A patient who withdraws from pain, is mumbling inappropriate words, and opens his eyes to pain has a GCS score of:
The Glasgow Coma Scale score* table:
*Add the three scores to obtain the Glasgow Coma Scale (GCS) score, which can range from 3 to 15 . Add 'T' after the GCS if intubated and no verbal score is possible. For thesme patients, the GCS can range from 3T to 10T.
The most common malignant tumor of the brain is:
Astrocytoma is the most common primary central nervous system (CNS) neoplasm. The term glioma often is used to refer to astrocytomas specifically, excluding other glial tumors. Astrocytomas are graded from I to IV Grades I and II are referred to as low-grade astrocytoma, grade III as anaplastic astrocytoma, and grade IV as glioblastoma multiforme (GBM). Prognosis varies significantly between grades I/II, III, and IV, but not between I and II. Median survival is 8 years after diagnosis with a lowgrade tumor, 2 to 3 years with an anaplastic astrocytoma, and roughly 1 year with a GBM. GBMs account for almost twothirds of all astrocytomas, anaplastic astrocytomas account for two-thirds of the rest, and low-grade astrocytomas the remainder. Figure below demonstrates the typical appearance of a GBM.
A. Postcontrast Tl -weighted axial magnetic resonance imaging (MRI) demonstrating a ring-enhancing lesion in the anteromedial right temporal lobe with centra l necrosis (dark area) consistent with glioblastoma multiforme. B. T2-weighted axial MRI with extensive bright signal signifying peritumoral edema seen with glioblastoma multiformes.
A 25-year-old man is seen in the emergency department after he struck his head against the windshield in an automobile accident. He opens his eyes and withdraws his arm during painful stimulation ofhis hand. He responds verbally to questions with inappropriate words. His GCS score is:
The initial assessment of the trauma patient includes the primary survey, resuscitation, secondary survey, and definitive care. Neurosurgical evaluation begins during the primary survey with the determination of the GCS score (usually referred to simply as the GCS) for the patient. The GCS is determined by adding the scores of the best responses of the patient in each of three categories. The motor score ranges from 1 to 6, verbal from 1 to 5, and eyes from 1 to 4. The GCS therefore ranges from 3 to 15, as detailed in Table below. Tracheal intubation or severe facial or eye swelling can impede verbal and eye responses. In these circumstances, the patient is given the score of 1 with a modifier, such as verbal "1T" where T = tube.
The most common level of cervical radiculopathy from cervical disc herniation is:
The cervical nerve roots exit the central canal above the pedicle of the same-numbered vertebra and at the level of the higher adjacent intervertebral disc. For example, the C6 nerve root passes above the C6 pedicle at the level of the C5-C6 discs. The cervical nerve roots may be compressed acutely by disc herniation, or chronically by hypertrophic degenerative changes of the discs, facets, and ligaments. Table below summarizes the effects of various disc herniations. Most patients with acute disc herniations. Most patients with acute disc herniations will improve without surgery, nonsteroidal antiinflammatory drugs (NSAIDs), or cervical traction may help alleviate symptoms. Patients whose symptoms do not resolve or who have significant weakness should undergo decompressive surgery. The two main options for nerve root decompression are anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (keyhole foraminotomy). ACDF allows more direct access to and removal of the pathology (anterior to the nerve root). However, the procedure requires fusion because discectomy causes a collapse of the interbody space and instability will likely occur. Fig. below demonstrates a C6-C7 ACDF with the typical interposed graft and plating system. Keyhole foraminotomy allows for decompression without requiring fusion, but it is less effective for removing centrally located canal pathology.
Cervical disc herniations and symptoms by level table:
A. Anteroposterior cervical spine X-ray showing the position of an anterior cervical plate used for stabilization after C6-C7 discectomy. Patient presented with right triceps weakness and dysesthesias in the right fifth digit. Magnetic resonance imaging (MRI) revealed a right paracentral C6-C7 herniated disc compressing the exiting C7 nerve root. B. Lateral cervical spine X-ray of the same patient clearly demonstrates the position of the plate and screws. The allograft bone spacer placed in the drilled-out disc space is also apparent.
A 35-year-old mother of two children, 5 and 6 years, has had amenorrhea and galactorrhea for the past 12 months. Her serum prolactin level is elevated, and radiographs of her skull show an "empty sella:' The most likely diagnosis is:
Pituitary adenomas arise from the anterior pituitary gland (adenohypophysis). Tumors <1 cm diameter are considered microadenomas; larger tumors are macroadenomas. Pituitarytumors may be functional (ie, secrete endocrinologically active compounds at pathologic levels) or nonfunctional (ie, secrete nothing or inactive compounds). Functional tumors are often diagnosed when quite small, due to endocrine dysfunction. The most common endocrine syndromes are Cushing disease, due to adrenocorticotropic hormone secretion, Forbes-Albright syndrome, due to prolactin secretion, and acromegaly, due to growth hormone secretion. Nonfunctional tumors are typically diagnosed as larger lesions causing mass effects such as visual field deficits due to compression of the optic chiasm or panhypopituitarism due to compression of the gland. Figure below demonstrates a large pituitary adenoma. Hemorrhage into a pituitary tumor causes abrupt symptoms of headache, visual disturbance, decreased mental status, and endocrine dysfunction. This is known as pituitary apoplexy.
Postcontrast T1 -weighted sagittal magnetic resonance imaging (MRI) demonstrating a large sellar/suprasellar lesion (arrowheads) involving the third ventricle superiorly and abutting the midbrain and pons posteriorly. The patient presented with progressive visual field and acuity loss. Pathology and laboratory work revealed a nonfunctioning pituitary adenoma.
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