Leibold RA.Yealy DM, Coppola M.Cantees KK. Post-dural-puncture headache:characterisbcs.management,and prevention.Ann Emerg Med 1993;22:1863-1870.

Lexi-Comp Online '

. Hudson:Lexi-Comp.2011.

Lezak MD. Howieson DB, Loring OW.etal. Neuropsychological assessment (4th ed.). Oxford University Press, USA.2004.

Lindsay K.Bone I. Neurology and neurosurgery illustrated. Philadelphia:Churchill Livingstone.2003.

lowcnstcin OH. Alldrcdge BK.Status cprlcpticus. NEJM 1998:338:970 976.

Mainland BJ.AmodeoS, Shulman Kl. Multiple clock drawing scoring systems:simpler is better.Int J Geriali Psychiatry 2014:29:127-136.

MarcusC.Mena E, Subramaniam RM.Brain PET in the diagnosisol Alzheimer'

sdisease.Clin Nud Med 2014;39:e413-e426.

Marcus D.Chronic pain - a primary guide to practical management. New Jersey:Humana Press.2005.p.111-128.

ManixM.Katakoti P. Henry M, etal.Creutzfeldt-Jakob disease:updated diagnostic criteria,treatment algorithm, and the utility of brain biopsy. Neurosurg Focus 2015;39:E2.

McKeith IG.Boeve BF, Dickson 0W.etal.Diagnosisand managementol dementia with Levry bodies:fourth consensus report of the OLB Consortium.Neurology 2017;89:1-13.

McKhann GM.Knopman DS.Chertkow H. et al.The diagnosis of dementia due to Alzheimer'

s disease:recommendationsfrom the National Institute on Aging-Alzheimer'

s Association workgroupson diagnostic guidelines

for Alzheimer'sdisease.Alzheimers Dement 2011:2263-269.

Montalban X.Hauser SL.Kappos L.etal.Ocrelizumabvs.placebo in primary progressive multiple sclerosis.NEJM 2017;376:209-220.

Mullcncrs WM. McCrory DC. Linde M.Antiepilepticsin migraine prophylaxis:an updated Cochrane review.Cephalalgia 2015;135:51-62.

Mullins ME,lev MH.Schcillingcrhoul 0. et al. Intracranial hemorrhage complicating acute stroke: howcommon is hemorrhagic stroke on initial head Clscan and how often isinitial clinical diagnosis of acute stroke

eventually confirmed

’

Am JHeuroradiol 2005:26:2207 2212

Mumcnthalcr M. Mattie H. Fundamentals of neurology.Stuttgart and New Yoik:Thieme, 2006.

NasreddmeZS, Phillips NA. CharbonneauS.et al. The Monlreat Cognitive Assessment.MoCA:a brief screeningtool for mild cognitive impairment.J Am Genatr Soc 2005:53:695-699.

Neary D.Snowden JS.Gustafson L,etal.Frontotemporal lobar degeneration: a consensus ondinical diagnostic criteria.Neurology1998;51:1546-1554.

Nirmalananthan N.Holton JL,Hanna MG.Isitreally myositis

’

Aconsideration of the differential diagnosis.Curr Opin Rheumatol 2006;16:684- 691.

NogueiraRG.Jadhav AP, Haussen DC.etal.Thrombectomy 6 to 24 hours afterstroke with a mismatch between deficitand infarct.NEJM 2018:378:11-21.

Noseworthy JH. Lucchinetti C.Rodriguez M.et at.Multiple sclerosis.NEJM 2000;343:938-951

Olek MJ (editor).Multiple sclerosis:etiology,diagnosis, and new treatmentstrategies. New Jersey:Humana Press. 2005. p.36- 40, 57,131.222-223.

PasseroS. Rocchi R, Rossi S.et at.Seizures after spontaneoussupratentorial intracerebral hemorrhage. Epilepsia 2002:43:11751180.

Patterson C. FeghlncrJW, Garcia A. etal. Diagnosis and treatment of dementia; riskassesjment and primary prevention of Alzheimer disease. CMAJ 2008:178:548 556.

