symptoms which may improve after surgery"". Laminectomy may improve bladder function. but thi, cannnt be allSU red PHYSICAL FINDINGS IN RADiCULOPA THY Back pain per se i8 usually a minor component (only 1% nf potientB with scute low buck pain have $Ciatica' ), and when it is the only presenting symptom, othe r cause.. should be sought (see £,ow bod. poin, page 907 ), Sciatica has such a high sensitivity for disc herniation , thst the likelihood of a clinically significant disc heroiatio,," in the absence of sciatica is 1 in 1000. ExceptioIl8 include a central disc hemilltion which may cause sym ptoms of lumbar ~ tenosi8 (i.e. neurogenic daudication)or a cauda eq uina syn· drome . Nerve root impi ngement giVO'fl riM to a set or signs and symptoma present to "ari· able degrees. Cha racteristic $yndromes Bre described rnr the mO$t cornmnn nerve rootll invnlved (~Nerw mol synd.-omes below). [n a aeries ofpatientll referred to neurosurgical outpatient clinics for radisting leg pain, 28% had motor loss (yet only 12% listed motor weakness as a presenting oom· ph.int), 45% hRd ..,n~"ry di_I>I<Mn,..,. Rnd 51% h~d rene~ ~h~n~ . N Findings suggestive of nerve root impingement indude the following. Toble 14·8 shows the sensitivity a nd «pecHkityofsome findings on the exam among patientll with sciatica. 1. signs/symptoms of ndiculopathy (Il00 Tabu 14·9, page 304) A. pain radiating down LE B. motor weakness C. dennatomru sensory cha~ D. renex cbanges: mental factors may innu .. nce l ymmetryM 2. posi t ive n.. rv.. root teasion sign(s): including LQ~gue's sign (_ below ) 3. tenderness over the sciatic notch Nerve root tension s igns Includes'": 1. Lasell\1e's sign: AKA straight leg railling (SLR) test. Helps differentiate Sciatica from pain due to hip pathology. Test: with pstient supi ne , raise amicted limb by the snkle until pain ia elicited'" (should occur at < 60'. tension in nerve increases little above this angle). '" 14. Spme and spinal cord NEUROSURGERY A pIlaltiv., tell con,;al.l of leg pain or 2. 3. 4. 5. 6. ~rilthfSin in the dia· Table 14·8 II I tribution o(pain :back pIIin lea l I II , Ion., doel not qualify). The pa· t;e!'lt mBy a llO utend the hip (by liftina: ito/flabl,,) to reduce the anile . AlthoUlfh not part of LaHg'ue', aign. aMI. dOrline.ion with SLR U$ij . lly lUI' menu pain due ~ nerve root com preulo n. SLR primarily tenMI L5 and 51, tA lellllO. and m"~ pronmal rool.l "ery little. Nerve·root compreuion produca. poeiti~ La.Mgue', aif'l in _ 83" of cases- ( mo~ likely to be poeit;v. in patien"" '" 30ynage wil.l\ HLD" ). May be po$ilive in lumbosacral ple~opatb)' (_ PClI{C ~). r-;'nt.e: n.xi", both thilh. witll the kf\<!ft .xu...ded (0 ong ... ;(ling" or .itHn,Me.! htenlion) may be Loleraud furthe r than nUlD, the .ingle Iy rnptomatie . ide alone l' Cram luI: with patient Illpine, rlise the aymptomBtic leg with the klM!e alightly n."ed. Then, ."tend the kneoe. Reaui"" aimilar to SLR "roued atr algh t leg· r aiaiD' test AKA F llie rszt llin'. alga: SLR On the pain' len leg ca ......seontralaterallimb pain la greater degree of elevation is usu ally required than tlw painfu l . ide). More specific but less sens itive than SLR (97% of patients undergoingluTi...., with thia sign haveeonfirmed HI...O*"), May correlate with a mil"' I:!:DJJ:Dl disc herniation fe mo r al stretch test'"', AKA ",verse I tra ig ht I"g rai aing: patient prone, ex· aminer's palm at popliteal fossa, knee il maximally doraiflexed . Often ~itive with L2. L3. or 1,1 nerve root COO'lprn.aion (e., . in upper lumbar di, c herniation). or with ntreme lateral lumbar disc herniation (mly a\$o be positive in diabetic femoral neuropathy or psoas hematoma l; in thelle . ituations SLR (Las~gue·•• ign) it frequently negative (.ino. L5 &. SI not involved) "bowatring , i p"; Onte pain oocura with SLR. lower the foot to the bed by fl e";ng koee, keepiog the hip flued. !kiatic paio eeal ... with thil maneuver. but hip plin pl:'r:lisu litting knee""I" nalo n tat: with patientM!ated and both hipa.nd knee! flexed 90' , llowlyextend one knee. Strttch.... nerve roots al much a.I a tnoderatedegree ofSLR Otbe r s ips uae.flIl in eva luat ion fo r hun ba r rad iclllopathy FABER: ao acronym for Flexion ABduction Extern al· Rotation , AKA FABERE test (the t,ailina:"e" it for ..x """'ion), AKA Patrick·t-tt\$l . A tat of hip O'IOlion. Method: the hip and knee are flned and the lateral mal leolus il pla<*l on til., <:ontral.ter, 1 knfl!. The ipSilate ral knee " ge ntly ditpla:ed downwlrd towarda !he eum table . Th il al._a the hipjoiM and d_ not ul uilly ..acerbate tru e nerve-root eompreasion, often ml.k«lly pOti t i"" in the prtsellOe of hip joint disease (e.a: . trochanteric: burlitis.&ft ~ 326), »e roi liiti, or me<:hanical low·back pain 2. Tren de lenburg .ir'" examin.. obMrv.. pelvis from behind while patient raise, one lea: while .tanding. Normally t he pelv is rtlIlllin.l horhon tal. A plNitiv. lip occu.. .... hen the pelvis tllt.l down toward theaideofthl lifted tegindicatina: weak. neas of the <:ont"lal.etllt thigh add udora (primarily U 1I'lnervated) 3. CToued . d d uct(l ...: in elicitinr kntoejerk (KJJ , the contra llteral thia:h addu~. tors contract. In the presence of I hmlraet.ive ipeilateral KJ it may indicate an u~per motor neu ron letion, in the pretence ofl hxgQactive ipAil.terl] KJ it may be a rorm of patholoa:ical . pre.d, indieatina: nerve root i:"titability I. NEUROSURGERY 14. Spine and spinal COld "" N ERVE ROOT SYNDROMES Due to the fact.8listed below, a herniated lumbar disc (HLD) usually Spa",8 the nerve root exili ng at that interspa~, and impinges on the nerve exiting from the neural fora men one level ~ le.g. a lb-51 HLD usually causes 51 radiculopathy). Thi. gives rise to the cha racteristic lumbar nerve root syndromes shown in Table /4.9 Ta bl e 14·9 Lumbar disc I yndromes "' Importan t fatUI in lumbardis: diaease: !. in the lumbar region, the Mrve root exiUl ~ ~ a nd in dose pm,,_ imity to the pedicle or iUllike_numberll(! verJen<lr,,"I ~ """""' . ... moy reln/oree (pa,"'" p ..... t>ana. _" tebra againSieach OIh .. wMe ,..tie. is e'ia''''') 2. the in tervertebral disc medial I>.1msl' .... rene. is unr .. latlle IfoOl a/Wavs PI". 1.51, ma1 space is located well . '00 S1imulare eadUClGrS when . ' ia~ng below the pedicle I _WE.AKNESSIn TaOle tH/. P"!Ie303lot br/la~CIOWIl 3. in t he modal (most ~ MMOrYOnpeir~"I1IO$I_inlloedlSlal."' r_oIlh. common ) human spine, .,.,malo....... the", are 24 prtS9cral vertebme, however some individuals have 23 and others have 25"'. Thus, a HLOat the ultima te disc space(usu ally L5-SlJrnnstn!ten impin.ges on t he 25th nerve rootlhowever, in the varia nt cases, it may actuaJly impinge on the 24th or 26th rootJ"' R ADIOGRAPHIC EVALUATION See Radiographj,c f uoluolion On page 293 under Low back poi" . N ONSURGICAL TREATMENT For nonsurgical trea tment, se.e "Conurooli",,·In!lIlmerll. p88e 296. SURGICAL TREATMENT INOICA TlONS In s pite of multiple attempts, nO One has been able to detennine which patients are likely to improve on their own and which wouJd be better served with $Urgery. 