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Colen Publishing

www.colenpublishing.com

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

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

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

Colen Publishing

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Glossary

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

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

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

Chaim September 9, 2008

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The Colen Flash-Review

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

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

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

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

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

Thank you All,Chaim September 9, 2008

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How to use this Flashcard review

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

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

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Faculty Reviewers

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

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

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

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

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

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

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

Forward

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Physician Contributing Authors

Mahmoud Rayes, MDDepartment of Neurological Surgery WSU School of Medicine

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

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

Doha Itani, MDDepartment of PathologyWSU School of MedicineDetroit, Michigan

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Contributing Medical Students

Darmafall, KristynWayne State UniversitySchool of MedicineClass of 2012

Davis, Naomi Wayne State UniversitySchool of Medicine Class of 2011

Dub, LarissaWayne State UniversitySchool of MedicineClass of 2012

Faulkiner, RodneyWayne State UniversitySchool of MedicineClass of 2012

Galinato, AnthonyWayne State UniversitySchool of MedicineClass of 2012

Gotlib, DorothyWayne State UniversitySchool of MedicineClass of 2009

Kozma, BonitaWayne State UniversitySchool of MedicineClass of 2008

Lai, Christopher Wayne State UniversitySchool of MedicineClass of 2010

Larson, SarahWayne State UniversitySchool of MedicineClass of 2012

Martinez, DerekWayne State UniversitySchool of MedicineClass of 2011

Matthew SmithWayne State UniversitySchool of MedicineClass of 2011

Matto, ShereenWayne State UniversitySchool of MedicineClass of 2012

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Contributing Undergraduates

Jeffrey P. KallasWayne State UniversityClass of 2010

Abhinav KrishnanWayne State UniversityClass of 2010

Peter PaximadisWayne State UniversityClass of 2008

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• A 47 year-old male presents with a complaint of pain “shooting down” his right leg. The MRI is shown here. Which of the following is the most appropriate management for this patient?

A. Do nothing, MRI looks normalB. Laminectomy and discectomyC. Laminectomy and instrumentation of

L5-S1D. Tethered cord release

NeuroradiologyQ?

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NeuroradiologyA.• The correct answer is B, laminectomy and

discectomy.• Lumbar spine MRI shows a right far-lateral

herniated disc (T2 axial view). Note that the disc bulge is not noted on the midline sagittal view.

• Far-lateral herniated discs commonly impinge on the exiting nerve root (same level) while more central discs affect the transiting nerve root (level below).

• These patients generally do well with simple laminectomy and discectomy. There is no need to perform laminectomy and instrumentation of L5-S1. There is no evidence of a thickened filum or low conus suggestive of a tethered cord.

H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 4514-7.

BOARD FAVORITE!

Classification: Neuroradiology, Herniated Disc, Laminectomy and Discectomy

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• This MRI of the brain is most suggestive of:A. Iron depositionB. MacrocraniaC. HypoxemiaD. Generalized atrophyE. Butterfly glioma

NeuroradiologyQ?

3

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NeuroradiologyA.• The correct answer is A, iron deposition.• Hallervorden-Spatz syndrome - involves the

deposition of iron especially in the globus pallidus and the retina.

• Dystonia, rigidity and neurobehavioral changes• MRI: Globus pallidus on T2-weighted images • "Eye-of-the-tiger" sign• Central region of hyperintensity

– Primary tissue insult – Produces edema

• Surrounding hypointensity – Region high in iron – May be 2° process

H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 2720.

BOARD FAVORITE!

Classification: Neuroradiology, Hallervorden Spatz Syndrome, Iron Deposition

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• Based on the AP and lateral cerebral angiogram of the right external carotid artery shown here, the most appropriate statement to tell this patient is that:

A. The risk of bleeding is high due to the cortical venous drainage.

B. The risk of bleeding is low due to the cortical venous drainage.

C. If the flow has rapid drainage into a sinus the bleeding risk is increased.

D. This is a normal cerebral angiogram.

NeuroradiologyQ?

4

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NeuroradiologyA.• The correct answer is A. The risk of bleeding

is high due to the cortical venous drainage.• This AP and lateral angiogram shows a dural

arteriovenous fistula with main feeders from the occipital and middle meningeal arteries. Multiple venous lakes and varices are identified including two large lesions (these suggest high pressure). Drainage of the dural AVF is via cortical veins primarily into the sagittal and transverse sinuses.

• The risk of bleeding is high not low with cortical venous drainage.