Perry J, Alyalrya B.Sivilotli MLA. et al. Differentialion between traumatic tap and aneurysmal subarachnoid hemorrhage:prospective cohort study. 8MJ 2015;350:h568.

Peterson RC.Lopez 0. Armstrong MJ.ct al. Practice guideline update: Mild cognitive impairment.Report ol theguideline development,dissemination,and implementation subcommittee ol the American Academy of

Neurology.Neurology 2018:90:126 135.

Pexman JH,Barber PA, Hill MD.et al. Useof the Alberta Stroke Program Early ClScore (ASPECTS) for assessing CT scans in patientswit h acute stroke.Am J Neuroradiof 2001:22:1534-1542.

Pierrot-Deseilligny C,Souberbielle JC.Vitamin 0 and multiple sclerosis:An update. MultSder Relat Disord 2017;14:35-45.

Postuma RB.Berg D.Stern M.et al.MDSdinical dia gnostic criteria for Parkinson'sdisease.Mov Disord 2015;30:1591-1601.

Pringsheim T.Davenport W. Mackie G.et al.Canadian Headache Society guideline for migraine prophylaxis.Can J Neurol Sd 2012;39:S1-S59.

Pringsheim I.Okun MS. Miillet-lfehl K. etal. Practice guideline recommendations summary:Treatmentol tics in people with Tourelte syndrome and chronic tic disorders. Neurology 2019:92:896 906.

Rascoesky K. HodgesJR,Knopman D. etal.Sensitivity ol revised diagnostic criteria for the behavioural variantof frontotemporal dementia.Brain 2011:134:2456-2477.

Robertson l. Kesteven P, McCaslin JE.Oral direct thrombin inhibitorsor oral factor Xa inhibitorsfor the treatment ol deep vein thrombosis.Cochrane DBSyst Rev 2015;6:CD010956.

Rodrigues FB. Neves JB.Caldeira 0.cl al. Endovascular treatment vs. medical care alone for ischaemic stroke:systematic reviewandmeta analysis.BMJ 2016;353:i1754.

Rolmski M.Fox C. Maidmenl I, etal.Cholinesterase inhibitors lor dementia with lewy bodies. Parkinson'sdisease dementia and cognitive impairment in Parkinson'sdisease.Cochrane DB Syst Rev 2012:C00065D4.

Salinas RA Alvarez G. Daly F. et al.Corticosteroidsfor 8el!'s palsy (idopathic facial paralysis).Cochrane DB Syst Rev 2010:CD001942.

Samuels MA.FeskeSK (editors).Office practice of neurology. 2nd ed. Philadelphia: Elsevier Science.2003. p.410- 411.

Scherokman B.Sehva L.Alguire PC.Approach to common neurologicalsymptomsin internal medicine:clerkship core curriculum guidelines.American Academy of Neurology and American College of Physicians.2011.

SchapiraAHV.McDermottMP, Barone P.etal.Pramipexole in patienIswith early Parkinson'sdisease (PROUD):a randomized delayed start trial.Lancet Her*

ol 2013;12:747-755.

Stovre RL.hres NJ.Clarke CE, etal.Dopamine agonist therapy in early Parkinson's disease.Cochrane DB Syst Rev 2008:C0006564.

Stroke Unit Trialists' Collaboration.Organized inpatient (stroke unit) care for stroke. Cochrane DBSyst Rev 2009:CD000197.

Sturrock A, Leavitt BR. The dinicaland genetic featuresol Huntington disease.J Gcriatr Psych Hour 2010:23:243-259.

The ESPRII Study Group.Aspirin ’ plus dipyridamole vs. Aspirin '

alone after cerebral ischaemia of arterial origin ( ESPRIT):randomized controlled trial, lancet 2006:367:1665-1673.

(he Heart Outcomes Prevention EvaluationSludylnvestigalors. Effects of an angiotensin-converting enzyme inhibitor, ramipnl.on cardiovascular events inhigh- risk patients. NEJM 2000:342:145 153.

