Functional Neurosurgery

Functional Neurosurgery

Deep Brain Stimulation

1. Characterize Parkinson disease.

 

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a. Best target is the_____ _____

subthalamic nucleus

 

b. It has similar efficacy to_____

levodopa

 

c. with fewer_____ _____.

side effects

 

d. ablative surgery is giving way to _____.

deep brain stimulators

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Surgical Treatment of Parkinson Disease

2. Matching. Regarding surgical ablative treatment of Parkinson disease and its historical background, match the listed procedures with the appropriate phrase(s) and benefits.

 

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Abandoned because:

 

 

unpredictable results; tremor did not improve; bradykinesia did not improve; rigidity did not improve; ipsilateral tremor persists; side effects/resistance; only modest benefits Procedure:

 

 

a. anterior choroidal artery ligation

 

b. anterodorsal pallidotomy

,

 

c. ventrolateral thalamotomy

, ,

 

d. L-dopa

 

e. transplantation

 

3. How beneficial is pallidotomy of globus pallidus interna for the following (percentage)?

 

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a. Dyskinesia is _____%.

90%

 

b. Bradykinesia is _____%.

85%

 

c. Rigidity is _____%.

75%

 

d. Tremor is _____%.

57%

 

4. True or False. The following symptoms improve after anterodorsal pallidotomy:

 

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a. tremor ipsilateral

false

 

b. rigidity

true

 

c. bradykinesia

false

 

d. ataxia

false

 

e. tremor contralateral

false

 

5. Ventrolateral thalamotomy can improve tremor; it cannot be performed bilaterally because bilateral thalamotomy causes

 

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a. d_____ and

dysarthria

 

b. g_____ d _____.

gait disturbance (Incidence of postoperative dysarthria and gait disturbance is high.)

 

6. Complete the following about surgical treatment of Parkinson disease:

 

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a. The target today is the _____ _____

posteroventral pallidum

 

b. specifically the

 

 

     i. _____

GPi—internal segment of the globus pallidus

 

     ii. which blocks the input from the _____

STN—subthalamic nucleus

 

7. How might pallidotomy work?

 

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a. direct destruction of the _____

GPi

 

b. interrupt _____ fibers

pallidofugal

 

c. diminish input from the _____

subthalamic nucleus

 

8. Answer the following about surgical treatment of Parkinson disease:

 

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a. What was an early procedure for the treatment of Parkinson disease?

ligation of the anterior choroidal artery

 

b. What are the mechanisms by which pallidotomy may work?

 

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     i. destroy _____

GPi or

 

     ii. interrupt p _____ p _____

pallidofugal pathways

 

     iii. reduce input into m _____ p _____

medial pallidum

 

c. What is the target for the tremor treatment?

ventralis intermedius nucleus (VIM)of the thalamus

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d. True or False. Pallidotomy is primarily focused on the treatment of motor symptoms.

true

 

e. What are the most common complications of pallidotomy? Hint: vhid

 

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     i. v _____

visual field deficit

 

     ii. h _____

hemiparesis

 

     iii. i _____ h _____

intracerebral hemorrhage

 

     iv. d _____

dysarthria

 

9. Characterize thalamic lesions.

 

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a. Lesioning in the thalamic _____ nucleus

intermedius

 

b. reduces parkinsonian _____.

tremor

 

c. however it does not improve _____

bradykinesia

 

d. and may worsen

 

 

     i. g _____ s _____ and

gait symptoms

 

     ii. s _____ p _____.

speech problems

 

10. Characterize subthalamatomy.

 

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a. Lesions in the STN classically produced _____.

hemiballism

 

b. Selective lesions may give relief on a par with _____.

pallidotomy

 

11. Characterize dystonia.

 

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a. Stimulationof the _____is the primary surgical treatment for the dystonia.

pallidum

 

b. Results are better for _____ dyskinesia.

tardive

 

c. The most common target is _____.

GPi

 

12. True or False. Stimulation has attracted increasing interest in patients with Parkinson disease who are refractory to medical drug treatment. The deep brain stimulator (the electrode) is placed in which of the following locations? (There are three true answers.)

 

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a. zona incerta

false

 

b. posterior ventral pallidum (PV)

false

 

c. substantia nigra (SN)

false

 

d. Forel field (H)

false

 

e. subthalamic nucleus (STN)

true

 

f. globus pallidus internus (GPi)

true

 

g. pedunculopontine nucleus

true

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13. True or False. Indications for pallidotomy in parkinsonism include

 

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a. refractory to drug therapy

true

 

b. drug-induced dyskinesia

true

 

c. rigidity

true

 

d. tremor

false

 

e. dementia

false

 

14. Ipsilateral hemianopsia is a contraindication to ventral pallidotomy because one of the side effects of the procedure could be o _____ t _____ i _____ and would cause the patient to be _____.

optic tract injury; blind (Visual field defects could occur in 2.5% of patients; blindness could result.)