• If the flow has rapid drainage into a sinus the bleeding risk decreases.

Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg. 1995 Feb;82(2):166-79.

BOARD FAVORITE!

Occipital artery

Classification: Neuroradiology, duralarteriovenous fistula, cortical venous drainage

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• Locate the central sulcus:A. AB. BC. CD. DE. EF. F

NeuroradiologyQ?

ABCD

EF

8

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NeuroradiologyA.• The correct answer is C.• Sigmoid “Hook” or “Ducky Sign”• Hook-like configuration (B) of the posterior

surface of the precentral gyrus. The “hook” or “ducky’s breast” corresponds to the motor hand area. The “hook” is seen well on CT (89%) and MRI (98%).

• Pars bracket sign• The paired pars marginalis (F) form a

“bracket” to each side of the interhemispheric fissure at or behind the central sulcus (96%).

• A = precentral sulcus• D = postcentral gyrus• E = postcentral sulcus

Colen CB, Handbook of Neurosurgery and Neurology in Pediatrics, 2006

ABCD

EF

BOARD FAVORITE!

Classification: Neuroradiology, Neuroanatomy, Location of Central Sulcus

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• A 2 day old asymptomatic neonate is transferred to your institution with the following image. Which of the following is CORRECT regarding this pathology?A. It rarely presents with congestive heart

failure.B. It never presents in older children. C. The embryonic correlate to this

malformation is the median prosencephalic vein.

D. Treatment for this neonate should include immediate embolization.

NeuroradiologyQ?

11

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NeuroradiologyA.• The correct answer is C, the embryonic correlate to this

malformation is the median prosencephalic vein.• Vein of Galen aneurysmal malformations (VGAM) probably

represent an arteriovenous fistula (AVF) in the wall of a persistent embryonic vascular channel called the median prosencephalic vein.

• By week 10 of normal fetal development, the median prosencephalic vein regresses as the definitive internal cerebral veins appear. A caudal remnant remains as the vein of Galen.

• Neonatal presentation with congestive heart failure is frequent with these malformations.

Lasjuanias P. Vascular Diseases in Neonates, Infants and Children. New York: Springer Verlag 1997. Horowitz MB, Jungreis CA, Quisling RG, Pollock I. vein of Galen aneurysms: a review and current perspective. AJNR 1994; 15:1486-1496. H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3434.

Vein of Galen aneurysmal malformation

•Initial treatment of VGAM is conservative. Embolisation of a neonate is a high risk procedure and the child should be treated medically (for cardiac failure) until aged 5 or 6 months with regular outpatient assessment. Elective embolisation can be scheduled for this time with the aim of closing the AVS with cyanoacrylate glue. If the infant deteriorates (seizures, failure to thrive, worsening cardiac failure, etc) treatment is performed earlier.

BOARD FAVORITE!

Classification: Neuroradiology, Vascular Pathology, Vein of Galen AneurysmalMalformations

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Neuroradiology

• A five-month-old male infant presents with an abnormal head shape. What is the most likely diagnosis?

A. Sagittal synostosisB. Bicoronal synostosisC. Left unicoronal synostosisD. Right unicoronal synostosisE. Metopic synostosis

Q?

12

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NeuroradiologyA.• The correct answer is C, left unicoronal synostosis.• Coronal synostosis can occur either on the right or left side

(unicoronal), or both (bicoronal.) It frequently occurs prenatally, and appears to occur more commonly in males. Restriction of normal cranial growth at one suture between the frontal and parietal bones produces a characteristic flattening of the forehead on the fused side, and a bulging of the forehead on the non-fused side.

• This bulging, or bossing, is a result of compensatory growth of the contralateral (opposite side) coronal suture. Secondary bulging of the temporal region on the ipsilateral (same) side can also occur. The placement of the eyes within the orbit is also typically affected. The superior margin of the orbit on the synostosed side is raised, a feature known as Harlequin eyedeformity.

H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3300-01.

Contralateral•Frontal bossing•Displaced fontanelle

Ipsilateral•Flattened forehead•Raised brow(Harlequin Eye)•Temporal bulging

Classification: Neuroradiology, Infantile Pathology, Unicoronal Synostosis

©™©™Used with permission from Handbook of Neurosurgery andNeurology in Pediatrics; By Chaim B. Colen, MD, PhD.

• This x-ray demonstrates which of the following?A. McRae’s lineB. McGregor’s lineC. Rule of SpenceD. Chamberlain’s line

NeuroradiologyQ?

