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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.

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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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• When the interpeduncular cistern is filled with blood secondary to a ruptured posterior communicating aneurysm, which of the following choices describes the safest surgical approach?A. Superior to the posterior communicating artery, because there is only one

perforating arterial branch and so this area is safeB. Opening the membrane of Lilliequist above the posterior communicating artery to

avoid injury to the perforators that may be covered with bloodC. Opening the membrane of Lilliequist below the posterior communicating artery to

avoid injury to the superiorly directed perforators that may be covered with bloodD. The membrane of Lilliequist should not be opened

NeurosurgeryQ?

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• The correct answer is C. It is safer to open the membrane of Lilliequist below the PComA to avoid injury to the superiorly directed perforators that may be covered with blood.

• The posterior communicating artery (PComA) usually gives off 2–10 perforators which begin approximately 2 to 3 mm from its origin. Branches, the anterior thalamoperforating arteries, run postero-medially into the interpeduncular cistern and supply the inferior optic chiasm, optic tract, tuber cinereum, mammillary bodies, subthalamus, posterior hypothalamus, and the anterior thalamus.

• An important point is that aneurysms almost always arise from the superior medial aspect of the PComA so that when the interpeduncular cistern is filled with blood, in case of a ruptured intracranial aneurysm, it is safer to open the membrane of Lilliequist below the PComA to avoid injury to these superiorly directed perforators that may be covered with blood. Of these perforators, the largest and most constant one is referred as the premamillary artery or thalamotuberal artery.

NeurosurgeryA.

Zeal AA, Rhoton AL Jr. Microsurgical anatomy of the posterior cerebral artery. J. Neurosurg. 1978 (48) 534–559.

Classification: Neurosurgery, Ruptured Posterior Communicating Aneurysm,

Surgical Approach

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• Which of the following choices best describes the Wartenberg’s sign? A. Ulnar nerve compressionB. Adduction of the index fingerC. Weakness of the third palmar interosseous muscleD. Inability to flex the thumb

NeurosurgeryQ?

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NeurosurgeryA.• The correct answer is C, weakness of the third palmar

interosseous muscle• Wartenberg’s sign is one of the earliest signs of ulnar

nerve entrapment. It is the result of the weakness of the third palmar interosseous muscle, which leads to abducted posture of the small finger.

A. M. Richards. Key Notes on Plastic Surgery. Blackwell Publishing. 2002. p. 215.H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3925.

Wartenberg’s sign

• Ulnar nerve compression locations:• Upper arm: arcade of Struthers – aponeurotic band anterior to

the medial head of the triceps (NOT STRUTHER’S LIGAMENT which is a ligament connecting the medial epicondyle and the supracondylar process).

• Elbow/Forearm: in the cubital tunnel between the two heads of the flexor carpi ulnaris. MOST COMMON LOCATION (see neuroanatomy section)

• Wrist: Guyon’s canal (see neuroanatomy section)

BOARD FAVORITE!

Classification: Neurosurgery, Clinical findings, Wartenberg’s Sign

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• When should an open craniotomy be used to eliminate a vein of Galen malformation in an infant or older child?

A. Yasargil I and IIB. Yasargil II and IVC. Yasargil I and IVD. Yasargil III and V

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NeurosurgeryA.• The correct answer is A, open craniotomy should be used with Yasargil types I and II.• Vein of Galen aneurysmal malformation is a rare congenital anomaly of the cerebral circulation. It

makes up approximately 1% of intracranial vascular malformations, but they represent 30% of pediatric intracranial vascular malformations.

• Two methods of classifications had been used extensively in the literature. The first classification divided it into mural and choroidal type. The choroidal type is where there are multiple shunts communicating with the anterior dilatation of the median prosencephalic vein. The mural type is where the arteriovenous shunt is in the wall of the dilated vein. The second classification described by Yasargil divides into type I to IV in which type I corresponds to mural types and type II and III correspond to the choroidal type.

C.A. Raybaud, C.M. Strother, J.K. Hald. Aneurysms of the vein of Galen: embryonic considerations and anatomical features relating to the pathogenesis of the malformation. Neuroradiology 1989;31:109-128.H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3442.

