常見疾病、手術 及值班常見問題介紹 lecture/surgery/神經外科工作簡介... ·...
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?? 70 %
19 %
8 %
3 %
Emergency room care ABC first (Airway)(Breathing)
(Circulation) -
Initial radiological studies () Foley, NG tube, Laboratory studies ( ABG, . ) EKG
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The Glasgow Coma Scale
: GCS score 13-15 : GCS score 9-12 : GCS score 3-8
ATLS, 8th edition
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Neurological examination /, EOM, MP/ DTR
- 5 %
MP
5
4
3
2
1
0
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Guideline 2 GCS score15 ,
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Options 2 65 2 30
1 5
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Monitoring cerebral physiology Intracranial pressure (ICP) monitor
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1.2. IICP
hyperventilation PCO2 30 -35mmHg mannitol sedation barbiturate coma CSF
3.
10-15 mmHg 3-7mmHg 1.5-6 mmHg
Monro-Kellie Hypothesis Brain + CSF + Blood =
(1,400+150+150=1,700ml)
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Cerebral blood flow: regional or global cerebral blood flow and metabolismJugular venous oxygen saturation: indirect assessment of global cerebral blood flow and metabolism; SjvO2
Transcranial Doppler: traumatic vasospasm EEG EP
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(IICP)1.2.(byperemia)3.(traumatic induced mass)4.(EDHSDHICHcontusion
hemorrhage)5.(hypoventilation)6.(systemic hypertension)7.(venous sinus thrombosis)8.(hydrocephalus)9.(fever)10.(ischemia)
1.2.(GCS) 83.4.
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Mannitol1.2.3.mass effect(hemiparesis)4.brain CTIICP5.brain CT
Mannitol
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(Second Tier Therapy)1. Hypertonic saline :
2. Barbiturate coma :
3. Hyperventilation PaCO2 30 mmHg
4. Hypothermia : 5. Steroid :
Hemodynamic support and CPP management Guideline 1. 0.9% (Saline)
(Lactate Ringer's) (Level ) 2. (Level )
(Sedation) Options 1. GCS score 3-8
2. GCS Score 3-8
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(Seizure Prophylaxis) Options 1.
2. GCS score 10 24
Nutritional Support Guideline 1.
15% 2.
(resting metabolic expenditure) 100% 140%
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Intracranial Complications1. Posttraumatic seizures: one week2. Ventriculostomy-related complications
- parenchymal injury, hemorrhage: 1.4 %- ventriculitis: +1 % per day, 2 weeks
Systemic or Extracranial Complications1. Electrolyte derangements2. Pneumonia3. Thromboembolic events4. Gastrointestinal hemorrhage
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8%20%
20-30%
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40358750(6.1%)356
: CT \ MRI \ Angiography
MRI
CBCPT \ APTTelectrolyte EKG chest x-ray
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ABC
compartment syndromes
130
mmHg 110
mmHg
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ICP
ICP>20mmHg ICP20mmHgCPP
70mmHg
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CT1/2
10 mL
ICH3 GCS< 5
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3cm30cc
AneurysmAVMcavernous hemangioma
60lobar or basal ganglion hemorrhage50cm3GCS1430-50cm3GCS1230cm3
/
11.6%(1992 ) 1993
54.614.356.513.855.714.02:3
199326.7%22.0%20.1%19.6%12.2%8.1%3.2%2.9%
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2492%
CTA
MRA
TCD
(1)(2)(3)(4)(5)
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(1)()
1. 3~4%(24)1~2%33%
2.( level of evidence to grade B )
3.Antifibrinolytic therapy /( level of evidence to grade A )
4.ligation( level of evidence to grade A )
()1.