27

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NeuroradiologyA.• The correct answer is C, rule of Spence.• McRae’s line - foramen magnum diameter: 35 mm+/- 4• McGregor’s line - line from the hard palate to the caudal most part of the opisthion

(odontoid should be < 4 mm above this line > 4 mm suggests basilar impression). • Rule of Spence - if the sum of A + B ≥7mm, consider disruption of the transverse

ligament (requires rigid immobilization).• Chamberlain’s line - diagonal line from the hard palate to the posterior foramen

magnum (odontoid should not extend 1/3 of its height above this line).

Colen CB, Handbook of Neurosurgery and Neurology in Pediatrics, 2006.

BOARD FAVORITE!

Classification: Neuroradiology, Rule of Spence, Clinical Definition

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• What is the most likely diagnosis depicted in this MRI and MRS?A. Low grade gliomaB. Pleiomorphic xantho-

astrocytomaC. High grade gliomaD. None of the above

NeuroradiologyQ?

34

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NeuroradiologyA.• The correct answer is C, high grade glioma. • N-acetylaspartate (NAA) is predominantly located in neurons and is thus decreased in all

neoplasms that cause the neurons to be displaced or replaced with malignant cells. Findings of numerous studies have demonstrated decreased NAA values in glial neoplasms.

• Choline (Cho) peak contains contributions from glycerophosphocholine, phosphocholine, and phosphatidylcholine components that are thought to reflect cellular membrane density and turnover. As in any process that leads to hypercellularity and increased membrane proliferation, the Cho value is consistently elevated in gliomas.

• Lactate (Lac) indicates that cellular respiration has shifted from the oxidative metabolism of carbohydrates to nonoxidative metabolism. Increased reliance on anaerobic glycolysis is found in highly malignant tumors.

Law M, Hamburger M, Johnson G, Inglese M, Londono A, Golfinos J, Zagzag D, Knopp EA. Differentiating surgical from non-surgical lesions using perfusion MR imaging and proton MR spectroscopic imaging. Technol Cancer Res Treat. 2004 Dec;3(6):557-65. Review.

BOARD FAVORITE!

Classification: Neuroradiology, Magnetic Resonance Spectroscopy, High Grade Glioma

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• A 64 year-old black male presented with left sided headache and slurring of speech. Head CT is shown. Which of the following would likely be found on physical examination?A. Contralateral hemiparesisB. Ipsilateral hemiparesisC. Restricted left (lateral) gazeD. Restricted right (medial) gazeE. Locked-in-syndromeF. Both A and C

NeuroradiologyQ?

49

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NeuroradiologyA.• The correct answers are A, (C and F).• This patient has Millard Gubler syndrome!• REMEMBER - 7th nerve (7 letters in Millard) and - 6th nerve (6 letters in Gubler)• PLUS the corticospinal tract.• Millard-Gubler syndrome is associated with abducens (CN6) and facial nerve

(CN7) paralysis, as well as contralateral hemiplegia of the extremities. It involves unilateral damage to the inferior pons, commonly caused by pontine infarction or hemorrhage, and leads to damage of the above structures. The muscles of the ipsilateral side of the face are paralyzed, diplopia, internal strabismus, and loss of extroversion are also typically present.

Onbas O, Kantarci M, Alper F, Karaca L, Okur A. Millard-Gubler syndrome: MR findings. Neuroradiology. 2005 Jan;47(1):35-7.

Classification: Neuroradiology, Millard Gubler Syndrome, Physical Exam

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• A 57 year-old male underwent transnasal/ transfacial ethmoidectomy for metastatic squamous cell carcinoma. Post-operatively he developed clear rhinorrhea. Lumbar pucture was performed daily for 3 days draining 20 cc each time. On the third day he became confused and lethargic. On examination he was non-verbal and localized to painful stimulus. Head CT is shown. What is his most likely diagnosis?A. Recurrent tumorB. MeningitisC. Tension pneumocephalusD. Normal postoperative scan

NeuroradiologyQ?

50

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NeuroradiologyA.• The correct answer is C, tension pneumocephalus.• This head CT shows the Mt Fuji sign - twin peaks with bifrontal pneumocephalus.

The Mount Fuji sign is a finding that can be observed on computed tomographic (CT) scans of the brain (1), in which bilateral subdural hypoattenuating collections cause compression and separation of the frontal lobes. The collapsed frontal lobes and the widening of the interhemispheric space between the tips of the frontal lobes have the appearance of the silhouette of Mount Fuji hence, the Mount Fuji sign.