Angiogram showing a mural type vein of Galen aneurysmal malformation supplied by the right posterior choroidal artery.

vein of Galen aneurysmal malformation

Classification: Neurosurgery, Vein of Galen Malformation, Open Craniotomy

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• According to this cervical x-ray which of the following statements is most accurate?

A. You must surgically fuse this fracture.B. Most of these fractures will heal without

surgical fusionC. It is likely due to flexion injuryD. It is due to fracture of the pedicles

NeurosurgeryQ?

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NeurosurgeryA.• The correct answer is B. Most hangman’s fractures heal with

immobilization and do not warrant surgical intervention. In general, type 1 injuries are treated with a rigid collar for 8 to 12 weeks. Type 2 injuries are initially reduced with traction in slight extension followed by a halo vest for 12 weeks. A halo vest in compression and slight extension is used for type 2A injuries. Immediate surgery is required for type 3 injuries to stabilize the C2/C3 facet joint.

• The hangman's fracture consists of bilateral pars interarticularisfractures involving the C2 vertebral body. Anterior subluxation or dislocation of the C2 vertebral body will often occur in consequence to a hangman’s fracture, which itself occurs secondary to hyperextension injuries seen during automobile accidents or hangings.

Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am.1985;67:217-226.

BOARD FAVORITE!

Classification: Neurosurgery, Hangman’s Fracture, Treatment

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• In order to be directly above the foramen of Monro, where would the corpus callosum need to be incised?

A. At the genuB. 1 cm behind the genuC. 2.5 cm behind the genuD. 5 cm behind the genuE. 2.5 cm anterior to the splenium

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NeurosurgeryA.• The correct answer is C. The foramen of Monro is directly beneath the corpus

callosum at around 2.5 cm behind the genu.

2 cm

right hemisphere

genu of the corpus callosum

foramen of Monro

Classification: Neurosurgery, Corpus Callosum Incision, Foramen of Monro

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• The most appropriate next step in management for the abnormality seen in this image would be to:A. EmbolizeB. Inject alcoholC. Consider coilingD. Consider surgeryE. No intervention at this time

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NeurosurgeryA.• The correct answer is E, no intervention at this time.• The angiogram seen here depicts the classical findings seen in venous

malformations (VM), caput medusa. VM consist of a large cortical draining veinreceiving a collection of medullary veins that usually occurs near the angle of the ventricle. They rarely hemorrhage. Thus, when diagnosed, they do not require intervention.

• 30% are associated with cavernous malformations.• There may be multiple angiomas in blue nevus syndrome.

Perrini P, Lanzino G. The association of venous developmental anomalies and cavernous malformations: pathophysiological, diagnostic, and surgical considerations. Neurosurg Focus. 2006 Jul 15;21(1):e5. Review.

Classification: Neurosurgery, Venous Malformations, Management

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• The strength of a screw is proportional to:A. The length LB. The outside diameter (thread diameter)3

C. The inside diameter (ID)3

D. The product of the ID and length squared (ID x L) 2

E. All of the above

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NeurosurgeryA.• The correct answer is C, the inside

diameter (ID)3

ID

OD

Classification: Neurosurgery, Screw Strength

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• The order of structures traversed when doing Deep Brain Stimulation (DBS):A. Zona incerta, thalamus, subthalamic nucleus, substantia nigraB. Thalamus, zona incerta, subthalamic nucleus, substantia nigraC. Thalamus, subthalamic nucleus, zona incerta, substantia nigra D. Subthalamic nucleus, thalamus, zona incerta, substantia nigra

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NeurosurgeryA.• The correct answer is B, thalamus, zona

incerta, subthalamic nucleus, substantia nigra

• The thalamus (shown in green), subthalamic nucleus (in yellow) and the substantia nigra (in red) are also included in the basal ganglia. The putamen (in blue) can also be seen in this diagram. The zona incerta is the white area just inferior to the thalamus.

• The arrow depicts the trajectory traversed during DBS.