1 r~ il" .... of non_.".gic81 m''''~geme'' t' <W<>r 85% of pr>ti .. nt.!l with 9~l"e diS<" hemia_ tion will imp rove !d.t.kQJI.Is"rgical intervention in an average or6 weeks" (70% within 4 weeks'"'). Most clinicians advocate waiting somewhere between 5·8 weeks from the onset of rad i(ul<>pathy befort considering surgery (assuming none of the items listed belnw applies) 2. MEMERGENT SURGERY": (i.e. before:;,.8 w eek.. have lapsed ). Indications! A. cauda equina syndrome (CES): b<1f bElow) B. "roartsajye motor deficit (e.g. foot drop): pa resill ofWlknown duration is a doubtful indica t ion for surgery 01 . . . . . (no study has doc:ument.ed t hM there is less motor deficit in BurgicaJly lreated pa t ients with this finding) . How· ever , the acutecevelOpllleolor progre&!lion of motor weakness isconsidered an indication for rapid surgical decompreS8ion C. 'u r~nt' surgery may be indica ted ror patients whose pain .... maios intole r· able in spite of adequate nan:otic pain medication ..... _""li.ono iBdud.: II 0, 13";b t....rinr;: ...... b.... ora l~mboN<r.l tnm. it ion.I . . .... .....: <he te,· minology of. -l~rnb .. li:ted S t ·'..... br... • 01"' -... ,. li«<ll.5 ....... brae- i. irn~l"ffi .. and <OrIN.inll' 14. Spine and spinal cord NEUROSURGERY 3. :t pat.ien~ who do not want to invest the time in a trial of non·surgical treatment if it is possible thllt they will still require ~urgery lit the end of the trial Cauda equina lIyndrome Syndrome usually due to C()mpreSllion of the cauda equina. See Tllbl~ 17.70, page 517 fllr featUr1l8 to h~lp differentiate CES from a eonus lesion. Possible findings in CES: I . sphinCU: r disturbance: A. urinary re\.eotioo: the most consistent liDding. Sensitivity _ 90% (at 8I)me point in time during (ourse l '''''·'. Have patient empty bladder and (hed: post-vo id residual. In a patient without retention, only 1 in 1000 will have a CBS. Cystometrogram (when done) shows a hypotonic bladder with de · creased sensation and inCr1lased capacity B. uri.o.Pry and/or f<!'Cal incontinence'" (some patienlJl with urinary retention will present with overllow incontinence) C. anal spbinct<!r tone: diminished in 60·80% 2. "uddle IIneslhu)a ": the most COmmon sen8l)ry deficit. Distribution: region of the anus, lower genitals, perineum , OVer the buttocks, posterior-superior thighs. Sensitivity -75%. Onoe total perineal anelltheaia develops, patJenl$ tend to have permanent bladder paralysis'" 3. significant motor weakness: usually involves mOre than a aingle nerve root (if un· trooted , may progress to paraplegia) 4 . low back pain a •.d/or sciatica (sciatica is usually bilateral. but may be unilateral or entir1l1y absent, prognosi, may be worse when absent or bilateral'·') 5. bilateral absence of Achilles reflex has been no~'oo 6. "J<ual dysfunction (usually not detected until a later time) Etio logies ofCES includes: I . massive herniated lumbar disc: ue below 2. tumor A. from compression: e_g. with metastatic disease to the spine with epidural extension B. Intra vascwllrlympho mlltos ls (B.celllymphoma): a circulating lym· phoma without solid mass(s""pagt463l. Often presents with CNS findings: CES, dementia, enhancing meninges on MRI , lymphoma cells in CS F 3. trauma 4 . spinal epidural hematoma 5. free fat gran following discectomy'· 6. ankyl08ing spondyliti $: etiology is often obscure (Ut page 344) CES rrom HLD: May be due to mllJJsive ruptured disc, usually midlioe, most COmmOn at U ·5. often $uperimp:!aed On a p~J<isting condition (spinal stenosis, tethered cord ... )'''. Prevalence ofCES: I. 0.0004 in all patient$ with L.BPOO 2 . only _ 1-2% ofHLD that come to $W"gery"" Time course CES tends to develop either acutely, or (less typically) slowly (prognosis is wOrse in the acute onset group, especially for return of bladder function, which ocC\l~~Gd in only _ 50<1.)'110. 3 l>atw~M'OO: Croup I . sudden onset ofCES symptoms with no previous symptoms related to the low back Croup II • previou, history ofr<!'Current backache and sciatica, the latest episode resulting in CES Group III • preflentation with backache and bilateral sciatica that later develop CBS S urgical in ue" A bUaterallaminectomy i. advised'''. O<:casionally, when it i. difficult to remove a very teose midline disc, lransduTal removal will be n<!'Cusary'"'. Timing or di_etomy in CES: controversial, and the pJint of contention in nu· meroWllaw suils , In ~pite of early repor15 emphasiling rapid <:k><:ompreS!lion'''', other reo porta found nO correlation between the time to surgery aller presentation and th e return of function'''' "'. Some evidence supporta the gool of performing surgery withln 48 hou rs (although performing surgery within 24 hours is desira!>le if possible, there is no statistically significant proof that delaying up to 48 hrs is detrimental)'''' '·. NEUROSURGERY 14. Spine and spinal co rd J" SURGICAL OPTIONS FOR LUMBAR RAOICULOPATHY OI'lC<! it i. decided to trut . urgicaU,. options include: L lral\l~llnal appl'Olllchu It andard open lumbar laminec:l<Imy lind dikeclomy: 65·8S~ ~ported no . dlltka one yell' PGlt-<>p ((lmp.a.~ to 3&10 for con.ervative t .... lment' ... Long-term fUlIl", (> I ~ar) were . imilar. 10'11> ofpatienLi underwent further back s urge ry during the fi r. t ,u,'" B. "microdi$Ce<:t(lmy·"""': " mila r to , t. l'ldard procedun!, however am. Her in_ ci' ion il utiliud . Advantage. m.y boI rosmetie, . hortened hoepitalltay.lowat blood 10". May be more difficult to retriev • .orne fngmenu"'"'''''' '''. Overall efficacy is ,;ma.r to sta ndard discecl.Omy'H 2 . int.,d iscAI procedure. (SIt /)flow) A. ehemonuclwly.i,: using chymopaJ)1lln (_ btlow) a . automated perc utaneoul lumbar dise«tomy: utilizes. nudeotome C. perc ut.BneouI endGiCOpic di.~t()my: ' " /)flow D. ;n(radi"".. ] endothermal the rapy UDET or IDTN : IN bdow E. 18ser diS/: deoompreli$ion 1\. C h e mo Duc\eoiYlli 9 Ac<:eplllb~ trea t ment, but Ie.. efficacious than routine 0' rnicro-d itoeetomy'. Ut ili,es chymo pa pll;n (Chymodi l.eti~) iojected ;ntr.dilca lly. Proven nlore etreelive Ihl n placebo injection "" II •. Typical.u<:ce.M nlt.eI: at I yur 85... ofpalienU undel'iOin.r di.$· <:edomy had good or excellent resulU compared to ••,..,,, to forroemonueieoly. .. (CNL). Aithough S/:iatica improvu in botb group', only lbedi.eceetomy group had . ipjf. ic.nt improvemenl in back pain' ''. In one . tudy, a t 6 month. ~ of patienu ioili.ily h8ving CNL hlld undergone surgery for unrelieved . ymptoms'''. RiskB'·''': Ri$k of th e significant complication of lUlaphylaxi. (~timel fatal) may be reduced by sk.in·teats for .1Iergic Hnsitivity to thl 'lIent. Other complicalions reported indude: diS/:; t i.,H. neurologic injury. vascular injury, thrombophlebitia, PE. tr.nsvene myelitis'" (very uncommon ). 63,..'" Intradisea l surgical procedures (lSP) [SP. (.ft below for specific procedures).re among the IOOIt controversial proceduret for lumbar spine surgery. '!'be theoretical advantage is that epidunolsearring i. avoided, IlIId that a smaller incision Or ""enju,t a pt.lIIdure site is u$e<!. Thill i. also purported to redue<:! po6topenotive pain and hospital stay (o!\en performed all 8n outpatient procedure). The collCflptu.1 problem with ISPa is tha t tbey are di rect...d a1: removing disc mao terial from the centerohhe disc space (which is notprod""ingsymptonw)8nd rely on the reduced intradiseal pressure to decompress the herniated portion oft.he-disc from the ne .....e root. Only _ 10. 