Neurosurgery Case Review Questions and Answers 77005500000088FFMM..iinndddd ii 88//1122//0099 1122::1177::0033 PPMM 77005500000088FFMM..iinndddd iiii 88//1122//0099 1122::1177::0077 PPMM Neurosurgery Case Review Questions and Answers Remi Nader, MD, CM, FRCS(C), FACS Chief, Division of Neurosurgery Greenwood Lefl ore Hospital Greenwood, Mississippi Clinical Assistant Professor Department of Neurosurgery University of Mississippi Jackson, Mississippi Abdulrahman J. Sabbagh, MD, FRCS(C) Director, Neurosurgery Residency Program Department of Neurosurgery Neuroscience Center King Fahd Medical City–Ministry of Health Riyadh, Saudi Arabia Thieme New York • Stuttgart 77005500000088FFMM..iinndddd iiiiii 88//1122//0099 1122::1177::0077 PPMM Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Editorial Director: Michael Wachinger Executive Editor: Kay D. Conerly Editorial Assistants: Jacquelyn DeSanti, Lauren Henry International Production Director: Andreas Schabert Production Editor: Heidi Grauel, Maryland Composition Vice President, International Sales and Marketing: Cornelia Schulze Chief Financial Offi cer: James W. Mitos President: Brian D. Scanlan Compositor: MPS Content Services Printer: Everbest Printing Co. Library of Congress Cataloging-in-Publication Data Neurosurgery case review : questions and answers / edited by Remi Nader, Abdulrahman J. Sabbagh. p. ; cm. Includes bibliographical references and index. ISBN 978-1-60406-052-2 (alk. paper) 1. Nervous system—Surgery—Examinations, questions, etc. I. Nader, Remi. II. Sabbagh, Abdulrahman J. [DNLM: 1. Nervous System Diseases—surgery—Examination Questions. 2. Neurosurgical Procedures—methods—Examination Questions. WL 18.2 C338 2009] RD593.C38 2009 617.4'80076—dc22 2009014543 Copyright © 2010 by Thieme Medical Publishers, Inc. 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However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confi rm the information contained herein with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular impor- tance in connection with new or infrequently used drugs. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or propri- etary names even though specifi c 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. All chapters in this book are based on actual cases encountered by the primary or senior authors during the scope of their practices, as are the complications and challenges discussed in each case. Any resemblance with cases or questions presented in formal examinations (such as national board examinations or licensing examinations) or with cases discussed in organized review courses is purely coincidental. Printed in China 5 4 3 2 1 ISBN 978-1-60406-052-2 77005500000088FFMM..iinndddd iivv 88//1122//0099 1122::1177::0077 PPMM Dedication This book is dedicated to . . . My lovely wife, Candis, who endured me the past few years during the labor on this project! My parents, Eleonore and Joseph, and grandmother, Honeine, to whom I owe my life, discipline, and education. Our pets, Minou and Bibite, who have kept me company and cheered me up during this endeavor. Remi Nader To my heroes, my parents, Jafar and Wafa, who selfl essly dedicated their lives to their family and country, taught me tolerance and persistence, and told me “never stop before you reach the stars.” To my better half and best friend, my wife, Alaa, without whose true love, altruistic devotion, and unrelenting support I would never have achieved what I have. To my children, Leen, Jafar, and Omar, and my siblings, Heba, Ahmad, and Mostafa, for making it all worthwhile. Abdulrahman J. Sabbagh 77005500000088FFMM..iinndddd vv 88//1122//0099 1122::1177::0077 PPMM 77005500000088FFMM..iinndddd vvii 88//1122//0099 1122::1177::0077 PPMM Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Intracranial Pathology Brain Tumors Phacomatosis Case 1 Vestibular Schwannoma in Neurofi bromatosis Type 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Burak Sade and Joung H. Lee Case 2 Subependymal Giant Cell Astrocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Remi Nader Case 3 Sturge–Weber Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Remi Nader Case 4 Von Hippel–Lindau Disease—Hemangioblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Ramez Malak and Robert Moumdjian Meningioma Case 5 Parasagittal Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Remi Nader Case 6 Olfactory Groove Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Stephen J. Hentschel and Lissa Marie Ogieglo Case 7 Sphenoid Wing Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Remi Nader Case 8 Hemangiopericytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Burak Sade and Joung H. Lee Case 9 Clinoidal Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Burak Sade and Joung H. Lee Case 10 Velum Interpositum Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Michel W. Bojanowski and Denis Klironomos Pituitary Tumors Case 11 Pituitary Apoplexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Michel W. Bojanowski and Denis Klironomos Case 12 Pituitary Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Remi Nader and Marc-Elie Nader Case 13 Craniopharyngioma: Endoscopic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Daniel M. Prevedello, Amin B. Kassam, Paul Gardner, Arlan H. Mintz, Carl H. Snyderman, and Ricardo L. Carrau Gliomas Case 14 High-grade Glioma: Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Ramez Malak and Robert Moumdjian 77005500000088FFMM..iinndddd vviiii 88//1122//0099 1122::1177::0077 PPMM viii Contents Case 15 High-grade Glioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Remi Nader and Abdulrahman J. Sabbagh Case 16 Eloquent Cortex Low-grade Glioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 John Winestone and Allen K. Sills Jr. Malignant Intracranial Neoplasms Case 17 Single Brain Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Joseph A. Shehadi and Brian Seaman Case 18 Multiple Brain Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Ramez Malak and Robert Moumdjian Case 19 Meningeal Carcinomatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Ramez Malak and Robert Moumdjian Case 20 Primary Central Nervous System Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 John Winestone and Allen K. Sills Jr. Case 21 Posterior Fossa Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Julius July and Eka Julianta Wahjoepramono Other Intracranial Tumors Case 22 Fibrous Dysplasia of the Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Burak Sade and Joung H. Lee Case 23 Orbital Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Michel Lacroix Case 24 Multiple Ring-enhancing Cerebral Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Kevin Petrecca and Rolando Del Maestro Case 25 Paraganglioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Nazer H. Qureshi and Ossama Al-Mefty Case 26 Colloid Cyst of the Third Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Remi Nader Vascular Neurosurgery Arteriovenous Malformations Case 27 Dural Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Nancy McLaughlin and Michel W. Bojanowski Case 28 Cerebral Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Pascal M. Jabbour and Erol Veznedaroglu Case 29 Cavernous Angioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Julius July and Eka Julianta Wahjoepramono Intracranial Aneurysms Case 30 Subarachnoid Hemorrhage and Vasospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Qasim Al-Hinai, Claude-Edouard Chatillon, David Sinclair, and Dennis J. Sirhan Case 31 Unruptured Anterior Communicating Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Yasser I. Orz Case 32 Posterior Communicating Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Pascal M. Jabbour and Erol Veznedaroglu 77005500000088FFMM..iinndddd vviiiiii 88//1122//0099 1122::1177::0077 PPMM Contents ix Case 33 Familial Cerebral Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Hossam Al-Jehani and Richard Leblanc Case 34 Blister Carotid Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Nancy McLaughlin and Michel W. Bojanowski Case 35 Concomitant Arteriovenous Malformation and Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Julius July and Eka Julianta Wahjoepramono Case 36 Middle Cerebral Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Julius July and Eka Julianta Wahjoepramono Intracerebral Hemorrhage Case 37 Hypertensive Putaminal Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Remi Nader Case 38 Intraventricular Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Hosam Al-Jehani, Dennis J. Sirhan, and Abdulrahman J. Sabbagh Case 39 Cerebellar Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Julius July and Eka Julianta Wahjoepramono Ischemic Cerebral Disease Case 40 Moyamoya Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Abdulrahman J. Sabbagh, Jean-Pierre Farmer, Jie Ma, Ahmad I. Lary, and José Luis Montes Extracranial Vascular Disease Case 41 Amaurosis Fugax with Carotid Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Glenn C. Hunter and Alwin Camancho Case 42 In Tandem Extracranial and Intracranial Carotid Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Glenn C. Hunter Case 43 Vertebral Artery Stenosis with Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Glenn C. Hunter and Rudiger Von Ritschl Case 44 High-grade Carotid Stenosis and Intracranial Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Glenn C. Hunter and Remi Nader Cranial Trauma Closed Head Injuries Case 45 Chronic Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Remi Nader Case 46 Mild Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Judith Marcoux and Abdulrazag Ajlan Case 47 Epidural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Abdulrazag Ajlan and Judith Marcoux Case 48 Traumatic Acute Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Abdulrazag Ajlan and Judith Marcoux Intensive Care Management Case 49 New Trends in Neurotrauma Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Judith Marcoux and Abdulrazag Ajlan 77005500000088FFMM..iinndddd iixx 88//1122//0099 1122::1177::0088 PPMM x Contents Case 50 Intracranial Pressure Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Abdulrazag Ajlan and Judith Marcoux Other Cranial Trauma Case 51 Gunshot Wound to the Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Remi Nader Case 52 Other Penetrating Intracranial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Domenic P. Esposito Pediatric and Developmental Disorders Hydrocephalus Case 53 Aqueductal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Jeff rey Atkinson Case 54 Cerebrospinal Fluid Shunt Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Jeff rey Atkinson Case 55 Slit Ventricle Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Jeff rey Atkinson Case 56 Mega-hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Maqsood Ahmad and Abdulrahman J. Sabbagh Pediatric Brain Tumors Case 57 Cerebellar Medulloblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Ali Raja, Ian F. Pollack, and Nazer H. Qureshi Case 58 Brainstem Glioma 1: Pons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Abdulrahman J. Sabbagh, Ayman Abdullah Albanyan, Mahmoud A. Al Yamany, Reem Bunyan, Ahmed T. Abdelmoity, and Lahbib B. Soualmi Case 59 Brainstem Glioma 2: Medulla Oblongata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Jean-Pierre Farmer, Abdulrahman J. Sabbagh, and Ahmad Al-Jishi Case 60 Pineal Region Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Claude-Edouard Chatillon, José Luis Montes, and Jean-Pierre Farmer Case 61 Endoscopic Treatment of Hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Jeff rey Atkinson Case 62 Neurofi bromatosis Type 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Jean-Pierre Farmer and Abdulrahman J. Sabbagh Case 63 Epidermoid of the Sella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Abdulrahman J. Sabbagh and Jean-Pierre Farmer Case 64 Frontal Abscess with Sinus Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Ramez Malak and Robert Moumdjian Case 65 Hypothalamic Hamartoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Abdulrahman J. Sabbagh, Sandeep Mittal, Fahad Eid Alotaibi, and José Luis Montes Pediatric Neurovascular Disease Case 66 Vein of Galen Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Samer K. Elbabaa and Sten Solander 77005500000088FFMM..iinndddd xx 88//1122//0099 1122::1177::0088 PPMM