Color Atlas of Neurology

data on the potential efficacy of chemotherapy against malignant forms of meningioma, plexus papilloma, pineocytoma, schwannoma, hemangiopericytoma, and pituitary adenoma.

Grade IV tumors. Patients with grade IV tumors survive a median of ca. 10 months from diagnosis even with the best current multimodality treatment (surgery, radiotherapy, chemotherapy). The 5-year survival rate of patients with glioblastoma is no more than 5%. PNET (including medulloblastoma) and primary cerebral lymphoma have median survival times of a few years.

Cerebral metastases: Solitary, surgically accessible metastases are resected as long as there is no acute progression of the underlying malignant disease, or for tissue diagnosis if the primary tumor is of unknown type. Solitary metastases of diameter less than 3 cm can also be treated with local radiotherapy, in one of two forms: interstitial radiotherapy with surgically implanted radioactive material (brachytherapy), or stereotactic radiosurgery. The latter is a closed technique, requiring no incision, employing multiple radioactive cobalt sources (as in the Gamma Knife and X-Knife) or a linear accelerator. Solitary or multiple brain metastases in the setting of progressive primary disease are generally treated with whole-brain irradiation. Chemotherapy is indicated for tumors of known

responsiveness to chemotherapy in patients whose general condition is satisfactory. Metastatic small-cell lung cancer, primary CNS lymphoma, and germ cell tumors are treated with radiotherapy or chemotherapy rather than surgery.

Spinal metastases: Resection and radiotherapy for localized tumors; radiotherapy alone for diffuse metastatic disease.

Leptomeningeal metastases: Chemotherapy (systemic, intrathecal, or intraventricular); irradiation of neuraxis.

! Aftercare

Follow-up examinations are scheduled at shorter or longer intervals depending on the degree of malignity of the neoplasm and on the outcome of initial management (usually involving some combination of surgery, radiotherapy, and chemotherapy), with adjustment for individual factors and for any complications that may be encountered in the further course of the disease. A single CT or MRI scan 3 months postoperatively may suffice for the patient with a completely resected, benign tumor, while patients with malignant tumors should be followed up by examination every 6 weeks and neuroimaging every 3 months, at least initially. Later visits can be less frequent if the tumor does not recur.

Traumatic Brain Injury (TBI)

The outcome of traumatic brain injury depends on the type and extent of the acute (primary) injury and its secondary and late sequelae.

Direct/indirect history. A history of the precipitating event and of the patient’s condition at the scene should be obtained from the patient (if possible), or from an eyewitness, or both. Vomiting or an epileptic seizure in the acute aftermath of the event should be noted. Also important are the past medical history, current medications (particularly anticoagulants), and any history of alcoholism or drug abuse.

Physical examination. General: Open wounds, fractures, bruises, bleeding or clear discharge from the nose or ear. Neurological: Respiration, circulation, pupils, motor function, other focal signs.

Diagnostic studies. Laboratory: Blood count, coagulation, electrolytes, blood glucose, urea, creatinine, serum osmolality, blood alcohol, drug levels in urine, pregnancy testing if indicated.

Essential radiological studies: Head CT with brain and bone windows is mandatory in all cases un-

less the neurological examination is completely normal. A cervical spine series from C1 to C7 is needed to rule out associated cervical injury. Plain films of the skull are generally unnecessary if CT is performed.

Additional studies, as indicated: Cranial or spinal MRI or MR angiography, EEG, Doppler ultrasonography, evoked potentials.

In multiorgan trauma: Blood should be typed and cross-matched and several units should be kept ready for transfusion as needed. Physical examination and ancillary studies for any fractures, abdominal bleeding, pulmonary injury.

! Primary Injury

The primary injury affects different parts of the skull and brain depending on the precipitating event. The traumatic lesion may be focal (hematoma, contusion, infarct, localized edema) or diffuse (hypoxic injury, subarachnoid hemorrhage, generalized edema). The worse the injury, the more severe the impairment of consciousness (pp. 116 ff). The clinical assessment of impairment of consciousness is described on pp. 378 f (Tables 33 and 34).

Head trauma (schematic)

Subdural hematoma

Retroauricular ecchymosis (due to basilar skull fracture)

Severe

HT

GCS: 3-8

Spinal Trauma

Spinal injury can involve the vertebrae, ligaments, intervertebral disks, blood vessels, muscles, nerve roots, and spinal cord. The spinal cord and spinal nerve roots may be directly injured (e. g. by gunshot or stab wounds) or secondarily affected by compression (bone fragments), hyperextension (spinal instability), and vascular lesions (ischemia, hemorrhage). Diagnosis: Bone injuries can be identified by radiography and/or CT; spinal cord lesions (hemorrhage, contusion, edema, transection) and softtissue lesions (hematoma, edema, arterial dissection) are best seen on MRI.

Cervical spine distortion (whiplash injury). Indirect spinal trauma (head-on or rear-end collision) leads to sudden passive retroflexion and subsequent anteflexion of the neck. The forces acting on the spine (acceleration, deceleration, rotation, traction) can produce both cervical spine injuries (spinal cord, nerve roots, retropharyngeal space, bones, ligaments, joints, intervertebral disks, blood vessels) and cranial injuries (brain, eyes, temporomandibular joint). There may be an interval of 4–48 hours until symptoms develop, rarely longer (asymptomatic period). Symptoms and signs: Pain in the head, neck, and shoulders, neck stiffness, and vertigo may be accompanied by forgetfulness, poor concentration, insomnia, and lethargy. The symptoms usually resolve within 3–12 months but persist for longer periods in 15–20% of patients, for unknown reasons. Severity classification: Grade I = no neurological deficit or radiological abnormality, grade II = neurological deficit without radiological abnormality, grade III = neurological deficit and radiological abnormality.

bral disks as composed of three columns. Involvement of only one column = stable injury; two columns = potentially unstable; three columns = unstable. For details, see p. 380 (Table 36).

Trauma to nerve roots and brachial plexus.

Nerve root lesions usually involve the ventral roots, and thus usually produce a motor rather than sensory deficit. Nerve root avulsion may be suspected on the basis of (multi)radicular findings and/or Horner syndrome and can be confirmed by myelography (empty root sleeves, bulging of the subarachnoid space) or MRI. Downward or backward traction on the shoulder and arm (as in a motorcycle accident) can produce severe brachial plexus injuries accompanied by nerve root avulsion. Brachial plexus lesions can also be caused by improper patient positioning during general anesthesia, intense supraclavicular pressure (backpack paralysis), or local trauma (stab or gunshot wound, bone fragments, contusion, avulsion). These injuries more commonly affect the upper portion of the brachial plexus (pp. 34, 321).