15... ofpatienu eoosidered for .qal treatment ofdisc di.eaae artcandi d8tea for.n iSP. ISP. are ... uallydoneurnier local Me5ti>etlC;n order topenni t t he patient to ~port ne ..... e root paio to identify impin~~nt on a ""rve root by th<! Sur· rical in, trument or needl". Overall. ISPI are not I'KOmroend~ until controlled trials prove the efficacy '. Ind ication. util il~ by proponeot.ll ofintradisce l procedures: I. type of disc herniation: I ppmpriate only for "contained" disc hern iation (i.e. outer ma "-;n of anu lul r.brosu. ;nUld) 2. appropriate ]evel: best for U·S HLD . May allo be uJIed II L3-4. Difficult butonen worbble (utilililllll.nlled inatroment.a or other technique,) at 1..5-51 beeauge of the angle required and interrer~1"ICOI by iliac crest 3, not recommended in presence of"HVere I'\eurologic defICit '" Re.ul u: "SU«eII" rate (_ pain f~ and retum to work when appropria.te) reported ranges from 37.7511.'.'''. Au tom a ted pereu taaeoualumba . d i..::ectomy, Utiliztt . n ... deotome'" to remove dilC material from the untet ofth. intervembral dilC apace. Sil"iticalltly leu efficacio... than cbymopapain ''', ...,th l}'Nr ' UCHM nlltof37'40 (c:ompaml t.o 66,.. for CNL), ComplicalionJ include cauda equina , yndrom<:t from improper n""leotome placement'·. [.alter d ilC d ecamp",.. ;on: IIIJertion of a needle into the di lC, and Introduction ofala· Hr fiberoptic cable throulh the need le to allow al.ate r to b... rn a hole in the center of the disc .... 'J! (with or without ndoseopic vitualitation), 14. Spine alld ' pina l cord NEUROSURGERY Percutaneoull e ndosco pi c lumbar dil",ectQmy (PELD): Thi$ ~nn refers to a n essentially intradi5"81 procedure indicated primarily for contained disc hemiations, although some small "nooconwined" fragroenUl may be treatabl~'>I. No large randomiud study has been done to compare the technique to the accepted s tandard, open discectomy (wilh or without microsco~). [n One report ...... of326 patients ",ith LA·S HLD. only 8 ap· propriate candidates for PELD (i.e. 2.4% ofHLD at L3-4) W~re found. Of these 8 , only 3 were reported as havinga good result. This study is not adequate forevaluating the technique. Intradi scal endotbermal therapy (lDt.'T): AKA intradiscal electrothennalanuloplasty (lDTA). Efficacy: 23·60% at I yea r for treating"internal discdisroption"'" (radial fissures in th e nucleus j:>ulposus extending into the anulus fibrosus) which is purported to account for 40% ofpatienUl with chronic low back pain of unknown etiology'·. A DJUNCTIVe TREATMEIflIN LUMBAR LAMINECTOMY Epi dural steroids following di scecto my In a single-blinded non-randomized study oflhe u~ or fJ).i.!1luaI steroids (methylprednisolone acetale (Depo- Medrol®). dor;e not specified) irriga t ion of the thecal sac and nerve root following discectomy prior to wound closure found no statist ically s ignifi<:ant evidence of benefit in t",ms of amount of post-op analgesic medication needed, du ration of hospital stay , or time to retum to work'''. However. the combination of sysftmic steroids at the start of the use (Depo-Med rol® 160 mg 1M and methylpredn isolone sodium su«inate (Solu ·Medrol®) 250 mg [V) combined with infi!tration of30 ml of 0.25% bi puvicain,, (Marcaine®) into the paraspina! muscles at incision and closure, may reduce hos· pital stay and post·op narcotic requirements'"'. Method s to reduce IIcar ronnatioo Epidural r..... e rat gr-aft' The use of an autogenous fl"fll fat graft in the epidural space is a fa irly common practice, that i.!I employed in an attempt to reduce post-op epidural scar format ion. Opinion vari" widely as to the effectiveness, some fe.:,l it is helpful , other$ fe.!l it actually ex ace rbales seamng '''. 1n some patienUl, no evidence of the graft. will be found on reoperstion years later. The rat graft can very rarely be a cause of nerve root compression'" Or cauda equina syndrome'" within the first few days post-op. and there i. a case report Qfcompr~nion 6 years following surgery '''. Otber meaau ..... s: Other measures include the placement of barrier films or gels"'. RISKS OF WMBAA LAMINEcrOMY Overall risk of morta lity in large serie8"~ ,<3: 6 per 10,000 (i.e. 0.06%), most ollen due to septicemia. MI . or PE. Complication rates are very di lli cult \.0 determine accurately''', but the following is included as a guideline. Co mmon complications (consider discussing these as part ofinforllled consent) I. 2. 3. 4. infection: A. superficial wound in fection: 0.9·5%'''' (risk is increased with age,long tenn steroids, obesity. ? DM): most are caused by S. IJUP"('U5 (oee Laminu/cmy wo"nd ill{tCfWII. page 216 for managemenl) B. d .... p infection: "" 1<Jl,( .... 1Hk>w undor U".,.""""." , ""mplicalio,..) increased motor deficit: 1·8%(some transient) unintended ' incidental'durotom~ (S'-'" bit/ow) incidenoe i.!I 0.3·13% (risk increases to _ IS% in re-do operations)"'. Possible sequelae incl ude those listed in Tobie 14·10 A. CSF fistula (extemal CSF lea k): the risk of a CSF fistula ~uiring operative repair is _ 10 per 10,000'" B. pseudomeningocele: 0.7.2%'" ( may appear sim ilar radiographically to spinal epidural abscess (SEA), but post-op SEA o!\.en enhances, is mOre irreg' ular. aAd is associated with muscle edema) recurrent herniated lumba r disc (&a rne level either side): 4% (with 10 year rollowup)'" C.... e page 317) Uncommoo comp licat ions 1. direc~ i!\j ury to NEUROSURGERY ~u ral strocturea. For large disc hernialions, <:(Insider a bilalera! 14. Spine and spinal coro 2. 3. 4. 5 6. 7. 8. 9. exposure to reduce ri~k injury to structu"", anterior to the vertebral bodiu (VB): injured by breaching t he anterior longitudinal ligament (ALL) through t he disc space, e.g. with pitu· itary rongeur. Tho> depth of disc space penetration with inlltruments should be kept ~ 3 em , since 5%of lumba r disca had diameteTlu small as3.3 em'''. Asymptomatic perforations cfthe ALL occu r in up to 12$ ofdiscectomi..... Breach of the ALL riaks potential injuri .... to: A. great veliSels"': risks include poteotial1y fatal hemorr~.age, and arteriovenous fist ula which may present YMnllate r. Moat aueb injuriea OCCur with U·S discectomies. Only - 50% bleed into th e diae space intraopentively. the rest bleed into the retroperitoneum. Emergent laparotomy is indicate<i, preferably by a surgeo;>n with vascular surgical experience, [f available. Mor_ t.ality rate is 37·67% I. aorta: the aortic bifurcation is on the left .ide ofilie lower part of the lA VB, and so the aorta may be injured above this level 2. below lA , t he a:)mmon iliac arteries may be injur..d 3. veina (mOle common than arterial injuries) a. vena cava at and above 1.4 b. common iliac veins below lA B. ureters c. bowel: at LS·SI the ileum is the most likely viscus to be injured D. sympathetic trunk ran! infections: A me ningiti, B. deep infect ion: « l'itt. Including; I . d i,..,;tis: 0.5% (sfe ptJ//f 245). 