Neurosurgery

Paramedics arrive at the trauma bay with a 19-year-old male who was injured in a high-speed skateboarding accident without a helmet. He is profoundly comatose with a Glasgow Coma Scale score of 5. Initial physical examination reveals a fixed, dilated left pupil and right-sided extensor posturing in response to pain. Determine the correct chronological order for the subsequent management steps in this scenario.

A trauma team evaluates a 32-year-old male construction worker who fell 15 feet from a scaffold, striking his head on a concrete slab. On primary survey, he does not open his eyes, makes incomprehensible sounds, and exhibits decorticate posturing to painful stimuli. His right pupil is 8 mm and nonreactive to light. Vital signs show a blood pressure of 190/110 mmHg, a heart rate of 48/min, and a respiratory rate of 8/min with irregular breathing patterns.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 54-year-old woman is evaluated in the neurosurgical intensive care unit for worsening somnolence over the past 12 hours. She was admitted 6 days ago with a subarachnoid hemorrhage secondary to a ruptured left middle cerebral artery aneurysm, which was successfully treated with surgical clipping. Over the last 24 hours, her urine output has been 4.5 liters.

Vitals:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $88/54 \text{ mm Hg}$
- Heart rate: $122/\text{min}$
- Respirations: $16/\text{min}$

Physical examination shows dry mucous membranes and poor skin turgor. Neurologic examination reveals a Glasgow Coma Scale of 13 (E3, V4, M6). She has a right-sided pronator drift and mild right facial droop, which are unchanged from her immediate postoperative baseline.

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

A 25-year-old man is transported to the trauma center after being struck on the right side of the head with a heavy metal wrench during an altercation. He experienced a brief loss of consciousness lasting approximately one minute at the scene, but was subsequently awake, alert, and answering questions appropriately during transport. Three hours after arrival, he becomes acutely lethargic and stops following commands. His blood pressure is 165/95 mmHg, and his heart rate is 55/min. Neurological examination reveals a Glasgow Coma Scale score of 6 and a right pupil that is 7 mm and unresponsive to light. A non-contrast head computed tomography scan demonstrates a hyperdense, lens-shaped collection over the right frontotemporal convexity that does not cross cranial suture lines. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the neurosurgical intensive care unit due to a sudden decline in consciousness. He underwent an uncomplicated right frontotemporal craniotomy for resection of a meningioma 48 hours ago. Over the past hour, the nurse noted that he became increasingly difficult to arouse. His temperature is 38.1°C (100.6°F), blood pressure is 180/100 mm Hg, pulse is 48/min, and respirations are 10/min and irregular. Glasgow Coma Scale score is 7 (E2, V2, M3), decreased from a baseline of 14. Neurologic examination reveals a 7-mm, unreactive right pupil and a new profound left-sided hemiparesis. The surgical incision site appears clean and intact. Which of the following is the most appropriate next step in management?

Match each clinical presentation to its most likely neurosurgical diagnosis.

An ambulance brings a 48-year-old female to the emergency department following a sudden collapse at a grocery store. Bystanders report she grabbed her head and screamed about a sudden, explosive headache before briefly losing consciousness. In the ED, her blood pressure is 165/90 mm Hg and heart rate is 88/min. She is groggy, heavily photophobic, and strongly resists neck flexion. Neurologic examination reveals no focal motor or sensory deficits. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for the standard clinical management of this patient's suspected condition.

A 32-year-old man is brought to the emergency department 45 minutes after being struck on the right side of the head with a heavy wrench during a workplace altercation. Witnesses report he lost consciousness for approximately one minute immediately after the impact, but then awoke and was able to converse normally. Over the past 15 minutes, he has become progressively lethargic and is now unresponsive to verbal commands. His blood pressure is 165/90 mmHg, and his pulse is 52/min. Neurologic examination reveals a dilated, unreactive right pupil and left-sided hemiparesis. A non-contrast CT scan of the head demonstrates a large, biconvex hyperdense mass over the right temporoparietal convexity with a 12-mm leftward midline shift. Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old man with a history of hypertension and atrial fibrillation treated with apixaban is brought to the emergency department by emergency medical services. His wife reports that he experienced a sudden, severe occipital headache and intractable vomiting 45 minutes ago before collapsing. Upon arrival in the trauma bay, he is unresponsive. His eyes do not open to pain, he makes incomprehensible sounds, and he exhibits abnormal extensor posturing to painful stimuli. His blood pressure is 220/115 mmHg, heart rate is 52/min, and respiratory rate is 10/min with irregular breathing patterns.

Arrange the following clinical interventions in the most appropriate, evidence-based sequential order for the acute management of this patient.

A resident is reviewing imaging studies and physical examination findings of patients with elevated intracranial pressure in the neurocritical care unit. Match each specific pattern of tissue displacement and associated clinical presentation with the correct brain herniation syndrome.