3mm3mm
2. ( level of evidence to grade B )early surgerydelayed surgeryearly surgery ( level of evidence to grade B)wrappingcoating
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(2) Hypertension/hypervolemia/hemodilution (triple H)
( level of evidence to grade C )hemodynamic function
Nimodipine()5cc/hr10cc/hr( level of evidence to grade A )( level of evidence to grade B )
Transluminalangioplasty
(3) 20%
( level of evidence to grade C )
( level of evidence to grade C )
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(4) 10
27.5%( level of evidence to grade C )
(level of evidence to grade C )
(5) volume
contraction( level of evidence to grade C )
volume statuscentral venous pressurepulmonary capillary wedge pressurefluid balance
cerebral salt wasting syndrome SIADS
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1%
3%4%1%
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1.2.(radiosurgery)3.
Spetzler-martin 3
Spetzler-Martin AVM
6 3 0 1 0 1
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Astrocytic tumors Oligodendroglial tumors Mixed gliomas Ependymal tumors Choroid plexus tumors Neuronal and mixed neuronal-glial tumors Pineal parenchymal tumor Embryonal tumors Meningeal tumors Germ- cell tumors Tumors of the sellar region Metastatic tumors
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A.
B. C.
D.
: A. XB. (CT)C. (MRI)
CTMRIMRA(MRI)MRI
D. (EEG)EEGMRI
(MSI)E.
()MRACTA
-
1.
a)b)
c)d)
()bromocriptone
e)
2.: a)
(brain mapping)(electrocortico-graphy)
b)c)MRI
(mural nodule)d)
(1)(2)Karnofsky(3)
e)CTMRI1
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1.10%
BBBBCNU2.(anaplastic
oligodendroglioma)
3.(medulloblastoma)(pinealoblastoma)
4.FDA1996BCNUGliadel
1.
a)b)
c)(germinoma)
d)Medulloblastoma, ependymoma, germinoma(seeding)HCG, AFP, CEA
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2.(Brachytherapy)a)125192b)32
3.(Stereotactic radiosurgery)a)
b)6015~25Gy
c)
d)(boost)e)
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()
()
Hydrocephalus ex vacuo()
Communicating
non-obstructive hydrocephalus Non-communicating
obstructive hydrocephalus
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1,0003-4
1,0000.9-1.5(sping bifida)(myelomeningocele) 1,0001.3-2.9
(/cytomegalicinclusion virus/toxoplasmosis)
A.
(/setting-sun sign)
(cracked pot)Macewens sound 91
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B.
()
()
(suprapineal recess)
Parinaud
C.(Normal Pressure Hydrocephalus; NPH)
()
(classicfriad)(dementia)
(incontinence)(disturbance of gait) (presenile demenlia)
(senile dementia)
()
-
(Endoscopic 3rd Ventriculostomy )
suprasellar cistern
(50%)
A.(Ventriculo-Peritoneal Shunt; VP
Shunt) B.(Ventriculo-Pleural Shunt) C.(Ventriculo-Atrial Shunt; VA
Shunt) D.(Lumboperitoneal Shunt)
-
()
(pseudocyst)
7-10%()
(5-48%)()()()()
-
1.