2. spinal epidural absceu (SEA>: 0.67% (ree po.ge 240) cauda equi na syndrome: may becaused by post-(lpapinai epidural hematomll(su bdow). Incidence wao 0.21'11 in one series of 2342 lumba r dd.te<:tomiu'" and 0.14 % in a aeriea of 12,000 spine opera t ions'''. Red flags: urinary n!l.ention, Dnesthes ia that may be I18ddl~ or b.i.la.tJ:m.l LE complicationBofpoaitioniog: A. compression neuropathies: ulnar , peroneal nerves. Use padding over elbowa and avoid pressure on posterior popliteal r<><lsa B. anterior t ibial compartment syndrome: due tQ preaaur~ on anterior com· partment of leg {reported with Andrew'. frame). An orthopedic emergency that may require emergent fasciotomy C. preaaure On the eye: corneal abrasioos, damage to the anUlrior chambe r D. cervicalapin e ;rouries during )XI'!itioning due w relaxed muscles under an· esthesia post op arachnoiditis: risk factors include epidural bematoma, patients who tend to develo\l hypertrophic s<:a r . post op disci tis, and intrathec:al if\jection of Pant<>paqul4l, anesthetic agents or steroids. Surgical treatment is dia.appointing. In· tmthetsl depo-medrol may provide ahort-te rm r.,lieflin 'pili! of the fact that steroids are a risk faewr for the development of arachnoiditis). Nsoset ptJ//e 315 th rombophlebitis and deep-vein thrombosis with risk of pulmonary embolism (PE)"': 0.1% (see Thrornboembo/um in rt.t"roa"rgt ry. pllge 25) reflex sympathetic dyatrophy (RSDl : IuuI been reported in up to 1.2'11 of CS$e$, usually after J>(lllteriordec:0Illpre8lJion with fusion. often follow ini: reoperlltions'" with onset 4 days to 20 weeka post-op. See pogt 396 for a critiqUl! ofRSD. Treatmentincludea some or alJ of: PT, sympatheticbloc:ks, oral methylpredniwlone, reo moval of ha rdware ifany very rare: Ogilvie's ayndrome(paeudo·obatruction of the colon) hall been reported as a a:)mplication of spinal surgeryftrauma , spinal or epidural anesthesia, spinal metastal!e6. and myelography''l Uni nte nded dur o tomy Unintentional opening of the dura during spinal surgery has an incidence of 014%'''". T e rm ino logy: The terms · u:!intended durotoroy·, "incidental durotomy"''', or even just "dural opening", have been recommended in preference to ·dural war" wbich may imply careles.sneu'''when none wu present. Dural openingll have been auoc;ated with One or more aUl'ged complicationa o. sequelae in medical malpractice suits mvolving s urgery on tht lumbar spin e. 14. Spine and spinal a:)rd NEUROSURGERY The injury: By itself, opening the dura inten tionally or otherwise is not e~pected to have a Table 14·10 Possible sequelae deleterious effed on the patient '#. .... In fact, of dural opening dural opening i. ofU!n a standard part of the op" .... tion for intradural disc he,..,,;ation' '', tu· mors, etc .. Although not frequent, unintended durotomy is not an unusual oe<;urrence, and alone, is not con sidered an act of malpractice. However, itmay result froman eventor events that produce more serious injuries. Thest! events and if\iuries should be dealt with on their own meri ts. Possible sequelae indude those listed in Tobie 14·10. A CSF leak may produce 'spinal headache" with its a!lSOciated symptolTUl (S« past 46), snd if it bresches th e s!tin it may be a risk factor for developing meningitis. Pain or sensory/motor deficits may be associated with injuriea to nerve roots ar herniation of nerve roots through the dural opening. Etiologies: For incidence. S« oboue . Potential causes are many, and include"' : Wlanticipated anatomic variations. adhesion of the dura to romoved bone. slippage of an instrument. an obscured fold of dura caught in a rongeur Or curette. thinning of the dura in cases oflong!!ta.uding SWnosis. and the pos.sibility of a delayed CS~'leak caused by p"r· foration ofthe dura when it expands onto a surgically croated spicule of bone'''. The risk may be increased with anterior decompression for OPLL. wit h revision surgery, and with the use of high .speed drills ''''. Tn:atmeot: [fthe opening is recognized at the time of surgery, watertight primary clo· sure (with or without ps tch graft) should be attempled with nan absorbable s uture if at all possible to prevent pseudomeningocele andlorCSF fistula . Fibrin glue may be used to supplement primary c!C5Ure lU. Although bed rest.o: 4--7 days is often advocated to reduce symptoms and facilitate healing. when watertight c1o~ u re has been achieved . normal post·op mobiEtation is not a.ssociated with a high failure rate (bed reat i! recommended if symptoms develop)'''. In one report ofS patienta with leaks that appeared post·op, re-Op"rat;on wa~ avoided when treated by resuturing the s!tin under locsl anesthesia, followed by bed rest in slight Trendelenburg position (to reduce pre\lsure on the leakage site). broad spectrum antibiotics and antibiotic ointlllent Over the s!tin incision. and daily puncture and drain· age of the subcutaneous collection"'. Also, set! po.ge 46 for other treatment measu res for HlA associated with CSF leak. PosT-QP CARE P ost-op orders The following are guidelines for post-operative orders for II lumbar lam.inectomy without intra-opera tive complications: variations between surgeons and ill$titutions muat be taken into coru.ideration: 1. admit post·anesthesia recovery (PAR) unit 2. vital SlgoS On the nursing unit: q 2" II: 4 hNl , q 4" II: 24 ' , t hen q S" 3. activity: up with ass ist. advance as tolerated 4 . nu !"!!ing care A. 1'5&0'$ B. iDteno;ttent catheteri .... tion q 4·6' PRN 00 void C. optional : TEO hose (may reduce risk of OVT) or PCB D. optional (if drain usedJ: empty drsin q 8" and PR.'I 5. diet: clear liquidll. advance u tolerated 6. IV: 05 112 NS +- 20 mEq KCIII @75 mllhr.OICwhen tolerating PO well (after an · tibiotics D/C'd if prophylactic antibiotics are U$oo ) 7. meda A. laxative of choice (LOC) PRN B. sodium dOC\ln ate (e.g. Colace®) 100 mg PO BIO when tolerating PO (stool softener, does not Bubstitute for LOC ) C. oplwnal: prophylactic antibiotics if used at you r institution O. acetaminophen (TylenoJ®) 650 mg PO Or PR q 3" PRN NEUROSURGeRY 14. Spin e and spinal cord ." £. 8. fCOrcot.ic lJnlJlgf,h; F. lJplilJnlJl: .teroidlll!"e ulled by some I U rgelJns tel reduce nerve·root irritlltilJn from . urgical manipuilition labs A. lJplilJfUJl fif l ignj{lCtJrll blood 1~1 during 'ur~ry): CDC POlt-Op c bec k In additioo 100 routine, tile foIlO""ng . lIou ld be cheeked: o t . 'lr'enith ofl_er tlltrem'tiH, Mpedlilly muteles relevllnt 100 nt-rve root. e.g. gill' trocnemiul for L,5·S1 surgery, EHL flJr lA·S .urgery .. a 2. appeart.r>c. of dressing: look for l ign. of nreSlive bleeding. CSF leak ... a s . • ign. of Clludll equilu. syndrome (1ft /KIIJc 305). e.,. by post-op .pin.1 epiduTlI hematelm.: A. loti of peri nul "nution (' •• ddle .neslhtli.· ) 8 . inability to void : may not be not unulu.1 .f\.er lumbar laminectomy. more C(Once ming ifa(:((l:npanied by ION ofperiM/l I "filiation C. pain out of the ordi nlry ror the post-()p period D. wealmesl of multiple m....,l. graup$ Any new Murologi( deficit should prompT. rapid euluation for . pin.l epidural hemotoma' " (EDH) . ~Iayed defi";uo may be due to EOH or epidural Post.-op films in the recovery room can rul e out graft or hlrdwan! malpotitioo for fuaio ... or in. slrumentlltion procedures, orchangM in sUgrunent. The dilgno.tic!at oI'ehoice i. MR1. Ifcontraindicated or oot available. CTlmyelography may be indic:llt.ed. An extradural defect immediately post.-op .uggesta ECH . .hKa,. OUTCOME OF SURGICAL TREATMENT In a stries of 100 patientB undergoing diseectomy, at I year post-op 73.. hid com· plete relief oneil' pain and 63% had complete relief of back pain;.t S-10 yea .. the numbef1!l were62% for each ~ategory". At 5-10 yeart post-op. o nly 14% felt that the ~in will the seme Or worse than pre-op (i.e. 86% felt improved), and S" qualified .. h.vinll' a fai led back aynd r .. me (not returned I.