Neurosurgery

Match each lumbosacral nerve root compression or spinal syndrome with its classic neurological examination findings. This clinical localization is essential for determining the appropriate neurosurgical intervention.

A $68$-year-old man presents to the emergency department complaining of severe, progressively worsening mid-back pain over the past $2$ weeks. He has a history of advanced prostate cancer treated with androgen deprivation therapy. Over the past $24$ hours, he has developed difficulty walking and states his legs feel "heavy." He also reports an inability to urinate since early this morning. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/88\text{ mm Hg}$, and pulse is $88\text{/min}$. On physical examination, there is exquisite point tenderness to palpation over the T10 spinous process. Neurologic examination reveals $3/5$ motor strength in the lower extremities bilaterally. There is decreased sensation to pinprick and temperature below the umbilicus. Deep tendon reflexes are $3+$ at the patellae and ankles, with bilateral upgoing plantar responses. Post-void residual ultrasound shows $550\text{ mL}$ of urine in the bladder. Which of the following is the most appropriate initial step in the management of this patient?

A 24-year-old man is brought to the emergency department via ambulance after diving into a shallow lake and striking his head on the bottom. He is conscious but reports an inability to move his arms or legs. His blood pressure is 78/40 mm Hg, heart rate is 52/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. He has flaccid paralysis and absent reflexes in all four extremities. Arrange the following steps in the optimal sequence for the management of this patient, from initial presentation to definitive treatment.

A 45-year-old woman is brought to the emergency department by her partner after developing a sudden-onset, excruciating headache that she describes as the 'worst of my life.' The headache began abruptly 2 hours ago while she was moving heavy furniture. She reports associated nausea, photophobia, and neck stiffness. Her temperature is 37.2°C (99.0°F), blood pressure is 168/94 mm Hg, and heart rate is 92/min. Neurological examination reveals intact cranial nerves, normal symmetric strength, and marked nuchal rigidity. Arrange the following steps in the correct sequential order for the standard diagnostic workup and definitive management of this patient, assuming the initial head imaging does not demonstrate an acute hemorrhage.

A $58$-year-old right-handed woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she underwent successful surgical clipping of a ruptured left middle cerebral artery aneurysm. Her postoperative course had been uncomplicated, and she was alert and fully oriented this morning. Over the past hour, the nurse noted that the patient developed right-sided hemiparesis and severe expressive aphasia.

Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $82 \text{ /min}$, blood pressure is $112/74 \text{ mmHg}$, and respirations are $14 \text{ /min}$. A stat noncontrast head computed tomography scan shows expected postsurgical changes with no evidence of new hemorrhage, cerebral edema, or hydrocephalus. Continuous electroencephalography reveals no epileptiform activity.

Which of the following is the most appropriate next step in management?

Correlate the following clinical scenarios with their most likely intracranial hemorrhage diagnosis.

Emergency medical services transport a 32-year-old female to the hospital due to altered mental status and intractable vomiting. According to her husband, she developed a relentless, diffuse headache yesterday, which has progressively worsened. Her past medical history is notable for congenital hydrocephalus secondary to aqueductal stenosis, managed with a ventriculoperitoneal shunt that was last revised 15 years ago. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $165/95\text{ mm Hg}$, and pulse is $52/\text{min}$. On physical examination, the patient is somnolent but arouses to loud verbal stimuli. Pupils are sluggishly reactive to light, and fundoscopy reveals bilateral papilledema. She exhibits an inability to look upward. Which of the following is the most appropriate next step in management?

Brain herniation syndromes occur when elevated intracranial pressure forces brain parenchyma across rigid intracranial structures. Based on the clinical features provided, match each clinical presentation to its corresponding specific brain herniation syndrome.

A 42-year-old male is brought to the emergency department after a high-speed motor vehicle collision. His initial Glasgow Coma Scale score is 6 (E1, V1, M4), and he is promptly intubated for airway protection. A non-contrast head CT demonstrates extensive traumatic subarachnoid hemorrhage, a large right-sided acute subdural hematoma, and significant midline shift. The neurosurgery team discusses the risk of various herniation syndromes based on the imaging findings. Match the following brain herniation syndromes with their classic neurologic or vascular consequences.

A ward nurse urgently pages the on-call surgical team regarding a hospitalized 51-year-old man. The patient was admitted three days ago for bacteremia secondary to a skin infection and has been receiving targeted intravenous therapy. Over the last eight hours, he developed severe, progressive mid-back pain and new-onset difficulty moving his legs. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). Neurologic examination reveals $2/5$ motor strength in bilateral lower extremities, loss of pain and temperature sensation below the umbilicus, and a distended, palpable bladder. Immediate magnetic resonance imaging of the spine demonstrates a large, peripherally enhancing epidural fluid collection at the T9-T10 level compressing the spinal cord. Which of the following is the most appropriate next step in the management of this patient?

An $81$-year-old man arrives at the emergency department accompanied by his son, who reports that his father has become increasingly confused and clumsy over the past month. The patient has a history of a mechanical mitral valve replacement, for which he takes warfarin, as well as hypertension.

On examination, the patient is lethargic but arousable. He exhibits a left-sided facial droop and $4/5$ strength in his left upper and lower extremities.

Laboratory analysis reveals an International Normalized Ratio (INR) of $3.4$.