The InternationalClassification of Headache Disorders 3rd ed.(Internet]. London:Sage Publications ltd; c2019. Painful lesions ol thccranial nerves and other facial nerves. Availablefrom:https://ichd-3.orgi13- painlul

- cranial-neuiopathies-and -other-facial-pains/.

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemicstroke. NEJ M 1995:333:1581-1588.

The National Institute of Neurological Disorders andStroke rt-PAStroke Study Group.Effects of tissue plasminogen activator for acute ischemic strokeat oneyear.NEJM 1999;340:1781-1787.

The TRANSFORMSStudy Group.Oral fingolimod or intramuscular interferon for relapsing MS.NEJM 2010:362:402-415.

The Writing Group on behalf of the Edaravone (MCI-186) ALS19Study Group.Safety and efficacy of edaravone in well defined patients with amyotrophic lateralsclerosis:A randomised,double-blind,placebo-controlled

study.Lancet Neurol 2017;16:505-512.

Van Cauwenbctghe C. Van Broeckhoven C.SIeegcts K.The genetic landscape ol Alzheimer disease:dmicalimplicabons and perspectives.GenetMed 2016;18:421-430.

van der Vuurst de Vues RM. Mcscheriakova JY. Wong YYM. et al. Apphcabon ol the 2017 Revised McDonald criteria for multiple sdeiosis to patients with a typical clinically isolated syndrome.JAMA Neurol 2018:75:1392

1398.

Vurgas'Schaffer 6.Isthe WHO analgesic ladder still valid ? Twenty-four years of experience.Can Earn Phys 2010:56:514 517.

Vigen CL. Mack WJ, Keefe RS, et al.Cognitive effects of atypical antipsychotic medicationsin patients with Alzheimer's disease:outcomesfrom CATIE- AD.Am J Psythial 2011:168:831- 839.

Vosoughi R.Freedman MS.Therapy of MS.Clin Neurol Heurosurg 2010;112:365-385.

Wagner R.Jagoda A. Neurologicemergencies:spinal cord syndromes.Emerg Med ClinicN Am1997:15:699-711.

WalkupJT.FerraoY, LeckmanJF.etal.Tic disorders:some key issuesfoe DSM-V.DepressAnxiety 2010:600-610.

YamadaKAAwadallaS.The Washington manual of medical therapeutics.31st ed. New York:Uppincott Williams & Wilkins.2004.p.531-534.

Yeo L.Singh R, Gundeti M.et al.Urinary tract dysfunction in Parkinson'

s disease:a review.Int Urol Nephrol 2012;44:415-424.

Zayia LC. ladi P. Neuioanalomy, Motor Neuron.[Updated 2021 Jul 31].In:StatPearls[Internet], Treasure Island (Ft):Sta (Pearls Publishing:2022. Available from: https:Wwww.ncbi.nlm.mh.gov'booksf NBKS5461&I

Jerri, Pocchiari M. CollinsS. et al.Analysis of EEGandCSF 14 3-3proteinsas aids to the diagnosis of Creutzfeldt-Jakob disease. Neuiology 2000:55:811 815

2utr I,Kallenbetg K, Summers DM. et al. Updated clinical diagnostic ciitcria lor sporadicCreutzfeldt Jakob disease.8rain 2009:132:2659- 2668.

Zinncr SH. Min

SH. Mink JW. Movement disorders I:tics and stereotypies. Pediatr Rev 2010:31:223.

criteria. Mov Disord 2017:32:853 864.

+

Activate Windows

lings to activat Go t iA/imdows.

Neurosurgery

Dan Budiansky, Jack Su, and kaza Sycd, chapter editors

Vrati M. Mehra and Chunyi Christie Tan, associate editors

Arjan S. Dhoot, EBM editor

Dr. Sunit Das, Dr. Michael l-

'

ehlings, and Dr. Eric Massicotte,staff editors

Acronyms .NS35

Basic Anatomy Review

Differential Diagnoses of Common Presentations

INTRACRANIAL PATHOLOGY.

Intracranial Pressure Dynamics

ICP/Volume Relationship

Cerebral Blood Flow

ICP Measurement

ElevatedICP

Herniation Syndromes

Treatment of Elevated ICP

Idiopathic Intracranial Hypertension (Pseudotumour

Cerebri)

Hydrocephalus

Spontaneous Intracranial Hypotension.