() w"Tk , requiring analge\lio:., receiving w.. rlter'1 compenaation, see Fu.ilt!d bac.\ ~"dromt!. page 314). In the only random ized atudy comparing standard diMJect.omy with COIlSe ... Bt.Ve treatment, two groups of. SO patienta with a document.ed hemi.ted d isc that failed tel improve afl.er 14 d.y. of rut (without strong indicstions for SU~I)', e.g. csud. equin. syndrome, unbearable pain ... } were randomized to surgeI)' or cootinl>l.'<i CI;InSl' ... ative t restment (h_ever, . 2S'I(, ofpatienuo {roll) Ihe <XHl1e...ative treatment group were referred to surgery for prolonged or worsening pain). There will a .ignificantly bett<>r outcome at 1 year follow-up in tho! aurgkal grouP. this was not signifi(.8.1lt at4 years, Ind at 10 yurs neith<!r gnrup reported lCistictl or ba(k pain". provided lb.t pat>enta who did not improve sati.f.cloOrily .n.:r conservative lTe8trnent underwO!nt s l1lllery. In patient.l wilh. dimiru.hed knee-jerk or ankle.jen. pr1!-<Ip. 35<J,and 43<1(, ( re!lpec' tively ) 'ti ll had reduted renexu I year post-op"; rtnens wuO! lost post-op in 3'1(, snd 10'l& rffpeetively. ThO! ..me study found Ihlt mol.()r loa was improved in~, Iggravlted in 3",.nd w" newly PreHnt in 5* post.-op; and that lel1lOry loa was improved in 69'lo and was worsened in 15" post-op. Recurrent diK hemistion (m' pu.gt 317) HERNIATED UPPER LUMBAR DISCS (UV£lS LI-2, L2-3. & L3-4) lA-S &. 1.5-S1 herniated lumbar disc. (RW) account for most C8SC$ of HLD (up 100 24'111 ofPl"tienta wilh HL.D at L3-4 frequently have a PlSt history of. HLD It lAo S or L,5·SI. IU"estinll' a reneraliztc! tendency taward, dill( hern •• tion . ln. te ri« of 1.395 HLDt, there W.'I 4.t L I·2 (O. ~ incidence), 18 It L2-3 (I .3'iIlo). Ind SI at LS-4 98~); (3 .6")101. PRESENfATION Typiully presenU; wilh LBP,onselfoIlQWingll'tiumt.or at .. in in SI". With prove.· .ion. paresthesia.,nd pain in 1.he anuriorthillh occur. with complain:.. oriel .... alme.. (Clpecially 0<1 atoending , tai ..). '" 14. Spine .nd lpinal eord NEUROSURGERY SIGNS Quodriceps femonl wos !.he mOfit oommOo'l muscle involvt'd, demon~tra\i ng weak· nesa and sometim e&. atrophy. S trai~htJeg r~ising was positive in only '10%, P&(l8S st ret.<;h Le$Lwas pooi tin in 27'Jl>. Femoral strclI:h (en may be positive (.., />Ott' 303). 50'\ hod reduced Or eh/;o>:M knee jerk; 18% had ankJejerk abnormalities: nlfiex wangel! were more common witl! WI·4 HLO (SI,..,) lhan L j .\! (no"e) or L2.3 (44%). EXTREME LATERAL LUMBAR DISC HERNIATIONS De fin ition: hern iat ion of i!I disc at (foramina ' di$C herni lltioo ) Ot dis!IIl to (u trafo ramin a l lurabar disc he rnial lon ) t.... e facet (lome authors do r,o t consider foraminal di6C herniation 1.0 be ""Klreme lateral"). See Fisu.~ 14 -1. I ndden~.. (_ T"bJ~ 14· //) , 3- 1 ~ of hern iated lumbar discs (HLD ) (""lies with highe r numbers'" in· dude some HLD thot aN not truly exl~ttU laLera!), Di fTefll from Ihe more eommon (man!. medially loc;atell) HLO in that: the nerve root in· vol,,~d Is u~uaJ1y the one eKi tlnl~ that levol (c. r. the Table 14-11 Incirvot eKitinl a t the level below) dence 01 eX lreme lalstraigh t leg raising (SLR ) is negative in 85-90% OfC8&eS eral HLD by ]eveJ' ., I w"""k 8~r uR!;eL(udud mg double henJ;lItions: DIse Ihel No. - 65% will be negllt.iv~ ifdouhle hern illtions are indud4 edl; m ay have posit ivI'. femoral strekh teu{.ap<!Jf,3f)3t Lt·2 pa in i~ reproduoed by laural bending to the lIide of her· ~. niation in 75<K. 3S ~. myelography a lone rartly di~g"O!Itic (u~uatJy ""luifllfl l .. ~ CT''''''' or MRl) higher incidenu of ntrud~ fragment.!! (60% ) "'51 higher incidenu of double herni~tions on t ha IIIIme side at the .a.me lev..1 ( IS'JO) pai n tend. to he more !leVere than with rou tine HLD (may be due to r.ct t.h~! the dor8al TOOtgang1ion may be co mpressed dirK !lyl Occurs most common ly at..kl.:li pnd next a t La,"" (..-f '("ble II-II), thu~ lA il the most COmmon nerve invDlv~d and I...'l is ne><L With a clinical pietu~or~n upper lumbar ' '', ........ ·l'OOt <»"'p ...... . ion ! i.~ . ""diculop.tI,l' ...-ith no>ij~tiv. SLR). "h"""" ~'" _ g to I tha I it i, an ext remel,. late ... 1 HLD rather than an upper lumbn disc he rniation , .. • " " .,. '" • ' , . PRESENTATION Quadric'!ps ",·ea kn eBl. reduction ofpa te Uar reflex. and d,minisht'd sen8 Dlion in the L3 or U der(091.Onle are tbe most comnlon ('ndings. DifJ~ rent , al d;agn~i. ind udes: 1 late ral reces.'~nosi$ or superior artic ular face! hl'per1TGphy 2. relropj!ritoneal heOlatomft or tumor 3. diabf!tlc neuropath,. ( .m,.orTDph,.~ Uf p<JIJ;e fjij6 'I. spin all.uWOT A. benign (schwannoma or neurofibromal 8 . malignant (umOI'1l C. lymphoma S. i,,(<<tiou A. localized (. pinMI epidur1Il ablicess) NF.UROSURGF.RY 14. Spin!! and Ipina l co,'d a. plSmIS mWlde ab3<:e!lll C. granulomatouadisease 6. spondylolisthesis (witn pa rs defett) 7. compress ion of conjoined nerve root 8. on MRI. enlarged foraminal veins may mimic extreme late ral disc herniation RADIOGRAPHIC DIAGNOSIS Radiographic diagnosis may be elusive. and up to one third are initially misaed'~. However. ifactively sought, many asyroptomatit far·lateral disc herniations may be demonstrated on CT or MRJ. Mye logl"aphy : fails to disdose the pathology even with wa ler ooluble contrast in 87 % of rases due to the fact that the nerve root compression Dl'<'U1"8 distal to the nerve root sleeve (and therefore beyond the reach I)fthe dye)'''. CT $Can"': reveals s roaM displacing epidu ral fat and encroaching on the intervertebral foramen or late ral re<:us. compromising the emefJing TOOt. Or. may be Illto:ral to foramen. Sensitivity is - 50% and i8 similar with poll-myelographic CT..•. P09t-diseography CT'" may be the most sMaitive test (9 4%)" '. MRI: similar sensitiv ity to post-myelographic CT. Sagittal views th rough the neura l foramen may help demonnrate the di.., herniation'''. M RJ may have _ 8% false positive rate due to presenceofeolarged foraminal vei ns that mimieex~me lateral HLO'~. SURGICAL TREATMENT Fo ramin a l d is c s Usually requires mesial facetectomy to gain acress to the region lateral to the dural sac without undue retraction On n~rve root or cauda equina. Caution: total facetectomy combi ned with di$Ct!Ctomy may resu lt in a high incidence ofinstabiHty (tota l racetectomy alone eau.ses _ 10% rateofslippage). although ot he r aeries found this risk to be lower{~ 1 in 33'" "'). An alternative technique is to removejus~ the lateTaI portion of the superior a rticular fa"'!t below ..•. Endoscopic techniques may be well suited for hero.ia~ discs in this loeation'''. Disc s herniated heyo nd (lateral to) t b e fo rame n Numerous approaches are used. including: l. traditional lDidline bemilllminect.omy: the ipsilftteral facet must be partially Or completely removed. The safest way to fiod the e¥.iting nerve root is take t he laminectomy of the in ferior portion of the upper verteb ralle.el (e.g. lA for a lA5 HLDl high enough to expose the nerve root axilla, and then follow the nerve la t. erally through the neural foramen by removing facet until the HLD is identifIed 2. late r a l ap pro ... ch (i. e. eJ(tra-<anall through a paramedian indaioo''". Advantages: the facet joint is preserved (facet remov al combined with di5cectomy may lead to instability). muscle retraction is easier. DisadVantage" unfamiliar approach for most surgeons an': the nerve ca nnot be followed medial to lateral DI SC HERNIATIONS IN PEDIATRICS Less than one pero::ent of su rgery for hemiated lumbardiS(: is perfol"Tlre<l on patients age . of 10 and 20 yr8 (ono &eri"" a~ Mayo found O. ~ 'lo of operated HLD in patientll ., 17 yra age"'). These patients often bave rew neurologic findings ex"'!pt for a consisten t ly posi t ive straight leg raising test"'. Hemia~ disc materisl in youths tends to be firm , fibrous and strongly attaehed to the ca rtilaginous end_pla te unlike the degen_ erated material usually extruded in adult disc herniation . Plain radicgraphs disclosed an unusually high frequen9 I)f <ongenital spine aJlQma.lies (t ransitional vertebra. hyper lordosi s. spondylolisthesis. spina bifida .. .). 