Книги по МРТ КТ на английском языке / Neurosurgery Fundamentals Agarval 1 ed 2019

Fig. 17.4  Primary human immuno­ deficiency virus infection of the brain that shows diffuse abnormal high signal, mostly in the central cerebral white matter bilaterally. (Reproduced from Meyers S, Differential Diagnosis in Neuroimaging: Brain and Meninges, 1st edition, ©2016, Thieme Publishers, New York.)

treatment or cure for CJD yet; management is focused on comfort care.

17.8.4  Tuberculous Vertebral Osteomyelitis

Pott’s disease, also known as tuberculous spondylitis is the most common type of skeletal tuberculosis (TB). The presentation of Pott’s disease may be insidious over a long period and concomitant pulmonary involvement may not be present. Neurological deficits develop in majority of the patients due to medullary and radicular artery inflammation.33 Paraplegia in Pott’s disease is predominantly due to inflammatory compression of the cord of varying degrees, by edema,

inflammatory cells, tubercular pus or debris, and early granulation tissue ( Fig. 17.6). An MRI is the imaging procedure of choice, although obtaining appropriate specimens for culture of acid-fast bacilli is essential to establish a definitive diagnosis and recover Mycobacterium tuberculosis for susceptibility testing. Management includes the RIPE regimen of antitubercular drugs: rifampicin, isoniazid, pyrazinamide, and ethambutol, which treat spinal tuberculosis as well as additional primary tubercular foci in the body. Surgical decompression of the cord is recommended with debridement of the lesion through anterior or anterolateral approach for highgrade paraplegia.34

17.8.5  Skull Osteomyelitis

The skull is normally resistant to osteomyelitis, and most infections are due to contagious spread or penetrating trauma. The most common causative organisms in adults are S. aureus and S. epidermidis. In neonates, Escherichia coli infection is relatively more common.18 Imaging findings often show bony resorption, contrast enhancement, and periosteal reaction. Surgical debridement of the infected skull is critical; antibiotics alone are not sufficient. In the case of an infected craniotomy bone flap, the flap must be removed and discarded, and the edges of the skull rongeured back to healthy bone. Cranioplasty may be performed 6 months postoperatively if there are no signs of residual infection.

17.8.6  Spinal Epidural Abscess

Spinal epidural abscess should be considered in a patient with back pain, spinal tenderness, and fever, sweats, or rigors.

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The classic furuncle associated with an abscess presents only in a handful of cases. Early identification of an abscess is important because it can result in progressive myelopathy with precipitous deterioration. Major risk factors for an abscess include diabetes, intravenous (IV) drug use, chronic renal failure, and alcoholism.32 Patients with vertebral osteomyelitis present with similar symptoms and risk factors as a spinal abscess. A percutaneous needle biopsy is often required, and most cases can be managed with appropriate antibiotics such as ceftriaxone, vancomycin, and metronidazole. Surgical intervention is considered in cases of neurological compromise or spinal instability. In general, abscesses affecting lumbar spine are amenable to medical management, while those affecting cervical or thoracic may require surgical intervention for decompression to prevent neurological decline that would occur due to septic thrombophlebitis or other complications.

17.8.7  Viral Encephalitis

Encephalitides may cause imaging findings that mimic a mass lesion, which is often the reason why they come to the attention of a neurosurgeon. The most important hemorrhagic viral encephalitis that the neurosurgeon in-training must be aware of is a multifocal necrotizing encephalomyelitis caused by herpes simplex virus type 1 (HSV1). HSV1 has a predilection for temporal and orbitofrontal lobes as well as the limbic system ( Fig. 17.7). Patients commonly present with altered mental state, personality changes, fever, hemiparesis, irritability, and occasionally, seizures.35 CSF findings can guide diagnosis as explained in the section above. Additionally, EEG from the temporal lobe may demonstrate periodic lateralizing epileptiform discharges and imaging findings would be consistent with edema localized in temporal lobes. IV acyclovir is the drug of choice for HSV encephalitis.

17.9  Empiric Treatment

The most common empiric treatment regimen for meningitis comprises of vancomycin and ceftriaxone. For patients at risk for HSV encephalitis, IV acyclovir is often added. Similarly, for patients at risk for infection due to Listeria, ampicillin is commonly added. In neonates less than 56 days of age, ceftriaxone is

contraindicated because it displaces bilirubin from the albumin-binding site and is therefore associated with an increased risk of kernicterus. Thus, for a febrile neonate at risk for meningitis, the empiric regimen comprises of ampicillin/cefotaxime/acyclovir from birth to 21 days, ampicillin/cefotaxime from 22 to 28 days and cefotaxime alone from 29 to 56 days.36

Fig. 17.7  Coronal T2-weighted MR image from a 33-yeard-old female pa­ tient with HSV-encephalitis. High signal can be seen in the temporal lobes. (Image has been provided courtesy of Dr Laughlin Dawes [radpod.org].)