CNS Tumours

Metastatic Tumours

Adult Diffuse Gliomas

Primary Central Nervous System Lymphoma

Meningioma

Vestibular Schwannoma (Acoustic Neuroma)

Pituitary Adenoma

Cerebral Abscess

Blood.

Epidural (Extradural) Hematoma

Subdural Hematoma

Cerebrovascular Disease

Subarachnoid Hemorrhage

Intracranial Aneurysms

Intracerebral Hemorrhage

Vascular Malformations.

Arteriovenous Malformations,Cavernous Malformations,and

Dural Arteriovenous Fistulas

Cerebrospinal FluidFistulas

EXTRACRANIAL PATHOLOGY.

Approach to Limb/Back Pain

Extradural Lesions

Root Compression

Cervical Disc Syndrome

Degenerative Cervical Myelopathy.

Lumbar Disc Syndrome

Cauda Equina Syndrome

Lumbar Spinal Stenosis

Neurogenic Claudication

Intradural Intramedullary Lesions..

Syringomyelia (Syrinx)

Spinal Cord Syndromes

Peripheral Nerves

NS2 SPECIALTY TOPICS

Neurotrauma

Trauma Assessment

Head Injury

Brain Injury

Spinal Cord Injury

Fractures of the Spine

Neurologically Determined Death

Coma

Persistent Vegetative State

Paediatric Neurosurgery.

Spinal Dysraphism

Intraventricular Hemorrhage

Hydrocephalus inPaediatrics

Dandy-Walker Malformation

Chiari Malformations

Craniosynostosis

Paediatric Brain Tumours

Functional Neurosurgery

Movement Disorders

Chronic Pain

Surgical Management of Epilepsy

Surgical Management for Trigeminal Neuralgia.

Landmark Neurosurgery Trials

References

NS2 .NS35

NS4

NS4

NS4

NS41 NS7

NS8

,NS9

NS11

NS11 NS45

NS46

NS47

NS47

NS18 NS51

NS20

NS21

NS27

NS28

NS28

NS28

NS28

.NS30

NS33

.NS34

NS34

L J

+

NSl Neurosurgery Toronto Notes 2023

Activate Windows

Go to Settings to activate Windows.

NS2 Neurosurgery Toronto Notes 2023

Acronyms

ACom anterior communicating artery EVD SDH

AVF arteriovenous fistula

AVM arteriovenous malformation

blood-brain barrier

blood urea nitrogen

culture and sensitivity

cerebral blood flow

cranial nerve

CNS central nervous system

CPA cerebellopontine angle

CPP cerebral perfusion pressure

CSF cerebrospinal fluid

CVR cerebral vascular resistance

DBS deep brain stimulation

diabetes insipidus

ECF extracellular fluid

external ventricular drain

Glasgow coma scale

globus pallidus pars interna

headache

internal capsule

internal carotid artery

intracellular fluid

intracerebral hemorrhage

intraventricular hemorrhage

lower motor neuron

level of consciousness

lumbar puncture

mean arterial pressure

mldlinc shift

magnetic resonance

angiography

N/V nausea/vomiting

neurogenic claudication

non-contrast CT

neonatal intensive care unit

normal pressurehydrocephalus

ossification of posterior

longitudinal ligament

periaqueductal grey matter

posterior communicating artery

positron emission tomography

posterior longitudinal ligament

primitive neuroectodermal

tumour

periventricular grey matter

subarachnoid hemorrhage

spinal cord injury

subdural hematoma

syndrome of inappropriate

antidiuretic hormone

single photon emission

computed tomography

stereotactic radiosurgery

subthalamic nucleus

traumatic brain injury

upper motor neuron

ventral posterolateral

ventral posteromedial

whole brain radiation therapy

radiotherapy

GCS NC SIADH

GPi NCCT

BBB H/A NICU SPECT

BUN 1C NPH

C&S ICA OPLL SRS

CBF ICF STN

CN ICH PAG T8I

IVH PCom UMN

LMN PET VPL

LOC PLl VPM

LP PNET WBRT

MAP XRT

MIS PVG

Dl MRA SAH

SCI

Basic Anatomy Review

Primary Motor

Cortex /

Parietal Lobe Temporal Lobe Parietal Lobe Frontal

Eye Fields

Somatosensory

Frontal ’Cortex

Lobe \

Occipital

Lobe Broca'

s

Area

r

o

Frontal

Lobe Occipital

Lobe

Bed Nucleus

(midbrain)

