Modern neurosurgical practice
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Transcript of Modern neurosurgical practice
MODERN NEUROSURGICAL
PRACTICE
MICHAEL THOMAS D.O.
EDUCATIONAL REQUIREMENTS
FUNCTIONAL NEUROANATOMY NEUROPHYSIOLOGY NEUROPATHOLOGY NEUROPHARMACOLOGY NEUROANESTHESIOLOGY NEURORADIOLOGY NEUROONOCOLOGY NEUROTRAUMA PEDIATRIC NEUROSURGERY
TERMINOLOGY
CRANIOTOMY- REMOVAL AND REPLACEMENT OF PART OF CRANIUM
CRANIECTOMY- REMOVAL W/O REPLACEMENT OF PART OF CRANIUM
LAMINOTOMY- REMOVAL OF PART OF LAMINA
LAMINECTOMY- COMPLETE REMOVAL OF LAMINA
BONE FLAP- THAT REGION OF CRANIUM REMOVED
SURGICAL MICROSCOPE
LEICA OH3
MICROSCOPE TECHNOLOGY
FLORESCENCE TECHNOLOGY FOR NEUROVASCULAR SURGERY
FLORESCENCE TECHNOLOGY
BRAIN LAB NEURONAVIGATION
INTEGRATION WITH STEREOTACTIC NAVIGATION
MICROSCOPE TECHNOLOGY
TENSOR FIBER TRACT IMAGE
BRAIN LAB INTRAOPERATIVE MRI
BRAIN LAB WITH FUNCTIONAL MRI MAPPING
BRAIN LAB MAPPING AND FIBER TRACKING
FUNCTIONAL MRI
BRAIN LAB 3D RECONSTRUCTED IMAGE
NEUROENDOSCOPY
VENTRICULAR ENDOSCOPY – PRIMARILY USED TO TREAT INTRAVENTRICULAR TUMORS AND HYDROCEPHALUS
MAY BE USED TO ASSIST WITH DIFFICULT AND LIMITED OPERATIVE EXPOSURES -IE; ANEUYSM SURGERY, PITUITARY SURGERY
ASSISTANCE WITH SPINAL SURGERY
ENDOSCOPE USED WITH NEURONAVIGATION
HYDROCEPHALUS
OBSTRUCTIVE-BLOCKAGE WITHIN VENTRICULAR CSF PATHWAYS
COMMUNICATING- BLOCKAGE OF ABSORBTION AT ARACHNOID VILLI
OBSTRUCTIVE HYDROCEPHALUS
AQUEDUCTAL STENOSIS INTAVENTRICULAR TUMORS-IE; COLLOID
CYSTS,DERMOIDS, SUBEPYNDYMOMAS. PINEAL TUMORS, CERREBELLAR MASSES, CEREBELLAR STROKES/HEMORRHAGE, BRAINSTEM TUMORS
4th VENTRICLE IS USUALLY NORMAL SIZE OR SMALL
HYDROCEPHALUS - CLINICAL PRESENTATION
GAIT DISTURBANCE HEAD ACHE MEMORY DISTURBANCE LETHARGY URINARY INCONTINANCE
AQUEDUCTAL STENOSIS
SUPRACEREBELLARARACHNOID CYST
AQUEDUCT OF SYLVIUS
4th VENTRICLE (NORMAL SIZE)
AQUEDUCTAL STENOSIS
CORONAL MRI-OBSTRUCTIVE HYDROCEPHALUS
PINEAL TUMOR
BRAINSTEM GLIOMA
ASTROCYTOMA
COLLOID CYST
3rd VENTRICULAR COLLOID CYST
colloid
TREATMENT OF HYDROCEPHALUS
CSF DIVERSION – NORMAL SIZE VENTRICLES HAS 25 CC’s OF CSF – TOTAL PRODUCTION OF CSF IS 500 -750 CC’s PER DAY
OBSTRUCTIVE HYDRO-ENDOSCOPIC 3RD VENTRICULOSTOMY OR AQUEDUCTAL DILATATION AND STENTING. IF THIS FAILS
THEN VP SHUNT COMMUNICATING HYDROCEPHALUS-
VENTRICULOPERITONEAL SHUNT (VENTRICULOATRIAL , VENTRICULOPLEURAL)
ENDOSCOPIC VIEW OF 3RD VENTRICULOSTOMY FORMATION
ENDOSCOPIC VIEW OF OSTOMY AND PREPONTINE CISTERN
3rd VENTRICAL EXPLORATION
BRAIN TUMORS
MULTIPLE TYPES DEPENDING ON EMBRYOLOGICAL ORIGIN -ie; Astrocytoma derived from glial tissue origin
METASTASTATIC(secondary) BRAIN TUMORS MOST COMMON
ASTROCYTOMA MOST COMMON PRIMARY BRAIN TUMOR
BRAIN TUMOR CLINICAL PRESENTATION
HEAD ACHES SEIZURES NAUSEA/VOMITING MENTAL STATUS CHANGES GAIT DISTURBANCE VISUAL DISTURBANCE NEUROLOGICAL DEFICIT DEPENDING ON