78% did well alter thei r finlt operation"'. bc~wcen ~he INTRA DURAL DISC HERNIATION Herniation ofa fragment of disc into the tbecal sac,or into the nerve rootsleeve{the latte r so metimes referred to as "jntraradicular'" disc herniatio n) has been reoogni~ wi t h a reported ind<i<ll>Ce of 0.04-1.1% of disc herniations'''' "'_ Although it may be ,u,_ pected on the basis of pre-op myelography or MRI. the diagTlO.'lis is rarely made preoperativelym. l nttsoperstively. it may be suggested by the impreasion ofa tense firm 14. Spine and spinal cord NEUROSURGERY ma.. w,thin the nerve f'1;IOt sleeve or by th negative e~ ploration of a level with obvious clinical 'tgnl lind dear Cut radiographic abnonnalitiell (aJ\.er veri fying t ha t t he correct level is fllIposed ). S\lrlJical ~atment: A..Ithough a l urgical dural opening mllY be nec:esury in a minorit)' of cateS"'. u tili~"". othoers have found this to be INTRAVERTE8RAL DISC HERN1AnON AKA Schmorl's Mde or nodule. AKA &hmor'. (no ' I") nocule AKA Gf!ipel hoemill' lS. Disc hernia t ion th!"(lugh t ill! cartilaginoua end plate into the cancellous bone of the ver· tebral body (VB) (AKA int ral pOnlJiO\lS disc herniation). Ol\en an incidenta l finding on x· ray or MR I. Cli nical aigDificn nce i. controveraiBI. May prodUCtl low back pain inilially that laua ~ 3-4 montha al\eronHt . Di ff\la.edi.lplactroent(u may be seen in osteopOrosis l i. IOmet,mes Nlferred I<:> Bla blillooD d i~·. Clinic al findinga Ou ring the acu te (_ymptoma t id phase, patient.l may exhibit LBP that i. aqt1lvated by weight bea ring and movement. There may be tendem"l to pereu.-Ion or manual compTenion over t he involved a.egment. Radiographic flndin lf' Plain x·ray: ,,33% may be lun on plain x·rayl''" . They may not bedetectable acutely unlilscleroticOl1eOl.LS bone casting developl. MRI : the I)I t l"\lli(ll) of diK material into the VB i. easily appNlciated on IBgit181 images . It hal been suggested ,n that acute (symptomatk) lesion. may .ppur d ifferentieted from chronic (uymptomatic) Ielion. by the presence of MRI f,"ding. of inflammation in the bone I1)IIr!"(lW immedi.tely lI,fTounding the Mde .. outlined in Toble 14·12. Treatment Tlbl,1 4· 12 MRI ,lg NlIInlenllty In Schmorl '. nod" ' ..."" - "WI "WI ..-.." I- I '"....1 .... .., (dllO'IIcl ... _ .......... _ Conserv.tive trNlment i. indicated, Ulu.lly con· listing of non·ste roida l anti.inflamnuotory drop (NSA IDsJ. Ooca.ionally Itl"Onger pain med ication and/or lurn"r bncing may be ....• quired. Surg~ is rarely indicated. Outcome With cooservative treatment, symptoms generally rellOl ... within 3 .... month. of on· set {as "'ith m.o. t ,·e.l"tebral body fractural. JUJ(1"AFACET CYSTS OF THE LUM8AR SPINE The 1.ennjuxtafaoetcy.t (JFC) "'as originated by Kao et al."" and includes both aynovia l cy.~ (th ... having a .ynoviallioing membr.ne)and gaoglio o ey st e (thole lacking Iynoviallining) adjaunt to • • pin.1 facet joint Or .rising from the ligamentum fllvum. Oi.tinction between these two types of C)'It.I may be difficult {.su bflow l and ;. cl iniell\y unimportant It. JYC Ottu r primarily ill the lumbe r lpine (although cyIt.1 in the cemea!''''''' and thoracic'" Ipine have beeo t\e.uibed). They w.. re firat reported in 1880 by von Cruker durin,.n autopsy''', and were lirat di.gDOHd clinically in 1968". The et;olo(O' is un· known { po. .ibilitie. include: .ynovi.1 fluid .... tl"\ll ion from the joint capsule. latent fTOwth of. developme:lt.al nit, myxoid degeneration and CY'~ formation in collagenous connective ti..ue ... ), lncreaaed motion seem. to have a role in ma ny c)'IIta, and the role of t.nums in the pat.ho!lenesis il debated'" ,. but probably piaYI a !"(lIe ill a .mall n um· ba, (. 14'ii1o) .... JYC are .... I.tively rare , only 3 t.ses were iden:ified in a ... riel of 1,500 s pina l CT U&II\II'., but the frequency ordi'gROIis may be on th .. rioe d ue to the wide· .pn.d ute of MRI ."d.n lnc ...... in' aw.nne .. (If the condition. C linica l The average .~ .... 6:1 yeara In one .erie. '" and 58 yura in a I"Ilview of54 casl!; n the Iite,.ture" (range: 33·87) with. sUght fem.le pnponderllnce in both .., rin. Mo.r;t NEUROSURGERY 14. Spine and Ipi091 cord oocur in pati~nta with severe spondylGtil lind fllcetjointdegeneTlltion 1to, 25" had degen. erat ive spondyloll. Lhe.ia' .... 1A-5 i. the mooIt coml11on Ihe]'''' ''', Th ey mol' be bilattra l. Pain;' the roost COmmOn Iymptom , a nd i, ... ually radicular. Some ,IFe may contribute I.ocanal l tenOli.and can produce neurogenic d.udiclltion'" (Ju p~326)or on oca~io n .cauda equi.oa .ymirome. S)'Jll pl.olTUl may be man interm itte nt in natu l'iO than with firm Inion •• ",ell .. HLO. A , ,,dden exace rbation In p8in mllY be due to !lemo ... Th. within the cyst. Some J FC m'1 be • • ympl4matie'''. Differen tial dia(f1lo.il (llllOlIM Difftrfnlia/ dilllll1o,i•• Sda,;eQ on page 905). Oif. ferentilltingJFC frolll other m..... rt lie. Ill1Ielyon the IIppell TanC<l lnd loca ti on. Other diatinguialling futu ... include: L neurolibroro.: unlikely 1.0 be ulcili.d 2 . fTH fragment of HLD: nol CYltiC in ' .. pe'TIIOte 3. e pidW"1lI or nerve root metllitalel: not cYltic • . d ... Nl I .... bIor..clu>oid r"OI>t . 1..... dilatation : """ Sp,nlJ/ mfn'tIjJf"ll/ cy.If, page 3.8 b. I ..chnoid cyit (from 8llchnoid he rniation through. d ... NlI defect); notauoci.ted with feat joint. ma!"(inl thinner th an JFC'" 6. perineurill cysta (Tl rlov'l cflt): .rite in l pace between perineurium and endane ... ri ... m....,ulllyon ucrll roou' •. a«al;onllly &how delayed filling on myelog· ra phy comp~ssive PatbololY Cyst walla are compased Gf fibfO\.l' cono~tiva ti.,ue of varying thiekn..... and ceHu· lari ty. There is \l5ulHy no aigtll ori nCection or inflammation. There lIIay be a synovial lining'. (sync,...al (flt) 0 . it (I"IIY be Iblent'" (ganglion cflt). The distinction between the two me.y be dil'rlC:,,]t ''", pouiblyowingin part to the flct thst fibmblllJltJ in ganglion cYIU mly fonn In incomplete ')'1IO"ill.like lining'·. Prol,ferltion of .maU .. en ... les is lee n in !.he eonneclive liMue. He~iderin Itl ining may be p ~e llt. and lJIay Or may not be as· toci.ted with a history oft •• " ml'''. Evaluation Id enlifyingl J FC pN>oOp helps the . ...rreon, I' the approach differs slightly from that for HLD, end !.he qat mi~t otherwise be missed 0 ' ... n kn .... ingly deflated and un· nKelaery time wuted afterwards t.r)'iDg to find I oompreuive lesion. 