Another class of drugs that is used to reduce the inflammation caused by infection is corticosteroids. Corticosteroids decrease nuclear factor kappa B (NF-κB) and are associated with an increased risk of hearing loss and neurological sequelae. Additionally, patients with meningitis due to S. pneumoniae treated with cor­ ticosteroids have been shown to have a lower death rate, although no effect on mortality was seen in patients with Haemophilus influenzae and N. meningitidis meningitis.37

17.10  Big Data

Computational and data analysis skills are critical now more than ever. This chapter lends itself naturally to a discussion of computational biology because both surgeryand infection-related

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research can benefit tremendously from an understanding of how to find and understand useful signals in tremendously large sets of unsorted, noisy data. For example, large-scale data analysis is being used by the U.S. Geological Survey (USGS) to investigate the distribution of N. fowleri.38 We now know that N. fowleri is a thermophile that causes PAM, a fatal disease. Big data has allowed bioinformatics researchers to understand the thermal and geochemical gradients that influence pathogens in warm waters. Geomapping and geographic information system (GIS) models collected a wide range of environmental variables, which showed that the lethal amoeba infections were reported in areas of low levels of copper and high levels of zinc.38 Imagine that you are the researcher from USGS who is investigating whether N. fowleri is more likely to be found in soil with elevated zinc. You have recorded how long it takes for the amoeba to grow in soil with no zinc versus soil with zinc and have calculated the mean time to grow and the standard deviations. Scenario 1: You conduct your data analysis and find that growth time is faster in soil with zinc, but the difference is not “statistically significant,” say p = 0.3. Nevertheless, it may still seem sensible to check the zinc levels in the soil of the freshwater pool next to your house in Washington County, Minnesota. Scenario 2: You find strong evidence that amoeba grows faster with zinc, say p = 0.002. Although “significant,” it is important to consider the magnitude of the difference—how much faster was the growth?39 Your clinical judgement and scientific conclusions should not be based only on whether a p-value passes a specific threshold. Statistically significant is not the same as clinically important.40

Pearls

•Although viral and immune-mediated disorders of the nervous system are among the most challenging neurological disorders, remember to look for the common problems before you go for the "zebras." The most common neuroimmune disorder is multiple sclerosis, and HIV is the most common viral infection of the nervous system. Common to both disorders is the progressive loss of neurons, resulting in significant cognitive and motor dysfunction.

•Periodic postoperative follow-up is of utmost importance, and give special attention to the nutritional needs of your patient.

•As a neurosurgeon concerned about infection, take a minute to reflect on the pathophysiology of neuronal injury associated with an infection. This reflection will be critical in making meaningful consult requests.

•Never forget that p values do not measure the probability that the studied hypothesis is true, or the probability that the data were produced by random chance alone. A p value is an expression of the probability of getting results at least as extreme as what was observed, under the assumption that the null hypothesis is true. It carries no information about the magnitude of an effect.

17.11  Top Hits

17.11.1  Questions

1.A 38-year-old woman comes to the emergency department with 7 days of fatigue and headache that has worsened in intensity today. She also reports an episode of vomiting. The

patient is accompanied by her roommate, who has noted no confusion or personality changes. On physical examination she is awake, alert, and conversant. Her neck is supple and oropharynx shows thrush. An MRI of the brain is normal and ophthalmological examination shows bilateral papilledema. A rapid HIV test is positive. Which of the following is most likely to establish a diagnosis? a) Cytomegalovirus (CMV) IgG testing b) Serum Toxoplasma gondii antibody c) HSV1 PCR of the CSF d) Cryptococcal antigen testing of CSF e) JC virus PCR of CSF

2.A 36-year-old man is brought to the emergency department (ED) by his roommate with confusion and agitation for the last 2 days. While in the ED, he has generalized tonic–clonic seizures. His temperature is 40°C (104°F), blood pressure (BP) is 120/80 mm Hg, pulse is 105/min. There is no neck stiffness but a neurological examination shows upgoing plantar reflexes bilaterally. CT of the head reveals­ no abnormalities. An LP is performed and shows the following:

