Neurosurgery

A 46-year-old male with a history of an uncorrected right-to-left cardiac shunt is evaluated in the neurology unit for a progressively worsening, severe global headache over the past week. This morning, he developed new-onset weakness in his left arm and leg. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $145/90\text{ mm Hg}$, and heart rate is $88\text{/min}$. Neurologic examination reveals $3/5$ motor strength in the left upper and lower extremities and a left homonymous hemianopia. Fundoscopic examination shows bilateral optic disc swelling with blurred margins. A contrast-enhanced MRI of the brain demonstrates a $3.8\text{-cm}$ solitary ring-enhancing lesion with a necrotic core in the right frontoparietal lobe, surrounded by substantial vasogenic edema and a $7\text{-mm}$ midline shift. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and findings with the most appropriate definitive neurosurgical or endovascular intervention.

A 25-year-old male is admitted to the neurosurgical intensive care unit following a severe traumatic brain injury sustained in a motor vehicle collision. He is intubated, mechanically ventilated, and receiving continuous infusions of propofol and fentanyl for sedation and analgesia. An intracranial pressure (ICP) monitor is in place. His ICP acutely rises to 28 mm Hg and remains elevated for 10 minutes despite the current sedation. His vital signs show a blood pressure of 130/80 mm Hg, heart rate of 85/min, and temperature of 37.2°C (99.0°F). Arrange the following interventions in the most appropriate stepwise sequence for managing this patient's elevated intracranial pressure, proceeding from initial, least invasive measures to final salvage therapy.

Paramedics transport a patient to the trauma bay after he experienced a sudden loss of consciousness at his workplace. The patient's coworkers state that he abruptly grabbed the back of his head, complained of severe dizziness and nausea, and then collapsed. Medical records indicate he is 62 years old and has a long-standing history of medication nonadherence for essential hypertension. Currently, his blood pressure is 198/115 mmHg, and his heart rate is 54/min. Neurological assessment shows a profoundly lethargic patient who only localizes to painful stimuli and has irregular respirations. Non-contrast cranial computed tomography (CT) demonstrates a 4.2-cm hyperdense collection in the right cerebellar hemisphere, associated with compression of the fourth ventricle and significant dilation of the lateral ventricles. Which of the following is the most appropriate next step in management?

A 68-year-old man with a known history of metastatic prostate cancer is brought to the emergency department complaining of severe mid-back pain that has steadily worsened over the past two weeks. Over the last 6 hours, he has developed bilateral leg weakness and urinary incontinence. Vital signs are within normal limits. Neurologic examination reveals 3 out of 5 muscle strength in the lower extremities bilaterally, decreased sensation to pinprick below the umbilicus, and absent patellar and Achilles reflexes. Rectal examination demonstrates severely decreased anal sphincter tone. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for managing this patient's condition.

A 58-year-old man comes to the physician because of a 5-month history of progressive clumsiness in his hands and an unsteady gait. He frequently drops small objects and has difficulty fastening buttons. He has no history of trauma, fever, or preceding illness. Vital signs are normal. Neurological examination reveals decreased bulk and tone in the intrinsic muscles of both hands. Biceps and brachioradialis reflexes are 1+ bilaterally. In contrast, knee and ankle jerks are 3+ bilaterally, and sustained ankle clonus is present. Babinski sign is present bilaterally. Sensory examination shows decreased vibration and position sense in the toes. Which of the following is the most appropriate next step in management?

Match each neurosurgical emergency or traumatic brain injury with its characteristic pathophysiologic mechanism and classic neuroimaging findings.

A male patient, aged 45, presents to the emergency room with a 7-day history of escalating mid-thoracic back pain and subjective fevers. He has a known medical history of intravenous substance use disorder. Over the last 24 hours, he noted rapidly progressive weakness in both legs and an inability to void urine. Vital signs show a temperature of 38.9°C (102°F), heart rate of 110/min, and blood pressure of 122/78 mm Hg. Neurologic examination reveals 2/5 motor strength in the bilateral lower extremities, a distinct loss of pain and temperature sensation below the umbilicus, and 3+ patellar reflexes with bilateral Babinski signs. Bladder ultrasound reveals a post-void residual volume of 650 mL. Empiric intravenous vancomycin and ceftriaxone are promptly initiated. Magnetic resonance imaging of the spine demonstrates a peripherally enhancing anterior epidural collection spanning T9-T11, causing severe compression of the spinal cord. Which of the following is the most appropriate next step in management?

A 28-year-old man is brought to the emergency department after a high-speed motorcycle collision. In the field, his Glasgow Coma Scale (GCS) score was 6, and he was immediately intubated. On arrival, his blood pressure is 170/100 mm Hg, and his heart rate is 50/min. His right pupil is 7 mm and nonreactive to light, while his left pupil is 3 mm and briskly reactive. Extensor posturing is noted on the left side in response to painful stimuli. A stat non-contrast head CT reveals a large right-sided acute subdural hematoma with a 15-mm midline shift. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's condition, from the most immediate initial bedside action to definitive ongoing care.