0,.. the unwitting may mi sinterpret the cyst as a "tran5(\" ••1 disc extrusion" Il"d needll!tily open the d ...... ~pdi"",_ were ;nrolTe<:t in 3(W. of operated cases ofJFC'"'. Myelogrlpby: po$temla teral filJ;ngdef""t (whereu (IIOIIt d~ are , it ... ate<! an te· riorly, an ooeasion.1 fragment may mignlte poetemlaterally, where8ll a JFC will always be ~terolate..1), often with a ro ... nd ext ..du.alapP"arante. cr .can.: I hows a low denlity epidu ral cys~ lesion typiClUy with a posterolate ral jUlltaarticullr locat ion. SnIDe have calcifoed riUl '"'. I nd lOme m.y have gas within'''. Erosion of bony l.mina is ~asiona lly ~n '"'. ,-. MRI: variable findings (l":UIy be d"e todiffering compnsition ofcyu fluid: serous vs. proteinaceous'''"). Unenh. nced sipal ch.racterist ics of non·hemorrhaglc JFC.re very I;mi llr toCSF. H\!Ulorrhagic: JFC are hyperintense. May be missed ( n aa,gittal imaging without contrlL!lll Axial images may bette r d~mOllltrlteJFC. Gtdoli " l ... m enh811Ol!ment in<nases the seMitiv'ty'"". MRI usua lly mi ..... bony erosiDo. ."'f"K1!OlI Treatment OptiUl. 1 treatment i, not known. The.. it one ClK report ofa cyJl. thtt "'lOlved spontaneou.aly' •• lf . ympl.ol1ll persist with conserv.tive trn tment. _ promote CYlt IL!lIpiration or facet irUection w jth lteroid ....., "'!We mol t Idvocal.e . ... !"(ic.] excision ofth cYlt Sw-gical t reatmen t conaideratiOll" The cyst may be .dherent 1.0 !.he dura. The cyst mBy also coliapH d ... ring the n>~cal appl"Pllch and may be miaaed. A J FC mBy serv, II B Ula rker for po..ible inl tabil ity and ,hou ld prompt In eulultiDo for the ... ma. Sorne ar· gue for performi.nl' fu.ion .inee JFC UI.y ar; .. from inltability, however, it 'PPNrs th.t fUlion i. not required for I cood retult in many ClMI-. ",. ...1( . , it il IU"" ted that consideralioo for fUlion be mad e on the bIo,i. ofany instability.nd not marely on the ba.is of the pretence of a JFC . Sy mptomslic JFC may loter develop contr.loteral to a . u!'(iall,. treated cy.t"'. F AllED SACK SYNDROME Th is il ' con diti on where the ... II f.ilure to improve u ti.factorily followilll btoc:k '" tA . Spin. and spinal cord NEUROSURGERY 1Urvery (ror hemiatoed in~rvertebral disc. iarninect.omy for atenOllil .•. ). Thea" pat;en'" often require analgHiallnd • .., unable toNltum to work . The fai lure rate for lumbar di .... c;ectomy to provide M tidsctory long_term pain ",Iieri, ~ 8·251b" ' . Pending legal or work· er'. eompen98tioa claim. we.. the mO$t frequeM dete rrents to a good out.rome"', r a(ton thllt may CBuM or wntribut4: to th e fa iled back syndrom e: I. iTlC'O~ initial diagnOlii. A. inadequate pre-op imagil'l¥ B. dinic.J findi ngs not correlet.ed with abnormaHty demon. t. atoed (In imagi o, C. othe r ao utea oflymptorlll (Iometim e. in the prelM!:nce orwhat was coDsid· ered to be an appropriate Inion on imaging . tud i" wh ic h may h.~ been ..ymptomatic): e.g. trochanteric bursitis, diabetic amyotrophy ... 2. continued nerve root or cauda equ ina com p ~ion caused by: A. f'Midual disc material B. Teeu,",,,! d isc hemlation at th.tame level: u l ual :)' ha"e pain-free interval :> 6 ..... post-op (I« ~ 317) C. disc herniation at another levtl D. oompreMion or nerve root by perid uralllCar (il'"", lation)tlnue (lfe belowl E. pseuoorwningooele F. e pidural hematomll 3. 4. 5. 6. 1. 8. 9. G. aegmenta l instability: 3 pattem.e-, ) ) latera) >"OU tional in,tability, 2) poIIt. op . pOndylolil the, il , 3} poIt-<lp twliolil II. lumb.r .pi""l . ~is 1. in patienr.. operal<!d for ltenoail. recurrenee orstenOllis at the ope ra~ eo:! I...ltl (over mIIny yeara)M 2. devtlopment of ,teno.i. at ao\jaceM level.'" 3. devel09mentof . te ..... i. at levell fu$('(\ in themidline(the hillh rate of this h• • result.ed in .urgeons,witching to I.teral f\l.llion) pennanent ~rve root injury from the o riginal disc herniation or from surgery. includes de.fferentation pain "'hkh iI usually con$tant and burning or ice mid adheaive .... chnoldltl.: responsible for 6·16'JbofpersutentsympCOrn.os in post-op p8 l ienta" (au below, disciti.: usu. lly produce8 exquisite back pain 2-4 weeks po!!t-op (1ft page 245) spondylosis othe r QuSH of b.a. pain unrelated to the original cond ition; p8rnpin.1 mUlde 'palm, myofawlsyndrome ... Look for trigger points, evidence ofapasm polIt.-op rena $)VIpathet ic dystrophy (RSD1: I« page 308 - non·an.tomic facton": poor patient motivation, aeoondary gainll, drug addiction. P5ychologiQI pr¥bleons ... (I n ~luwJdoJ ftu:.IOI"I, page 296) ARACHNOIDITIS (AKA ADHESIVE ARACHNOIOmS) InnamlO8tof)' cond ition of the lumbar nerve roots. Mtu.l1y. misnomer, l inee tid· hesi"e araclmoiditi, is re.l1y an innamm.tory process 01' fibrosis that invol,,".n three meningea l layers (pill, arachnoid, lind dura). M.ny putat ive "risk f.cton- have been described for the development of arachnoid it;', including>-: 1. spin.l anesthesi$ : eithe r due to the .nathetic agen", to <feUrgent contami· nanta on the syringes used for same 2. $pinal meningiti " pyogenic, ,yphil itic, t ub...culow 3. neopl asms 4. rtlyelOiTaphic contrast agenr..: less common with currently .v.ilable ",.Ur solu· ble contr.st .genta S. tr.um . A. poIl-s urgic.l ; espeo;i.lly . ner multiple operatioN: B. utemal tr.uma 6. hemorrhage 7 . id iopathic ,r Radiographic findings in .rachnoiditi. NB: RadiOjl'aphic evidence ofa rlchnolditis m.y ,lao be foww:! in umptDm ltk patitnta-. A.. chnoiditis must be diffel't'nti. ttd from tumor: the oentrtl . dhet.ive type (.,.., bel/)W ) may rll$f!mbie CSF Heding oftumor, and myelOfnlphic block may mimic in_ tr.th eca l tumor. Mye logl'IIOl' May demonltrlte completa block, Ol'clu mpi ogofnel'V' roou. On. of m.ny myel0jl'8phic cI.Mif,cation ' ystam, - for arachnoid ili. i. Jho,!; n in Tabk 14· 13. MRI, 3 pfItUrllt On Mltl ...· ..: NEUROSURCERY 14. Spine.n d l pin.lcord lOS central adhesion of the nerve roots into lor 2 central ~C(lrds· "empty thecal aoc"pattern: roots adhere to meninges a round periphery, only CSP . ignal i. visible intl'llthecally 3. thecal sac filled with innammatory tissue, nO CSP signal. Correspond. with myelographic block end tlndlt·dripping appearance Arachnoiditis will usually not enhance with gadolinium WI much as tumor (In MRL 1. 2. PERIDURAL SCAR Table 14-13 Myelographic claasillcalio n 01 anlchnoidil is - , Iunilaleral focalDesctl ",Hm defecl Typo , h~ng centeled on lheoeM! root~ a~I\o ~ cncumf&/enlial consIriction aroond !hi.,~ 3 • oompIeIe obstrJCIion with · stalaCI~es· 01 'candle goJn.ring", 'cancle-dripping', 01 "painl-brush' liling cleJeelS Wllu'ldoboJlaf MOO·sac with loss oJ A1thougb peridural scar i8 frequently radicular strialicr1s blamed for causing recurrent 8ymptoms.... "·, there hou bee n no proofof corre lation"'. Peri· dUTIII fibrosis is an inevitable sequelae to lumbar disc Bu rgery. Even pat ients who are reo lieved of their pain following di$Cectomy develop some sca r tissue post·op'''. Although it has been shown that if a patient has recurrent redieul ar pain following a lumbar discec· tomy there is a 70% chance that extensive peridural sca r willllf! found on MRltl'. this Bt udy also Bhowed !haton post-op MR ls nt6 months, 43% of patients will have extensive star. but 84% of the time this willllf!