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15. Bilateral pallidotomies carry an increased risk of

 

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a. s _____ d _____ and

speech difficulties

 

b. c _____ d _____.

cognitive decline

 

16. True or False. What are the benefits for the patient from posteroventral pallidotomy as done currently?

 

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a. motor symptoms

true

 

b. dyskinesia

true

 

c. rigidity

true

 

d. bradykinesia

true

 

e. tremor

true

 

17. True or False. Common complications of pallidotomy (unilateral) include

 

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a. visual field deficit

true

 

b. dysarthria

true

 

c. hemisensory deficit

false (Hemisensory deficit is not a common complication.)

 

d. hemiparesis

true

 

Spasticity

18. True or False. A spastic bladder will

 

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a. have high capacity and empty spontaneously

false

 

b. have high capacity and empty with difficulty

false

 

c. have low capacity and empty spontaneously

true (Low capacity and spontaneous emptying are the hallmarks of the spastic bladder.)

 

d. have low capacity and empty with difficulty

false

 

19. True or False. The onset of a spastic bladder after spinal cord injury is

 

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a. immediate

false

 

b. delayed

true (Delayed onset is typical because the acute phase of spinal shock is hyporeflexic and hypotonic.)

 

c. can occur at any time

false

 

20. True or False. The Ashworth score can grade severity of spasticity. The highest score in this system is given when there is

 

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a. no increase in tone (full movement)

false

 

b. rigidity in all flexors

false

 

c. rigidity in all extensors

false

 

d. rigidity in flexion and extension

true

 

21. The Ashworth score is the clinical grading of the _____ _____ _____.

severity of spasticity

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22. What are the medications used in the treatment of spasticity?

 

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a. b _____

baclofen

 

b. d _____

diazepam

 

c. d _____

dantrolene

 

d. p _____

progabide

 

23. What are the nonablative procedures used for the treatment of spasticity?

 

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a. i _____ b _____

intrathecal baclofen

 

b. i _____ m _____

intrathecal morphine

 

c. e _____ e _____ s _____

epidural electrical stimulation

 

24. What are the ablative procedures with preservation of ambulation used for the treatment of spasticity? Name one.

motor point block, phenol nerve block, selective neurectomy, percutaneous radiofrequency foraminal rhizotomy, Bischof myelotomy, selective dorsal rhizotomy, stereotactic thalamotomy, or dentatotomy

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25. True or False. Fibers that are more sensitive to radiofrequency rhizotomy are

 

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a. small unmyelinated sensory fibers

true

 

b. large myelinated alpha motor fibers

false

 

26. What are the ablative procedures with sacrifice of ambulation used for the treatment of spasticity? Name one.

intrathecal injection of phenol, selective anterior rhizotomy, neurectomy, intramuscular neurolysis, cordectomy, cordotomy

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27. True or False. Spasticity can be treated with intrathecal baclofen pumps. Complications are mainly

 

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a. pump underinfusion

false

 

b. wound complications

false

 

c. catheter complications

true (Catheter complications may have a frequency of up to 30% in baclofen pumps.)

 

d. drug resistance

false

 

Torticollis

28. What is another name for torticollis?

wry neck

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29. What muscle is usually affected in spasmodic torticollis?

sternocleidomastoid

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30. What are the surgical procedures used for the treatment of spasmodic torticollis?

 

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a. stimulate _____ _____

dorsal cord

 

b. inject _____ _____

botulinum toxin

 

c. cut _____ rhizotomy

 

d. coagulate _____ _____

Forel’s H1

 

31. What artery is most commonly implicated in the torticollis of the eleventh nerve origin?

vertebral

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Neurovascular Compression Syndromes

32. Characterize root entry zone.

 

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a. Syndromes due to compression of

 

 

     i. _____ _____

cranial nerves

 

     ii. at the _____ _____ _____

root entry zone

 

b. This site, also known as the _____- _____ zone,

Obersteiner-Redlich

 

c. is the point where the central myelin from the _____ cells.

oligodendroglial

 

d. Changes to the peripheral myelin of the _____ cells

Schwann

 

33. True or False. Hemifacial spasm (HFS) starts from the lower half of the face and spreads to the upper half of the face.

false (starts with the orbicularis oculi)

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34. Complete the following about neurovascular compression syndromes:

 

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a. On what side is HFS more common?

left

 

b. What is the age and gender predilection?

women, after the teen ages

 

c. What is the most commonly involved artery?