A 74-year-old woman is evaluated in the clinic for a 6-month history of a slow, broad-based, shuffling gait, new-onset urinary incontinence, and mild cognitive decline. The physician suspects normal pressure hydrocephalus (NPH). Arrange the following diagnostic and therapeutic steps in the standard evidence-based sequence for managing this condition, from first to last.

A 62-year-old woman is evaluated in the neurosurgical intensive care unit on postoperative day 5 following a right temporal craniotomy for glioblastoma resection. Over the past 12 hours, she has become progressively lethargic. She now only opens her eyes to painful stimuli and mutters incomprehensibly. Her temperature is 38.9°C (102.0°F), blood pressure is 145/88 mmHg, heart rate is 105/min, and respiratory rate is 16/min. Physical examination reveals pronounced nuchal rigidity. The surgical incision is well-approximated, clean, and has no fluctuance or drainage. An indwelling urinary catheter, placed prior to surgery, remains in situ. Which of the following is the most appropriate next step in management?

A $62$-year-old man with a history of poorly controlled hypertension is brought to the emergency department after suddenly developing a severe occipital headache, intractable vomiting, and an inability to walk. On presentation, his blood pressure is $210/110$ mm Hg, heart rate is $58$/min, and respiratory rate is $14$/min. His Glasgow Coma Scale (GCS) score is $14$. Neurologic examination shows marked left-sided dysmetria on finger-to-nose testing, horizontal nystagmus, and truncal ataxia. There is no limb weakness. Noncontrast CT of the head reveals a $4.2$-cm hyperdense acute hemorrhage in the left cerebellar hemisphere with complete effacement of the fourth ventricle. While in the emergency department, his level of consciousness rapidly declines, and his GCS score drops to $7$ (E2, V1, M4). The patient is immediately intubated for airway protection. Which of the following is the most appropriate next step in management?

Family members bring a 68-year-old male to the emergency room due to a progressive decline in his mental status over the last 72 hours. He has a past medical history of normal pressure hydrocephalus, which was treated with the placement of a ventriculoperitoneal (VP) shunt four years ago. According to his relatives, he has been reporting severe, diffuse headaches and experienced two episodes of non-bilious vomiting this morning. Upon physical examination, the patient appears lethargic but localizes appropriately to painful stimuli. His temperature is $36.9^{\circ} \text{C}$ ($98.4^{\circ} \text{F}$), blood pressure is $170/92 \text{ mm Hg}$, pulse is $52/\text{min}$, and respiratory rate is $12/\text{min}$ and irregular. Funduscopic evaluation demonstrates bilateral blurring of the optic disc margins with absent venous pulsations. Which of the following is the most appropriate next step in the management of this patient?

Match the following clinical presentations and initial non-contrast head CT findings with the most likely specific type of intracranial hemorrhage.

A 68-year-old man is brought to the emergency department due to rapidly progressive weakness in his legs over the past 24 hours. He is now unable to walk unassisted. He also reports lower abdominal discomfort and an inability to urinate since yesterday evening. For the last 3 months, he has had a constant, aching mid-back pain that frequently wakes him from sleep and is unrelieved by over-the-counter analgesics. His medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a 50-pack-year smoking history. His temperature is 37.2°C (99.0°F), blood pressure is 158/92 mm Hg, pulse is 88/min, and respirations are 16/min. He is awake and fully oriented with a Glasgow Coma Scale score of 15. Neurologic examination shows 2/5 strength in the bilateral lower extremities with flaccid muscle tone. Deep tendon reflexes are 1+ at the patellae and absent at the Achilles tendons bilaterally. Plantar responses are absent. There is a distinct loss of pinprick and temperature sensation below the level of the umbilicus. A urethral catheter is placed, draining 750 mL of clear urine. Which of the following is the most appropriate initial step in the management of this patient?

A medical student is reviewing classic presentations of intracranial hemorrhages. Match the clinical presentation to the most likely corresponding intracranial hemorrhage.

A 22-year-old male is transported to the trauma bay via helicopter following a high-speed motorcycle collision where he was ejected and found without a helmet. Upon arrival, his blood pressure is 165/95 mm Hg, and his heart rate is 55/min. He does not open his eyes to pain, makes incomprehensible sounds, and exhibits extension of his arms and legs in response to painful stimuli. Examination reveals a 6-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil.

Arrange the following management steps in the most appropriate chronological order for this patient.

Match each clinical and neuroimaging presentation of a suspected intracranial mass with its correct diagnostic entity and characteristic pathophysiological or histological feature.

Match each patient's clinical history and mechanism of spinal injury with the specific pattern of neurological deficits most likely to be observed on physical examination.