Opening pressure:14 Protein: 85 mg/dL

Red blood cells (RBCs): 25/mL White blood cells (WBCs): 90/mL Lymphocytes: 90%

Which of the following is the next best step in management of this patient? a) IV amphotericin B

b) IV acyclovir

c) IV ceftriaxone and vancomycin d) MRI of the brain, with and without

contrast

3.A 15-year-old adolescent girl is brought to the emergency department (ED) due to 18 hours of headache and lethargy. The headache began last

night after she returned from 3 days of camping with friends. Temperature is 39.6°C (103.3°F), BP is 90/60 mm Hg, pulse is 120/min, and respirations are 22/min. The patient is obtunded and responds only to deep, painful stimulus. Physical examination shows resistance to passive neck flexion. Several petechiae are noted on the lower extremities. CSF results are as follows:

Glucose: 20 mg/dL Protein: 475 mg/dL Leukocytes: 2,000/mL Neutrophils: 90%

Which of the following is the most likely cause of this patient’s condition? a) Arboviral encephalitis

b) Acute Lyme’s disease c) Meningococcal infection d) Pneumococcal meningitis e) Rocky Mountain spotted fever

4.A 31-year-old man is brought to the ED due to 2 weeks of daily headaches and progressive confusion. He has a history of HIV. The patient appears unkempt and disoriented. Temperature is 38.6°C (101.4°F), BP is 118/75 mm Hg, pulse is 110/min. Neurological examination shows ataxia and right-sided hemiparesis. Brain MRI shows multiple ring-enhancing lesions. Which of the following would have most likely prevented this patient’s condition? a) Acyclovir

b) Azithromycin c) Trimethoprim–sulfamethoxazole d) Isoniazid

e) Ganciclovir f) Fluconazole

5.A 28-year-old man comes to the office due to trouble with his arm and face over the last week. He has had 1- to 2-minute episodes of twitching of the left arm and

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left side of the face. He has also had daily headaches for several weeks that are associated with nausea. The patient has a history of HIV but does not take his medications regularly. Three months ago, his CD4 count was 46/mL. Left arm motor strength is 4/5 and deep tendon reflexes (DTRs) are 3+. MRI of the brain reveals several ring-enhancing lesions at the gray–white junction and basal ganglia. Which of the following is the next step in management?

a) Albendazole b) Stereotactic brain biopsy

c) Clarithromycin and ethambutol d) Sulfadiazine and pyrimethamine e) Amphotericin B and flucytosine f) Vancomycin and ceftriaxone

6.A 35-year-old woman comes to the physician for the evaluation of increasing weakness and numbness of the upper extremities for 5 days. During the past 2 days, she has had urinary incontinence not related to sneezing or laughing. Last summer, she had numbness and weakness of her lower extremity transiently for 3 weeks. She has had 10 male sexual partners in her lifetime and uses condoms­ inconsistently. Examination shows an impaired tandem gait, DTRs are 4+ bilaterally. There is mild spasticity and muscle strength is decreased in both upper extremities. Sensation to vibration and fine touch is decreased in upper extremities. What is the most appropriate next step in management? a) Check serum vitamin B12 level b) Rapid plasma reagin (RPR)/Vene-

real Disease Research Laboratory (VDRL) test

c) MRI of the brain and spine d) Lumbar puncture e) Electromyography f) Muscle biopsy

7.A 22-year-old primigravid woman comes to the physician for her initial prenatal visit at 12 weeks’ gestation. She reports a tingling sensation in her legs for the past month. She follows a vegetarian diet since the age of 13. Examination shows pale conjunctivae, shiny tongue, and decreased sensation to vibration and position over the upper and lower extremities. When asked to stand, hold her arms in front of her, and close her eyes, she loses balance and takes a step backward. Which of the following is most likely to have prevented this patient’s condition? a) Folic acid supplementation b) Calcium supplementation

c) Iron supplementation d) Penicillin G therapy e) Vitamin B12 supplementation

8.A 38-year-old woman comes to the physician for the evaluation of progres-

sive weakness and numbness for 3 months. The symptoms started in her lower legs and gradually progressed up to her arms. During the past week, she has also had bilateral facial weakness and headaches. She is sexually active and uses condoms inconsistently. There is generalized weakness of the muscles, DTRs are 1+ bilaterally. Further evaluation is most likely to show which of the following findings? a) Positive Campylobacter stool

culture

b) Positive acetylcholine receptor (AchR) antibodies

c) RPR titer of 1:128 d) Positive GM1 ganglioside

autoantibodies

e) Positive serum botulinum neurotoxin f) Elevated thyroid-stimulating hor-

mone (TSH) and decreased T4 levels

9.A 71-year-old man comes to the physician because of a 2-week history of fatigue and 10-lb weight loss. Eight months ago, he underwent a kidney transplant. His current medications include prednisone and mycophenolate mofetil. While in the doctor’s office, the patient has a seizure and difficulty coordinating movements with his left hand. An MRI of the brain shows an intraparenchymal lesion with peripheral ring enhancement. A tissue aspirate yields weakly acid-fast, gram-positive bacteria with branching, filamentous shapes. What is the most appropriate initial pharmacotherapy? a) Trimethoprim–sulfamethoxazole b) Vancomycin