A non-contrast computed tomography (CT) scan of the head reveals a $2.1$-cm thick crescent-shaped, hypodense extra-axial fluid collection over the right frontoparietal cortex causing a $9$-mm leftward midline shift.

What is the most appropriate sequence of interventions for this patient?

A $28$-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive. His blood pressure is $175/95 \text{ mmHg}$, heart rate is $52 \text{ /min}$, and respiratory rate is $10 \text{ /min}$ and irregular. Neurologic examination reveals a Glasgow Coma Scale score of $5$ (Eye opening: $1$, Verbal response: $1$, Motor response: $3$). His right pupil is $7 \text{ mm}$ and unreactive to light, while the left pupil is $3 \text{ mm}$ and briskly reactive. He exhibits decerebrate posturing on the left side. Arrange the following steps in the most appropriate chronological order for the management of this patient.

Emergency medical services bring a $68$-year-old male to the trauma bay due to the abrupt onset of occipital head pain and intractable vomiting. The patient's wife notes he was previously healthy except for a long-standing history of medication nonadherence for hypertension. In the triage area, his blood pressure is $215/115$ mm Hg with a heart rate of $54$/min. While being evaluated, his level of consciousness rapidly declines; he only opens his eyes to painful stimuli and mumbles incomprehensibly. Neurological assessment demonstrates pronounced left dysmetria and gaze-evoked nystagmus. A stat noncontrast head CT demonstrates a $4.5$-cm hyperdense collection in the left cerebellar hemisphere, accompanied by compression of the fourth ventricle and dilatation of the supratentorial ventricular system. Based on these findings, which of the following is the most appropriate next step in management?

Match each clinical presentation and underlying pathophysiological mechanism to the correct brain herniation syndrome.

A trauma surgery team frequently evaluates patients with acute spinal cord injuries following motor vehicle collisions and falls. Depending on the mechanism of injury and the specific anatomical tracts involved, distinct clinical patterns emerge. Match the following incomplete spinal cord and nerve root syndromes with their most characteristic neurological deficits.

Paramedics bring a $31$-year-old male construction worker to the trauma bay shortly after he plunged $9$ meters ($30$ feet) off a roof. On primary survey, he is unresponsive, prompting immediate endotracheal intubation for airway protection. Before induction, his Glasgow Coma Scale score was calculated at $6$ (Eyes $1$, Verbal $2$, Motor $3$). Current vital signs demonstrate severe hemodynamic instability with a blood pressure of $72/40$ mm Hg and a heart rate of $142$/min. Cranial nerve assessment shows anisocoria; the right pupil is dilated to $8$ mm and fixed, whereas the left pupil is $3$ mm and sluggish. Palpation of the abdomen reveals board-like rigidity and significant distension. The pelvis is stable. Which of the following is the most appropriate next step in management?

A $24$-year-old man is brought to the emergency department after falling off his skateboard and striking the right side of his head. Witnesses report he had a brief loss of consciousness lasting approximately $1$ minute, followed by a period where he was awake and conversing. En route to the hospital, he became progressively lethargic and unresponsive. On arrival, his blood pressure is $170/95$ mmHg, heart rate is $52$/min, and respirations are $10$/min and irregular. His Glasgow Coma Scale score is $6$ (Eye: $1$, Verbal: $2$, Motor: $3$ with abnormal flexion). Physical examination reveals a right pupil that is $7$ mm and nonreactive to light, as well as left-sided hemiparesis. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 68-year-old man presents to the emergency department with a 5-day history of progressively worsening mid-back pain. He reports that over the past 24 hours, his legs have felt "heavy" and he has had difficulty walking. He also mentions not having a bowel movement in 3 days and experiencing difficulty initiating urination. His medical history is significant for advanced prostate cancer diagnosed 2 years ago. His temperature is 37.1°C (98.8°F), blood pressure is 145/90 mm Hg, and pulse is 82/min. Neurologic examination reveals 3/5 strength in the bilateral lower extremities. Muscle tone is increased in the lower limbs, and deep tendon reflexes are 3+ at the knees and ankles. Plantar reflexes are upgoing bilaterally. Perianal sensation is decreased. Which of the following is the most appropriate next step in management?

A 52-year-old woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she was admitted for a subarachnoid hemorrhage and underwent successful endovascular coiling of a ruptured anterior communicating artery aneurysm. Her postoperative course was initially uncomplicated, and she has been receiving standard medical therapy. Over the past 2 hours, she has become increasingly lethargic and developed right-sided weakness. Her temperature is 37.2°C (99.0°F), blood pressure is 112/72 mm Hg, and pulse is 84/min. Physical examination confirms right-sided hemiparesis and expressive aphasia. A noncontrast CT scan of the head reveals the coiled aneurysm with no new bleeding, hydrocephalus, or territorial infarction. Which of the following is the most appropriate next step in management?

A 28-year-old woman with a history of a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus presents to the emergency department with a severe headache, nausea, and projectile vomiting. Over the last hour, she has become increasingly lethargic. Her temperature is 37.1°C (98.8°F), heart rate is 52/min, respiratory rate is 10/min, and blood pressure is 165/95 mmHg. Physical examination shows bilateral papilledema and sluggishly reactive pupils. The emergency physician suspects an acute shunt malfunction leading to critically elevated intracranial pressure.

Arrange the following steps in the most appropriate sequential order for the evaluation and definitive management of this patient's condition.