LOCATION CEREBRAL HEMORRHAGE BRAIN HERNIATION
BRAIN TUMOR DIFFERENCIAL DIAGNOSIS
CEREBRAL ABCESS STROKE PSEUDOTUMOR CEREBRI CEREBRITIS (PRE-ABCESS STAGE) ARTERIAL-VENOUS MALFORMATION MS HYDROCEPHALUS
BRAIN TUMOR WORK UP AND INITIAL TREATMENT
DEXAMETHASONE- INITIAL 10 MG IV X 1 THEN FOLLOWED WITH 4-6 MG IV/PO q 6 hrs
OBTAIN CT OR MRI WITH AND WITH OUT CONTRAST
IF MASS IS PRESENT THEN RULE OUT ABCESS vs METASTATIC DISEASE
IF ORIGIN OF TUMOR CANT BE DISCOVERED THEN CEREBRAL BIOPSY AND POSSIBLY RESECTION IS INDICATED
FALX MENINGIOMA
MENINGIOMA
ASTROCYTOMA
ANAPLASTIC ASTROCYTOMA
ANAPLASTIC ASTROCYTOMA HISTOPATHOLOGY
PILOCYTIC ASTROCYTOMA
GLIOBLASTOMA MULTIFORME
GLIOBLASTOMA MULTIFORME
GBM HISTOPATHOLOGY
SUBEPENDYMAL GIANT CELL ASTROCYTOMA
FRONTAL CRANIOTOMY
EXPOSURE OF RIGHT FRONTAL LOBE
PARTIAL FRONTAL LOBECTOMY
FALX
PREMOTORCORTEX
SUPERIORSAGITALSINUS
LATERAL VIEW ANTERIOR FRONTAL LOBECTOMY
FALX CEREBRI
CORONAL SUTRE
TEMPORALIS MUSCLE
TRANSVENTRICULAR COLLOID CYST REMOVAL
SKULL BASE MENINGIOMA
SAGITAL CORONAL AXIAL
SKULL BASE MENINGIOMA – POST OP MRI
STRUCTURES OF THE CAVERNOUS SINUS
P
S
PITUITARY
SPHENOID SINUS
PITUITARY MACROADENOMA
PITUITARY ADENOMA CLINICAL PRESENTATION
HEADACHE BITEMPERAL HEMIANOPSIA APOPLEXY(RARE) SECRETING vs NON-SECRETING ENDOCRENOPATHIES –Cushings(ACTH)
ACROMEGALY(GH),PANHYPOPITUITARY FREQUENTLY HAVE ELEVATED
PROLACTIN LEVELS-(STALK EFFECT vs PROLACTINOMA SECRETING ADENOMA
PITUITARY SURGERY
MOST COMMON APPROACH IS TRANSSPHENOIDAL
GOALS OF SURGERY 1) PRESERVE VISION 2) CORRECT ENDOCRENOPATHY
CAVERNOUS SINUS INVASION WILL REQUIRE POST OPERATIVE STEREOTACTIC RADIOSURGERY ,CONTINUED MEDICAL MANAGEMENT, OR BOTH
CRANIOTOMY IS RARELY INDICATED
TRIGEMINAL NEUARALGIA ETIOLOGY
REDUNDANT SUPERIOR CEREBELLAR ARTERY COMPRESSION
SUPERIOR PETROSAL VEIN COMPRESSION
POSTERIOR FOSSA TUMOR MULTIPLE SCLEROSIS (bilateral TN)
TRIGEMINAL NEURALGIA(AKA tic douloureux) PATHOPHYSIOLOGY
SEVERE PAROXYSMAL LANCINATING PAIN LASTING ONLY A FEW SECONDS OFTEN TRIGGERED BY SENSORY STIMULI
CONFINED TO THE DISTRIBUTION OF ONE OR MORE DIVISIONS OF THE TRIGEMINAL NERVE ON ONE SIDE OF THE FACE
DUE TO EPHAPTIC TRANSMISSION IN TRIGEMINAL NERVE FROM LARGE DIAMETER MYLENATED A FIBERS TO POORLY MYLENATED A-DELTA AND C NOCICEPTIVE FIBERS
EPHAPTIC - conduction of nerve impulse across point of lateral contact rather than at synapse
VENTRAL BRAIN/POSTERIOR FOSSA
RIGHT CEREBELLOPONTINE ANGLE
TRIGENINAL NEURALGIA - TX OPTIONS
MEDICAL- TEGRETOL, NEURONTIN, DILANTIN PERCUTANEOUS RADIOFREQUENCY
RHIZOTOMY PERCUTANEOUS GLYCEROL INJECTION PERCUTANEOUS TRIGEMINAL BALLON
COMPRESSION MICROVASCULAR TRIGEMINAL
DECOMPRESSION STEREOTACTIC RADIOSURGERY
TRIGEMINAL NEURALGIA MICROVASCULAR DECOMPRESSION
CN VII+VIII A.I.C.A. SUP. PET. V. CN V S.C.A.