Auditory,

Cortex

Temporal Lobe L -V

~J

Cerebellum Aperture of the

Cerebellopontine

Angle

Pineal

Gland

Wernicke's

Area

© 2018 Robyn Hughes 2016 after Caitlin O'Connell 2009

Figure 1. Basic surface anatomy

Central sulcus MRI Brain Frontal lobe Parietal lobe Cingulate gyrus Septum pellucidum

^

Superior

sagittal sinus

Corpus callosum

Thalamus

^

Hypothalamus

Cerebral

aqueduct

Occipital lobe

Tentorium

— Midbrain

Fourth ventricle

Cerebellum

Frontal lobe

^

Caudate nucleus

Lateral ventricle

Putamen

Internal capsule

—Insula

Thalamus

Cerebral

Aqueduct

Parietal lobe

Pons

Medulla

Dens ol C2

Spinal cord — Occipital lobe

Bodyol C3

ri

L J

A. Sagittal Section B. Axial Section

Figure 2. MRI neuroanatomy. The left panel is a T1-weighted image;the right panel is T2-weighted

Stewart P. Cameron T.Farb R.Functional Neuroanatomy (Version 2.1).Health Education Assets Library 2005

+

Activate Windows

Go to Settings to activate Windows.

NS4 Neurosurgery Toronto Notes 2023

Differential Diagnoses of Common

Presentations

Table 1. Differential Diagnoses of Common Presentations

Intracranial Mass Lesions Disorders of the Spine Peripheral Nerve Lesions

Neuropathies

Traumatic

Entrapmenls

Iatrogenic

Inflammatory

Tumours

Tumour

Metastasis

Glioma

Meningioma

Vestibular schwannoma (acoustic neuroma)

Pituitary adenoma

Primary CNS lymphoma

Extradural

Degenerative:discherniation,canal stenosis,

spondyloiisthesis

'

spondylolysis

Infection.

'

'

inflammation:osteomyelitis,discitis

Ligamentous:OPLL

Trauma:mechanical compressiom'inslability,

hematoma

Tumours (55% of allspinal tumours):

lymphoma,metastases (lymphoma,lung,

breast,prostate),neurofibroma

Pus/Inflammation

Cerebral abscess,extradural abscess,

subdural empyema

Encephalitis.e.g.Herpes Simplei Virus (see

InfectiousDiseases.1018)

Tumelactive multiple sclerosis (MS)

Sarcoidosis

IntraduralExtramedullary

Vascular,dural AVE.SON (especially if on

anticoagulants)

Tumours (40% of all spinal tumours):

meningioma,schwannoma,neurofibroma

Blood

Extradural (epidural) hematoma Intradural Intramedullary

Tumours(5% of all spinal tumours):gliomas,

ependymomas,hemangioblastomas,and

dermoids

Syringomyelia:trauma,congenital,idiopathic

Infectousinflammatory:TB.sarcoid,

transrerse myelitis

Vascular:AVM.ischemia

SDH

Ischemic stroke

Hemorrhage: SAH.ICH.IVH

Cyst

Arachnoid cyst

Dermoid cyst

Epidermoid cyst

Colloid cyst (3rd ventricle)

INTRACRANIAL PATHOLOGY

Intracranial Pressure Dynamics

Table 2. Approach to Intracranial Pathology

Issue Time Frame Features

Vascular Sudden No H A - occlusive

H.A "hemorrhagic

Affects entire CNS

Often a source of infection or immunodeficiency on history

IncreasedICP:

Initially

- H A

Constant

Progressive

Sevete

Worse inmorning andlor wakes from sleep

AsICPtncreases:

Blurry vision

Projectile vomiting (may initially piesent without nausea)

Severely raisedICP:

Cushing's triad

1.Bradycardia

2.HTN

3.Sesplratory irregularity

Metabolic

Infectious

Hours to days

Days to weeks

Tumour Months

r

*

i

L J

+

Activate Windows

Go to Settings to activate Windows

XS5 Neurosurgery Toronto Notes 2023

Table 3.Consequences of Common Brain Lesions

Location of Lesion Consequence

Abulia,disinhibition.apathy, executive dysfunction,deficits in oiientation and judgment.

primitive reflex re- emergence, t contralateral UMN signs (upgoing Babinski reflex and

pronator drill)

Gate deviation toward side ol a destructive lesion

Gate deviation away from Irritative lesion (i.e.seizure)

Non-fluent, dysarthric. aphasia

Repetition impaired

Comprehension spared

Contralateral homonymous hemlanopla

Orcssmg apraxia, cortical sensory loss, lower homonymous quadranlanopia

Inattention or extinction of non-dominant side

Aphasias.Gerstmann'ssyndrome

Hemispatial neglect, apraxias, agnosias|if temporal involvement)

Hippocampus: anterograde amnesia

Upper homonymous heinianopia

Wernicke's aphasia (if loftfdominant side)

fluent aphasia

Repetition impaired

Comprehension impaired

Resting tremor

Chorea

Athetosis

Hemiplegia if 1C involved

Contralateral hemiballismus

Absent brainstem reflexes:oculocephalic. oculovestibular.corneal, gag.and cough

Dorsal midbrain/pineal gland: Parinaud’ssyndrome (supranuclear upward gaze palsy)

Pons:locked-in syndrome

Below red nucleus:decerebrate posture

Above red nucleus:decorticate posture

Reticular activating system (midbrain): reduced level of arousal

CPA:disequilibrium,ataxia,and CN V.VII, VIII deficits

Intention tremor

Ipsilateral limb ataxia

Fall towardsside of lesion

Truncal ataxia

Dysarthria

Frontal Lobe

Usually large lesions produce symptoms

Frontal Eye Fields

Broca's Area

Posterior inferior frontal gyrus of dominant

hemisphere

Occipital Lobe

Parietal lobe

Either side

Dominant side ( left)

Hon -dominanl side (right)

Temporal lobe

Wernicke's Area

Posterior superior temporal gyrus of dominant

hemisphere

Basal Ganglia

Subthalamic Nucleus

Brainstem

Cerebellar Hemisphere

Cerebellar Vermis

ICP/Volume Relationship

^ ICP inmHcj

• Monro-Kellie doctrine: the brain is encased in a rigid skull with constant intracranial volume

• the intracranial space contains C

'

Sl'

, blood, and brain

• the increase in one constituent will: 1) necessitate the redistribution of CS1-

'

, blood, and/or brain; and

2) increase ICP

• compensatory mechanisms initially maintain a normal ICP

• compensatory reserve (spatial compensation): 60-80 ml.in young people, 100-140 mL in elderly

(largely due to cerebral atrophy)

• immediate: egress of CS1- through foramen magnum to spinal canal, displacement of venous

blood from sinuses into jugular veins

• once compensation is exhausted, ICP rises exponentially;

• late: displacement of arterial blood (decreased CPP) eventually leading to ischemia, increasing

brain edema, or expanding mass displaces parenchyma into compartments under less pressure

(see Table4,NS7)

end: cessation of cerebral perfusion when ICP>MAP, cerebral herniation down into foramen

magnum

too

80

60

40

r* **

-

20

0

Volume *

Eventually, further

small Increment!

m volume pioduco

largor andlargor

increments in ICP

When a mass expands

within the skull,

compensatory

mechanisms initially

maintain a normal ICP

Figure 5. ICP volume curve

Adapted from:Lindsay KW. Bone I. Fuller G.

Neurology and Neurosurgery illustrated. 2004.

With permission from Elsevier

r t

L J

+