c) Rifampin, isoniazid, pyrazinamide, and ethambutol

d) Erythromycin e) Amikacin

10.A 7-year-old boy is brought to the ED due to high-grade fever and lethargy for 4 days. He has sickle cell disease and has not gotten any vaccines due to parental religious beliefs. Exam-

ination shows nuchal rigidity with positive Kernig’s and Brudzinski’s signs. An LP is performed and shows decreased glucose concentration, increased protein concentration, and numerous segmented neutrophils. A Gram stain of the CSF shows gram-negative coccobacilli. This patient is at an increased risk for which complication?

a) Cerebral palsy b) Hearing loss c) Adrenal insufficiency d) Brain abscess

e) Communicating hydrocephalus

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17.11.2  Answers

 1. d. Cryptococcosis is the most common fungal disease in HIV-infected persons, and it is the AIDS-defining illness for 60 to 70% of HIV-infected patients. The insidious onset of this patient’s symptoms together with bilateral papilledema supports a possible Cryptococcus infection. Cryptococcal disease usually develops only when CD4+ lymphocyte counts fall below 100 cells/mL.

 2. b. Tonic–clonic seizures and lympho- cyte-predominant CSF indicate a viral meningitis. The most common cause of viral meningitis in the United States is HSV. Thus, the correct and appropriate treatment is IV acyclovir.

 3. c. This patient’s physical examination findings of lethargy, neck stiffness, and petechiae point toward a Neisseria gonorrhoeae infection. The CSF findings of neutrophil predominance, elevated protein, and low glucose further strongly support a bacterial meningitis.

 4. c. Trimethoprim–sulfamethoxazole is the first-line treatment for ring-en- hancing lesions caused by Nocardia. The three most common causes of ring-enhancing lesions include toxoplasmosis, Nocardia, and CNS lymphoma. In this patient, the findings of unilateral hemiparesis, ataxia, and slow-onset confusion support Nocardia as the most likely cause.

 5. d. MRI of the brain revealing multiple ring-enhancing lesions at the gray– white junction and basal ganglia is virtually­ pathognomonic for toxoplasmosis infection. The first-line treatment for toxoplasmosis is sulfadiazine and pyrimethamine. Other features of unilateral twitching and low CD4 count support an infectious etiology that causes neurological symptoms in the immunocompromised.

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 6. c. This woman has relapsing neurological symptoms that suggest lesions of the pyramidal tract (weakness, spasticity, increased DTR), the dorsal spinal column (loss of vibration and fine touch), and the autonomic nervous system that are disseminated in time and space, which is indicative of multiple sclerosis (MS). MRI of the brain and spine is the test of choice to confirm the diagnosis, showing multiple sclerotic plaques (most commonly­ seen in periventricular, juxtacortical, infratentorial, or spinal cord white matter) with finger-like radial extensions.

 7. e. This patient presents with conjunctival pallor, fatigue, shortness of breath, and glossitis, which together indicate a nutrient-deficiency anemia. The patient’s vegetarian diet and pregnancy are important risk factors for

vitamin B12 deficiency. Given the concomitant neurological signs and symptoms (paresthesias, loss of vibratory sensation and proprioception, positive Romberg’s test), the most likely nutrient deficiency is that of vi-

tamin B12.

  8. d. Anti-GM1 autoantibodies are seen in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). In the most typical form of CIDP, patients present with ascending symmetric sensory and motor deficits that progress over a period greater than 2 months. Symptoms improve with treatment (intravenous immunoglobulin [IVIg], plasmapheresis, and glucocorticoids) over the course of months to years.

  9. a. Trimethoprim/sulfamethoxazole is considered the drug of choice for patients with nocardiosis. While the lungs are the most commonly affected site, nocardiosis can also affect the skin, CNS, or lead to a disseminated

infection,­ as in this patient. Nocardiosis is more common in patients with certain risk factors, which this patient does have, such as immunocompromise due to a kidney transplant.

10.b. Fever, headache, vomiting, and a stiff neck with positive Kernig’s and Brudzinski’s signs indicate meningitis. Given the appearance of gram-negative coccobacilli in CSF, the most likely pathogen is H. influenzae. Transient or permanent sensorineural hearing loss may occur as early as 48 hours after the onset of infection because of spread of infection from the meninges to the cochlea via the cochlear aqueduct.

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