Neurology, SurgeryPete Gutierrez MD, MMS, PA-C

Miami Dade CollegeJuly 2010

Internal Carotid Artery Major branches visible on Angiography:◦ 1. Meningohypophysial◦ 2.Inferolateral◦ 3.Ophtalmic◦ 4. Posterior Communicating◦ 5. Anterior choroidal◦ 6. Middle cerebral◦ 7. Anterior cerebral

Neurology

Circle of willis:◦ Is form by the:

1.Anterior communicating Artery 2. Internal Carotid Artery 3. Basilar Artery 4. Posterior Cerebral Artery

Surgical Interventions mostly malformations.

Neurology

Hydrocephalus:◦ General

1. 1% prevalence ; 1/1000 congenital incidence Divided into three general categories:

Communicating: All ventricles affected, defect in absorption at the arachnoid granulations

No communicating (Obstructive): Block in CSF flow proximal to arachnoid granulations. This may not affect all ventricle depending on the location of the block (e.g. aqueductal stenosis spares the fourth ventricle.

Ex Vacuo: Atrophic parenchymal tissue loss results in dilated ventricles. Not pathologic Hydrocephalus.

Neurology

Hydrocephalus:◦ Etiologies:

1. Congenital 2. Hemorrhage 3. Infectious/Inflammatory 4. Obstructive masses 5. Postoperative (Particular in pediatric posterior

fossa procedures).

Neurology

Clinical Presentation:◦ 1. ICP Headaches, nausea/vomiting, ataxia,

adbucens palsy.◦ 2. In children check for bulging anterior fontanels,

increase in head circumference, irritability, poor feeding, and engorged scalp veins.

Neurology

Treatment:◦ Acetazolamide to reduce CSF production and

furosemide to promote diuresis. ( This is only temporizing).

◦ Shunt placement: Most common a ventriculoperitoneal shunt is placed

alternatives include ventriculoatrial and ventriculopleural shunts.

Shunts are placed similar to an extra ventricular drain except that the catheter is subcutaneously tunneled behind the ear where a valve is attached and placed in the subgaleal space.

Neurology

Complications:1. Obstruction (usually proximal)2. Infection3.Patient growth4. Undershuting kinking5. Overshuting ICP6. Subdural hematomaEvaluation is done with a Shunt series plain film to assess location of ventricular catheterShunt O gram injection of radioisotope into shunt to confirm both proximal catheter patency and distal flow.

Neurology

Carotid Artery Stenosis: Symptomatic or Asymptomatic Syncope is not consider symptomatic because

unilateral carotid occlusion rarely results in impairment of consciousness.

Evaluation: Dopplex Ultrasound. MR Angiogram Carotid Angiogram

Neurology

Treatment:◦ Medical therapy

Aspirin Aspirin plus dipyridamole Clopidogrel Control of Hypertension Control of DM Control of Hyperlipidemia Smoking cessation

Neurology

Surgical ◦ Carotid endarectomy◦ Over medical treatment in men with

asymptomatic disease but over 60% occlusion complication rate 3%.

◦ Procedure can be done 4-6 weeks after CVA.◦ Risk complications:

Hoarseness (recurrent laryngeal nerve injury) Horner syndrome Partial tongue paresis Hematoma causing airway complications

Neurology

Central Nervous system tumors:◦ General tumors present with progressive

neurologic deficit, motor weakness headache and seizure.

◦ Posterior Fossa mass: Headache Nausea/vomiting Ataxia Diplopia Parinaud syndrome Cranial nerve paresis Vertical nystagmus

Neurology

Supratentorial mass:◦ Headache◦ Nausea/vomiting◦ Diplopia◦ Parinaud syndrome◦ Motor weakness◦ Aphasia

Neurology

Low grade Astrocytoma:◦ Approximately 12% of primary brain tumors◦ Mostly on children◦ Located in cerebral hemispheres, cerebellum

Treatment: Resected for cure Surgery not curative for most low grade gliomas. Radiotherapy for most postoperatively.

