Clinical assessment of neurosurgical patient

where should you admit an:

unconscious patient

confused/dysphasic

alert and cooperative

-ITU

-ward

-ward/clinic

What is the primary goal of doing a neurosurgical history and exam?

Anatomical Localisation (where?), Causative Pathology (what?), and Effect on Patient (how?).

What three things are assessed initially in an unconscious patient?

ABC (Airway, Breathing, Circulation), GCS (Glasgow Coma Scale), and Pupils

What formula defines Cerebral Perfusion Pressure (CPP)

CPP = MAP - ICP

What does the Monro-Kellie Doctrine describe?

The principle that the total volume of contents in the cranium ($V_{blood} + V_{CSF} + V_{brain} + V_{other}$) is constant⁴. This relates to intracranial pressure changes⁵⁵⁵⁵.

What does the GCS (Glasgow Coma Scale) relate to clinically?

cerebral perfusion

What do changes in pupil examination relate to clinically?

cerebral herniation

What are the key features of a Cord lesion (Myelopathy)?

Bilateral symptoms, a motor and sensory level, and UMN signs (long tract signs) below the lesion.

What are the key features of a Nerve Root lesion (Radiculopathy)?

Unilateral symptoms, involving a single myotome and single dermatome, with LMN signs (e.g., loss of reflex)

What are the Long Tract Signs (UMN signs) seen in Myelopathy?

Clonus, upgoing plantars, increased tone, Hoffman sign, brisk reflexes, and proprioception impairment (e.g., Romberg's test, tandem walking)

What is a common presentation of L5 Radiculopathy?

Pain down the leg all the way to the big toe. Examination should check for altered sensation in L5 dermatome and weakness of extensor hallucis longus

What are the clinical signs that suggest a Thoracic Cord Problem instead of Cauda Equina Syndrome (CES)

Long tract signs like clonus and upgoing plantars, as CES is an LMN problem.

What type of nerve damage causes a "glove and stocking" distribution?

Peripheral neuropathy (often medical)

What nerve injury is suggested by sensory/pain symptoms in the little finger and up into the hand

Inferior brachial plexus or ulnar nerve injury (e.g., C8 radiculopathy or ulnar neuropathy)

What are the key functions of the Frontal Lobe

Voluntary control of movement (precentral gyrus)

Speech

Higher order functions

Restraint

Initiative\

Order (RIO)

Gait (periventricular)

Saccadic eye movements (frontal eye field)

Bladder control (paracentral lobule

What three areas are associated with the RIO higher order functions of the frontal lobe?

Restraint (Orbitofrontal cortex)

Initiative (Supplementary motor cortex/anterior cingulate)

Order (Dorsolateral prefrontal cortex)

Which area relates to Restraint?

Orbitofrontal cortex

Which area relates to Initiative?

Supplementary motor cortex/anterior cingulate

Which area relates to Order (Executive function)?

Dorsolateral prefrontal cortex

What findings might be seen on frontal lobe examination?

Decorticate posture

altered behavior

urinary incontinence

pyramidal weakness

pronator drift

speech changes

saccadic eye movements

primitive reflexes.

A patient with a left frontal lesion is right-handed and presents with headaches. What other symptom would be expected based on localisation?

Dysphasia (speech trouble) and weakness on the right side.

What term describes difficulty with fluency of speech?

broca’s aphasia

What are the key functions of the Parietal Lobe?

Primary somatosensory area (Body image representation), Visuospatial coordination, Language, and Numeracy

What are examples of Cortical Sensory Syndromes?

Sensory inattention

Asteroagnosia (inability to recognize objects by touch),\

Dysgraphaesthesia (inability to recognize numbers/letters traced on the skin),

impaired two-point discrimination

What is Gerstmann's syndrome (Dominant Parietal Lobe)

Dyscalculia, finger anomia (inability to name fingers), left/right disorientation, and agraphia (inability to write).

What is Hemineglect associated with?

non dominant parietal lobe lesions

What are the key functions of the Temporal Lobe?

Processing auditory input (Heschl's gyrus)

Language

 Encoding declarative long-term memory (hippocampus)

Emotion (amygdala),

]Visual fields (Meyer's loop).

mnemonic for symptoms of Cerebellar dysfunction?

DANISH P

Dysdiadochokinesia

Ataxia

Nystagmus

Intention tremor

Slurred speech

Hypotonia

Past pointing