FLOCCULUS
CEREBELLUM
PONS
CN IV
PONTOMEDULLAY JUNCTION
DURA
CEREBELLUM
SPINALCORD TUMORS: CLASSIFICATION
EXTRADURAL-arise outside cord in vertebral body and epidural tissue(metastatic tumors most common)
INTRADURAL EXTRAMEDULLARY-arise from leptomeninges or nerve roots. ie; meningiomas and neurofibromas
INTRAMEDULLARY- primary and secondary tumors that destroy tracts and grey matter
INTRADURAL EXTRAMEDULLARY TUMOR
TUMOR
CONUS
CAUDAEQUINA EPENDYMOMA
CERVICAL MEDULLARY ANGIOMA
SYRINGOMYELIA
ARNOLD CHIARI MALFORMATION
INTRAMEDULLARY MASS IDIOPATHIC HYDROCEPHALUS
ETIOLOGIES
INTRAMEDULLARY ASTROCYTOMA
MEDULLOBASTOMA
MEDULLOBLASTOMA HISTOPATHOLOGY
INTRADURAL EXTRAMEDULLARY
T-1 WEIGHTED SAGITAL IMAGE OF A NEUROFIBROMA
CONTRAST ENHANCED T1 WEIGHTED AXIAL IMAGE OF NEUROFIBROMA
SPINAL CORD
C-6 SCHWANNOMA RESECTION
C-6 NEUROFIBROMA RESECTION
SUBDURAL HEMATOMA
POST OP CRANIOTOMY
SUBARACHNOID HEMORRHAGE
ANEURYSMAL SUBARACHNOID HEMORRAGE SEVERE SUDDEN ONSET HEAD ACHE MAY CAUSE ACUTE HYDROCEPHALUS HUNT HESS GRADING SCALE 0-5 HIGH GRADE PTS REQUIRE VENTRICULOSTOMY 4 PERCENT RERUPTURE RATE WITHIN 24 HR REQUIRES ANGIOGRAM MAY PRESENT WITH NO NEURO DEFICIT TO FOCAL DEFICIT
TO COMA 3rd OF PATIENTS DON’T EVEN MAKE IT TO HOSPITAL VASOSPASM CLINICALLY EFFECTS 30% NO SOONER THAN
DAY 3 ,USUALLY AROUND DAY6-8 ICP MANAGEMENT
MANAGEMENT OF ANEURYSMS
ANGIOGRAM TO DEFINE ANEURYSM ANATOMY IF GRADE 3 OR LOWER SURGICALLY CLIP OR
COIL VENTRICULOSTOMY FOR HYDROCEPHALUS CALCIUM CHANNEL BLOCKER (NIMODIPINE)-
HELPS PREVENT VASOSPASM STEROIDS (DEXAMETHASONE) ANALGESIA TRIPLE “H” THERAPY
TRIPLE “H” THERAPY
VASOSPASM TREATMENT
HYPER VOLEMIA HYPERTENSION HEMODILUTION
EARLY SURGERYCANT TREAT SAFELY WITHOUT SECURING ANEURYSM
CAROTID BIFERCATION ANEURYSM
CT ANGIOGRAM
BASILAR ANEURYSM
POSTERIOR CEREBRAL ARTERY
CTA BASILAR ANEURYSM
OCCIPITAL AVM
NEUROSURGICAL HORIZONS
GENE THERAPY STEM CELL IMPLANTS IMMUNOTHERAPY NANOTECHNOLOGY ROBOTICS MOORE’S LAW NEURO - CYBERTECHNOLOGY