Neurology

Malignant Glioma:◦ Anaplastic astrocytoma◦ Glioblastoma multiforme◦ Approximately 40% of primary brain tumors◦ Most commonly in the erderly◦ Treatment is palliative, not for cure.

Surgical excision Post operative radiotherapy Post operative chemotherapy

Neurology

Meningioma:◦ 12% of all primary brain tumors◦ 1.8:1 female to male ratio◦ Arise from arachnoid cells◦ Slow progresive growth◦ Treatment:

Observe if asymptomatic Surgical excision if symptomatic External beam radiotherapy/knife Outcome five year survival rate.

Neurology

Pituitary Adenoma:◦ 10% of brain tumors◦ Male=Female incidence◦ Associated with multiple endocrine neoplasia

(MEN) syndrome.◦ Located Silla Turca◦ Treatment:

Perform preoperative visual field testing Pre op endocrinological evaluation

Neurology

Medical treatment for:◦ Prolactinomas:

Dopamine agonists Surgical excision Acromegaly: Surgical resection 50% cure rate Avoid surgery in asymptomatic elderly patients as

there is no survival benefit. Medical therapy with octreotide (somatostatin

analogue).

Neurology

Cushing syndrome, surgery is the treatment of choice. 85% cure rate.

Thyroid stimulating hormone (TSH) adenomas Medical treatment with octreotide.

Nonfunctional adenomas observe if asymptomatic and surgical resection otherwise.

Neurology

Neuroma:◦ 8-10% of primary brain tumors:◦ 1 in 100.000 incidence◦ Most common affected is the CNS VIII nerve, but

any cranial nerve can be involved.◦ Usually unilateral◦ Treatment:

Perform pretreatment audiometric and vestibular testing

Surgical resection Conversional Radiotherapy

Neurology

Ependymona:◦ 6% of primary brain tumors◦ Location 4th ventricle most common◦ Mostly occur in children◦ Treatment surgical resection◦ Radiation if located in the fourth ventricle or

spinal cord◦ Chemotherapy of little benefit◦ Outcome 80% 5 year adult with surgical and

radiation◦ 30% 5 years survival in children

Neurology

Oligodendroglioma:◦ 4% of primary brain tumors◦ Male >female(3:2)◦ Mostly occur in middle age adults◦ Slow progressive present with a seizure◦ Treatment:

Surgery Radiotherapy Chemotherapy Survival 30-75% survival rate

Neurology

Pineal tumors:◦ One to two % of primary brain tumors◦ Most frequent in children's◦ Germinomas and teratomas have a male

preponderance◦ Location pineal region and third ventricle◦ Surgery only if well encapsulated◦ No evidence of metastases

Neurology

CNS Lymphoma:◦ 1% of primary brain tumors◦ May be primary of secondary◦ Associated with

AIDS Connective tissue disease Chronic Immunosuppression Epstein-Barr virus infection Male>Female (1.5:1)

Neurology

This tumors tend to melt away with an initial round of steroids treatment.

Radiation therapy is the mainstay of treatment

The main role of surgery is diagnosis biopsy Surgery does not improve survival

Neurology

Other non common tumors of the brain:◦ Epidermoid and Dermoid tumors◦ Primitive Neuroectodermal tumors◦ Choroid Plexus tumors◦ Glomus tumors◦ Chordoma tumors

1% of brain tumors Surgical treatment Chemotherapy and Radiation Survival 70-85%

Neurology

Metastatic Tumors: More than 50% Common Lung Cancer Breast Cancer Renal Cell carcinoma Colon adenocarcinoma Most occur in the cerebral hemispheres

Neurology

Management:◦ Biopsy for diagnosis identification purposes◦ Treatment for seizures◦ Palliative◦ Chemotherapy at time beneficial

Neurology

May the Force be with you? Break a leg? Enjoy Vacation!!!!! To be or not to Be that is the

QUESTION!!!!!!! GO FORTH AND CONQUER!!

CONGRAT’S!!!!!!!!!!!!!!!!!!!!!!!

Neurology