• Given this patient’s decline in mental status he is likely developing tension pneumocephalus.

H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 616.Ommaya AK: Cerebrospinal fluid fistula and pneumocephalus. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. 2nd ed. New York: McGraw-Hill; 1996: 2773-82

Classification: Neuroradiology, Tension Pneumocephalus, CT scan

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• A 4 year-old boy is brought to the emergency room after a fall. Lateral skull x-ray is shown to the right. Which of the following is the most likely diagnosis?

A. EpidermoidB. Eosinophilic granulomaC. HemangioblastomaD. Normal skull x-ray

NeuroradiologyQ?

66

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NeuroradiologyA.• The correct answer is B, eosinophilic granuloma.• AP view of the skull reveals an approximate 3 cm. circular lytic lesion overlying the left

frontoparietal region with well delineated non-sclerotic margins, suggestive of histiocytosis X (eosinophilic granuloma).

• Differential Diagnosis: Solitary lytic lesion in the skull includes metastatic lesion, myeloma, fibrous dysplasia, tuberculosis, trauma, histiocytosis X, osteomyelitis, leptomeningeal cyst, and epidermoid/dermoid.

• Eosinophilic granuloma - lytic lesion with well delineated non-sclerotic margins and beveled edges.

• Epidermoids - lytic lesion with sclerotic margins.

Yang JT, Chang CN, Lui TN, Ho YS. Eosinophilic granuloma of the skull--report of four cases. Changgeng Yi Xue Za Zhi. Dec 1993;16(4):257-62.

BOARD FAVORITE!

Classification: Neuroradiology, Pediatric Pathology, Eosinophilic Granuloma

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• Treatment for this lesion in a patient with neurofibromatosis type -1 should consist of:A. Removing the optic nerve and

attached globe.B. Removing the optic nerve and both

globes.C. Radiotherapy with 25 GrayD. Radiotherapy with 80 Gray

NeuroradiologyQ?

67

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NeuroradiologyA.• The correct answer is A, removing the optic

nerve and attached globe.• MRI demonstrates a high intensity lesion of

the distal right optic nerve, suggestive of optic glioma, especially in a patient with neurofibromatosis type 1.

• Treatment of optic glioma distal to the chiasm involves removing the optic nerve and attached globe.

• Treatment of optic glioma involving the chiasm involves removing the optic nerve, globe and radiotherapy (less than 8 Gray). Board Favorite!

Hollander MD, FitzPatrick M, O'Connor SG, et al: Optic gliomas. Radiol Clin North Am 1999 Jan; 37(1): 59-71.

BOARD FAVORITE!

Classification: Neuroradiology, NF-1 MRI, Treatment Modalities

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• This tumor most likely has elevated serum levels of which of following:A. Alpha-fetoproteinB. Carcinoembryonic antigen (CEA)C. Cancer antigen-125 (CA-125)D. β-human chorionic gonadotropin (β-

HCG)E. Placental alkaline phosphatase (PLAP)

NeuroradiologyQ?

69

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NeuroradiologyA.• The correct answer is D, β-HCG.• T1W non-contrast MRI sagittal image shows a pineal

recess mass compressing the tectal plate and causing triventricular hydrocephalus.

• INTRACRANIAL GERM CELL TUMORS• Germinoma is the most common.• Most common tumor of pineal recess 40%• Males• Respond well to chemo and radiotherapy• Cancer antigen-125 (CA-125)- ovarian cancer• Placental alkaline phosphatase (PLAP) - ovarian

cancer

Colen CB, Handbook of Neurosurgery and Neurology in Pediatrics, 2006 p. 41

BOARD FAVORITE!

Classification: Neuroradiology, Intracranial Germ Tumors, Serum levels

Teilum Concept

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• A 20 year-old female presents with 3 weeks of headaches, nausea, and vomiting. MRI is shown here. Which of the following is the most appropriate next step in management?A. Operative resectionB. No intervention neededC. Shunt placement or third

ventriculostomyD. RadiotherapyE. A and C

NeuroradiologyQ?

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NeuroradiologyA.• The correct answer is….• To obtain the answer to this question and to view over 250 more comprehensive

neuroradiology questions please purchase the full product here !

Barkovich AJ, Krischer J, Kun LE, et al: Brain stem gliomas: a classification system based on magnetic resonance imaging. Pediatr Neurosurg 1990-91;16(2): 73-83

BOARD FAVORITE!

Classification: Neuroradiology, TectalGlioma, Treatment Modalities