-
-
2. /
-
20292049
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Classification of Spinal Cord Injury
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Cervico-medullary syndrome ( Upper cervical cord to medulla syndrome ) Schneider, respiratory arrest, hypotension,
tetraplegia, and anesthesia Sensory loss over the face conforming to the onion
skin or Dejerine pattern ( pain and temperature loss )
Mimic the central cord syndrome ( Syndrome of cruciate paralysis of Bell )
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Central Cord Syndrome Within the centrum of the cervical spinal cord more weakness in the upper extremities, when
compared with the lower extremities sensory loss is minimal DTR - UE: absent ; LE: preserved Edema and hemorrhagic contusion, mechanical
disruption, ischemia Hyperextension, in elderly patient with cervical
spondylosis and a stenotic spinal canal
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Anterior Spinal Cord Syndrome anterior 2/3 of the spinal cord ( corticospinal tract
and the anterolateral spinothalamic system ) Loss of all voluntary motor activity Absence of sensation to pain and temperature Preserved posterior column function
( proprioceptive response ) Direct trauma Poor recovery, 10~20%
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Brown-Sequard Syndrome Ipsilateral loss of lower motor neuron Ipsilateral loss of strength and proprioception Contralateral loss of pain and temperature
sensation Most commonly observed secondary to penetrating
injury
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Reversible, transient syndrome Spinal cord injury without radiological
abnormality ( SCIWORA ) Spinal cord injury without radiological
evidence of trauma ( SCIWORET ) Anterior spinal artery syndrome
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Imaging X-ray film
Lateral plain film - 75~85% of CSI AP, open-mouth odontoid, flexion-extension 93% Downward pull on the arms or swimmers view- C7- T1 15~20% of C-SCI - Negative Flexion-extension - conscious & gross stability
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CT scan Thin-section 3-D
CT myelography MRI
soft tissue myelographic-equivalent image does not image cortical bone
Occipital-Atlantal Dislocation high fatality rate distraction with neck hyperflexed Types
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C1 arch fracture - Jefferson Fracture axial load 3~13% of cervical spine injuries lateral displacement of the lateral mass of C1 on
C2 , > 6.9 mm transverse ligament ( rigid external fixation or
surgical )
Atlantoaxial Instability adult > 3 mm ; child > 4.5 mm ( transverse lig )
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Odontoid Fractures
C2 traumatic Spondylolisthesis Hangmans Fracture 1913, Wood-Jones, judicial hanging 1965, Schneider et al, 8 injuries resulting from
motor vehicular accidents -- Hyperextension bilateral pars interarticularis fractures most are not associated with neurological injury stable and heal in a cervical collar
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Subaxial Spine ( C3~C7 ) Compression injuries
Flexion teardrop fracture Extension unilateral arch fracture
Distraction injuries Flexion hyperflexion sprain, bilateral interfacetal
dislocaation Extension whiplash
Lateral flexion injuries
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Management Systemic
Neurogenic shock Systemic hypotension, bradycardia Volume expansion and /or pressor agents
Loss of thermal regulation Hypothermal regulation
Loss of skin sensation, motor function Pressure sore and decubitus ulcer
Deep vein thrombosis, pulmonary embolization Early mobilization
GI function ( Ileus, UGI bleeding ) Nutrition
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Methylprednisolone treatment regimen(1) NASCIS-II ( National Acute Spinal Cord Injury
Study ) ( 24 hours ) Within 8 hours of the injury Closed injuries, not in penetrating injuries and below
conus medullaries Loading 30 mg/kg, bolus, > 15 min , followed by a
45 min pause Maintain 5.4 mg/kg/hour, the nest 23 hours
Methylprednisolone treatment regimen(2) NASCIS-III ( 48 hours )
Within 3 hours of the injury Loading 30 mg/kg, bolus, > 15 min , followed by a 45 min
pause Maintain 5.4 mg/kg/hour, the nest 23 hours
Within 3 ~ 8 hours Loading 30 mg/kg, bolus, > 15 min , followed by a 45 min
pause Maintain 5.4 mg/kg/hour, the nest 47 hours
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Alignment and immobilization of the spine Neck collar Gardner-Wells tongs Halo vest Surgical intervention
Decompression Fusion and Fixation
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Surgical intervention Goal Dural sac decompression Spinal stability
Avoidance of non-neurological complications that are shown to develop in patients not mobilized quickly following their injury
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Surgical intervention Early surgery ( emergency surgery ) ? Delayed decompressive surgery Indications for emergency decompressive surgery
( incomplete lesions ) Progression of a neurological deficit Bone fragments or soft tissue elements ( hematoma ) Penetrating trauma Non-reducible fracture dislocations from locked facets Timing - 8~12 hrs ( 24 hrs )
Surgical intervention Contraindications to emergent operation
Complete spinal cord injury > 24 hrs Medically unstable patient Possibly central cord syndrome
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Prognosis Patients neurological grading at admission to the
hospital 5% of SCI patients deteriorate in the early
postinjury period ( cervical spine ) Majority of neurological improvement occurs
within the 1st year ( ~ 18 months ) ( 2 years, 10% )