BOARD FAVORITE!

Fraix V, Pollak P, Van Blercom N, Xie J, Krack P, Koudsie A, Benabid AL (2000) Effect of subthalamic nucleus stimulation on levodopa-induced dyskinesia in Parkinson s disease. Neurology 55:1921–1923.

Classification: Neurosurgery, Deep Brain Stimulation, Structures

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• In doing deep brain stimulation of the subthalamic nucleus, going posterolateral will cause:A. Tetonic muscular contractionB. DysesthesiasC. Tremor reductionD. Double vision

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NeurosurgeryA.• The correct answer is B, dysesthesias.• NOTE –This is an important board question!

– Anterolateral: tetonic muscular contraction internal capsule– Dorsal: decrease in tremor zona incerta– Posterolateral: dysesthesias, sweating medial lemniscus– Medial: double vision, changes in pupils CN III, IV

BOARD FAVORITE!

Fraix V, Pollak P, Van Blercom N, Xie J, Krack P, Koudsie A, Benabid AL (2000) Effect of subthalamic nucleus stimulation on levodopa-induced dyskinesia in Parkinson s disease. Neurology 55:1921–1923.

Classification: Neurosurgery, Deep Brain Stimulation, Posterolateral to Subthalamic

Nucleus

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• A 76 year-old male presents to your clinic in consultation with results of a recent angiogram that suggest carotid stenosis with 45% occlusion by NASCET criteria. He denies current visual changes, headaches or weakness, but says that 2 weeks ago he did have “loss of sight” in the left eye for one day . You would recommend:

A. Medical therapy (ie, antiplatelet agents and cardiovascular risk factor control/prevention)

B. Recommend carotid endarterectomy after considering the patient's risk factor profile and comorbidities

C. Recommend endarterectomy without considering the patient's risk factor profile and comorbidities

D. Carotid endarterectomy plus antiplatelet therapy and cardiovascular risk factor control/prevention

NeurosurgeryQ?

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NeurosurgeryA.• The correct answer is A, medical therapy. (ie, antiplatelet agents and cardiovascular risk factor

control/prevention).• NASCET criteria for carotid stenosis:• Symptomatic (TIA or minor stroke) • Lower-grade carotid stenosis (<50% by NASCET criteria): medical therapy (ie, antiplatelet

agents and cardiovascular risk factor control/prevention)• Moderate-grade symptomatic carotid stenosis (50% to 69% by NASCET criteria): walk a finer

line. Consider patient's risk factor profile and comorbidities.• High-grade symptomatic carotid stenosis (70% to 99% by NASCET criteria): CEA plus

antiplatelet therapy and cardiovascular risk factor control/prevention is the treatment of choice.• Asymptomatic• >60% carotid stenosis (NASCET criteria): walk a fine line. If surgical complications exceed

3%, CEA would be harmful to the patient. Ferguson GG, Eliasziw M, Barr HWK, Clagett GP, et al. The North American Symptomatic Carotid Endarterectomy Trial. Stroke. 1999;30:1751-8.

BOARD FAVORITE!

Classification: Neurosurgery, NASCET, Carotid Stenosis

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Neurosurgery

• Match the appropriate indication for the given procedure:1. Dorsal root ganglionectomy 2. DREZ3. Cordotomy4. Midline myelotomy5. Intrathecal pump implant6. Spinal cord stimulator

A. Bilateral lesions, may cause Ondine’s CurseB. Severe spinal headache, seromaC. Unilateral allodyniaD. Incision 2 cm above pain siteE. Root avulsionF. Failed back syndrome; good for appendicular pain

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NeurosurgeryA.• The correct answer is….• To obtain the answer to this question and to view over 200 more

comprehensive neurosurgery questions please purchase the full product here!

H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3028, 3059-61, 3112-4.Romanelli P, Esposito V, Adler J. Ablative procedures for chronic pain. Neurosurg Clin N Am. 2004 Jul;15(3):335-42. Review.

BOARD FAVORITE!

Classification: Neurosurgery, Surgical Procedures and Their Indications