AICA

 

d. True or False. Carbamazepine and phenytoin are generally effective treatment.

false

 

e. What is the material used as a cushion in the microvascular decompression (MVD)?

Ivalon, polyvinyl formyl alcohol foam

 

35. What is the only other involuntary movement disorder besides HFS that persists during sleep?

palatal myoclonus

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36. What distinguishes HFS from blepharospasm?

 

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a. HFS is _____.

unilateral

 

b. Blepharospasm is _____.

bilateral

 

37. What distinguishes HFS from facial myokymia (FM)?

 

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a. Hemifacial spasm (HFS) is _____.

intermittent

 

b. Facial myokymia (FM) is _____.

continuous

 

38. True or False. The vessel most commonly associated with hemifacial spasm is

 

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a. posterior inferior cerebellar artery (PICA)

false

 

b. superior cerebellar artery (SCA)

false

 

c. anterior inferior cerebellar artery (AICA)

true

 

d. posterior cerebral artery (PCA)

false

 

e. vertebral artery

false

 

f. basilar artery

false

 

39. Hemifacial spasm

 

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a. is caused by compression at the _____ _____ _____

root entry zone

 

b. of the _____ _____

facial nerve

 

c. by the

AICA

 

d. This does not cause _____ conduction but

ephaptic

 

e. produces _____

kindling

 

f. and _____.

synkinesis

 

40. Synkinesis is a phenomenon where

 

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a. stimulation of _____ _____ of the facial nerve

one branch

 

b. results in _____ _____

delayed discharges

 

c. through _____ _____.

another branch

 

41. True or False. Postoperatively after microvascular decompression for hemifacial spasm the patient can expect

 

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a. immediate cessation of facial spasms

false

 

b. reduction starting 2 to 3 days later

true

 

c. better results the longer the patient has had HFS

false

 

d. better results the older the patient is

false

 

e. complete resolution of spasms eventually

true (in 81 to 93% of patients)

 

f. possible relapse even if free of spasms for a full 2 years

false (relapse after 2 years only1%)

 

42. Complications of hemifacial spasm (HFS) surgery include the following:

 

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Hint: hemifacial s

 

 

     i. h _____

hoarseness

 

     ii. e _____

elderly do less well

 

     iii. m _____

meningitis (aseptic)

 

     iv. i _____

ipsilateral hearing loss

 

     v. f _____

facial weakness

 

     vi. a _____

ataxia

 

     vii. c _____

CSF rhinorrhea

 

     viii. i _____

incomplete relief-

 

     ix. a _____

aseptic meningitis

 

     x. l _____

lip (perioral) herpes

 

     xi. s _____

swallowing (dysphagia)

 

Hyperhidrosis

43. Complete the following statements about hyperhidrosis:

 

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a. It is due to overactivity of the _____ _____ glands.

eccrine sweat

 

b. These glands are under control of the _____ _____ _____.

sympathetic nervous system

 

c. The neurotransmitter is _____.

acetylcholine

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d. Most _____ end organs are _____.

sympathetic; adrenergic

 

e. Some cases warrant _____ _____.

surgical sympathectomy

 

Sympathectomy

44. Name five indications for upper extremity (UE) sympathectomy.

 

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Hint: “crash” the sympathetic ganglia

 

 

a. c _____

causalgia major primary

 

b. R _____

Raynaud disease

 

c. a _____

intractable angina

 

d. s _____

shoulder-hand syndrome

 

e. h _____

hyperhidrosis

 

45. Complete the following statements about sympathectomy:

 

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a. What is the level for cardiac sympathectomy?

from stellate ganglion

 

b. What is the level for UE sympathectomy?

second thoracic ganglia T2

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c. What is the level for lumbar sympathectomy?

L2 and L3 sympathetic ganglia

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d. What is the most commonly used approach for lumbar sympathectomy?

retroperitoneal

 

46. What are the complications of UE sympathectomy?

 

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a. p _____

pneumothorax

 

b. i _____ n _____

intercostal neuralgia

 

c. s _____ c _____ i _____

spinal cord injury

 

d. H _____ s _____

Horner syndrome

 

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Aug 6, 2016 | Posted by in NEUROSURGERY | Comments Off on Functional Neurosurgery

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