~"·. Th us, One must U5e clinicsl grounds to detennlne if a patient with extensive scar on MR I ia in t..'e 16% mioori ty of patients with radicula r symptoms a ttributable to sea""". For a discuuion of mea&urflS to reduce peridu ral scarring, see polJe 307. RADIOLOGIC EVALUATION Patien14 with ollly persistent low back or hip pain withou t a strOllg radicu lar com· ponent, with a neurologic exa m that is Ilor mal Or unchanged from pre-op,should llf! treated symptomatica lly. Patielli.!l with ~ igns or symptoms of recurrent rndiculopathy (positive SLR is a sensitive test for nerve root compreeaion), especially if these follow a period of apparent recovery, should undergo fu rther evnluation. It is critical to d ilTerentiate UlIiduallreclll"re nt disc herniation from scor tissue and adhesive arachnoidi t iB as surgical t reatment has gellerally poor results with the hitter t wo (..,.. T~olmel1l o{{ailw back syndrome llf! lowl. MRI wmlOur AND WITH IV r;ADO/.lNlUM DiagnostiC ~1".d.tl!kl:. The llf!st exam for detecting residual 01" recurrent dis<: he r· niation, and to rflliably differentiate dis<: from scar tisaue. P re· contrast studies with Tl WI and 'l'2WI yields 8J1 accuracy of ~ 83%, comparable to IV enhanced CT'''·tlO. With the addition of gadolinium, using the protocolllf!low yields 100% sensit ivity. 71% speci· fidty. e nd 89% accu racy.. •. May also detect adhesive arachnoiditis ~ al><w<!). As scar becomes rnorfl f,brotic en d ca lcified wi th time, the differential enhan...-ement with respect to disc material attenuates and lIlay bec:ome undetectableet lOme p<Jint. ~ 1·2 yean post01"" (some scar con tinues to en hance for" 20 ytlIl. Recomme nded protoco l'" Get pre..:ootrast Tl WI and T2WI. Give 0.1 mmollkg gadolinium IV . Obtain TIW] images within 10 minutes (early post..:ontrastl. No benefit from post-<:onlrast T2WI. Findings On Wl..~ MRI Signal from a HLD becomes more intense as the sequence is varied from Tl WI T2WI , wbereas !!Car tissue bocomesless intense with this tra nsition. Indirect aigna (also applicable to CT), 1. mass efTect: a nerve root i8 displaced away fro m disc materi al , whereas it may llf! ret racted towaroscar tiS-llue by ad here nce to it 2. location: discmateria:l lenda to llf! in contiguity with the disc io lenpace (best8een on sagittal MRI) Findings On enhanced, MRI On tculy ( .. 10 millS pos:.-contrast) TlWI images: scar enhallces iohomogeneously. wherfl8S dis<: does not enhance at all. A nonen hancing central Drea surrou nded by i~g· ul ar enhancing material probably represents disc wrapped ill scar. Vellou s plexu s also '" 14. Spine and spinal cord NEUROSURGERY enhWlee.s, and may be mOre pronounced when it is distorted by disc material, but the mO'l'hology i~ easily differ ential.ed from 3C8r tinue in the8e U!IU, On /(;.tt (> 30 mi n9 post-contrast) T I W1: scar enhllll<'u homogeneou sly , disc had variable Or no enhancement. Nonnal nerve roota do not enha nce even on late images. C T SCAN WITHOUT AND WfTH IV (IODINA TED) CONTRAST Unenhanced CT scan densi ty measurements are unreliable in the poatoperative back'''. Enhanced C'T is only fairly good in di fferentiatiogscadenhancingl from disc (unenhancing with po&Sible rim enhancement). -'«uracy is about equal to unenhancd MR J. MYELOGRAPHY, WITH POST-MYELOGRAPHIC CT POlItoperatiV<! myelogrnphiccriteria aloneare unreUable for distinguishing disc material fro m 5"a.....·Il• • With t he addition ofCT 3C8n. neural compression is clearly demo onst rated, but SCar sti ll cannot be reliably diatinguished from disc. Myelogra phy (especia lly witb post_myelographic CT) is very ca pableofdemonstrating srachnoiditis'" (..... above). PlAIN LS X-RAYS Gene rally helpful only iu eases ofi'Ultability, malaHgnm~nt, or sp•.mdyIOllis:" . Flexion/extension views sre most helpful when trying to demonstrate instability. T REATMENT OF FAILED BACK SYNOROME For treatment ofinte,..,·ert.ebral disc-a pace infectil)fl, oee Discitis, page 245. S y mptomatic trea tme nt Recommended for patients who do not havII radicular $igns and symptoms. or for m06t patients demonst~ated to have scar tissue or adhesive anochnoiditis on imol,:ing. As in other case. of non ·~pecific LBP treatment includes: short-term bed rest, analgesics (non-narcotic in most cases), anti ·inflammatory medication (n(ln-steroidal, and occasion· ally a short course of steroids), and ph)'!lieal therapy. S urge ry Reserved for thOK with recttrrentor re sidua l disc herniation, segmental instability, or patients with a pseudoroeniogoeele. Patiente with post-op spinal in~tability should be "<,,,sidered for spinal fusion"" (;we pa.ge 300). In roostseriM wltb 8uffocient follow·up, $ueress rlttes after reopeTlltion are lower in patients with only epidural scar (as low as 1%) compared to those patients with disc and ..,af (.till only _ 37%»,'. An overall suec"". rate (> 5~ pain relief for ,,2 y,.,.) of - 34% was ~Ilfln in one series"', with better results in patients that .... ere young, female, with good results following previous surgery, a small number of previous operstions. employ· ment prior to surgery, predominantly radicular (cfaxial) pain , and ab.en"" of sea, reo quiring lysis. In addition to the absence ofdi.., mltterial, facto". associated with poor ouw;.mA were: sensory loss involving more than one dermatome, and patients with past Or pending compensation claims"'· ' ''. Arachnoiditi s: Surgery forcarefuUy selected patienta with 9T1lehlloiditis {those with mild .adi<>gra.,hie involvQm ..nl ('T'ypoo~ 1 & 2 in Tobl~ IJ.13 ). and ",-:I previou, back 0p" ' alions)"" haa met with moderate SUC""., (althoud! in t his slIries, nO patient retu rned to work). Approximate succe$S rate in other Mries''''''': 50% failure, 20% able to wo-rk but with sy mptoms, 10·19% with no symptomll. Surgery e<:>nsists of removal of ex tradural scar eoveloping the thecal sac, removi ng any herniated disc fragments, and performing (oramino1omie. when indkated. Intradural lysis of adhesion. is Jl2l indicated .ince nO means for preventing reformation of scar h88 bllfln identified"'. R ECURRENT HERNIATED LUMBAR OISC RllteS quoted in the literature ra nge from 3-19% with the higher rates usually in sotries with longer follow-u p"'. I" an individual series with 10 year mean FlU, the rate of rE~current disc herniation was 4% (same level, either side), OM third ofwhkh occu rred during the 1$t year poat-op (mean' 4.3 yrs)'''. A ~ recurrence a t the same site oc· curred in 1% in another series'" with mean FlU of 4.5 yrs. In this series"', patients preseoting for a second time with disc herniation had a recurnnoe at the same level in 74%. NEUROSURGERY 14. S pine and spinsl cord but 26\110 had a HLD at anothe. level. Recurrent HLO oc:eurred at lA·S more thon twice as o~n as 1.5·S1.... It i. often poMible for a 1/Illller omount of "",urrent herniated di.~ to UuIN .ymptoms thao in a 'virgin ba<:k". due to the f.el that the nerve root is o~n (juted by K a r tisaue and ha.liltle ability to deviate . w.y from the fragmeot"". TREATMENT Initi.l recommended Ire.Lment;8 at with a first t ime HLO. Nooaurgknl trutment abould be utilized in the ab$en:e ofprogn..ive neurologic denci t, clude equina Iyn· dronM (CES) or intractable J)l.in. Surgical treatment Disagreement oc:eu rs raprding optimal UlIalment. For re~WTen : HLO without demonatrsted I pinallnatabiUI}', a 1992 l urvey . howed opinion divided primarily between simple repeat diacectotlly (57\110) v• . rapellt diKectomy with fu.lI;Qn 1 ~ 0\II0) (when in· l tabllity ia preMnt, m