9. Describe laminectomy wound infection treatment.

G7 p.349:15mm

a. B_____

Betadine—if purulent—half strength follow with normal saline

b. c_____

culture

c. d_____

debride wound

d. e_____

empirically vancomycin plus third generation cephalosporin (ceftazidime)

e. f_____

fill (pack) with iodoform 1/4 inch

f. g_____

gradually reduce packing trim by 1 inch each day

g. h_____

hospital—change pack every 8 hours

h. h_____

home—change pack twice a day

10. Complete the following concerning Pott puffy tumor:

G7 p.349:130mm

a. Treatment

     i. f_____ r_____

flap removal

     ii. d_____

debridement

     iii. antibiotics for_____ weeks. For first week use_____

6 to 12; IV

     iv. c_____

cranioplasty after 6 months

b. Most common organism is_____ _____.

Staphylococcus aureus

11. What are the risk factors for cerebral abscess?

G7 p.350:85mm

Hint: Abcdefghi

     i. A_____

AIDS

     ii. b_____

bacterial sepsis

     iii. c_____

cyanotic heart disease

     iv. d_____

dental abscess

     v. e_____

endocarditis

     vi. f_____

fistula (arteriovenous)

     vii. g_____

gastrointestinal infection

     viii. h_____

hematogenous spread

     ix. i_____

infection pulmonary

12. Complete the following about cerebral abscess:

G7 p.351:75mm

a. What percentage of cerebral abscesses fail to grow organism on culture?

25%

b. The most common organism is_____.

Streptococcus, 30 to 50%

c. The most common organisms in frontal-ethmoid sinusitis are_____ _____and_____ _____.

Streptococcus milleri and Streptococcus anginosus

d. The most common organism in traumatic causes is_____ _____.

Staphylococcus aureus

e. The most common organism in transplant patients is_____ _____.

Aspergillus fumigatus

f. The most common organism in infants is_____ _____.

gram negative

g. The most common organisms in AIDS patients are_____ and_____.

toxoplasmosis and Nocardia

h. The most common dental source is_____.

actinomyces

i. The most common organisms following neurosurgical procedures are_____ and _____.

Staphylococcus epidermidis and aureus

13. Indicate the value of the following diagnostic tests or treatment for brain abscess:

G7 p.352:40mm

a. lumbar puncture (LP)

dubious value—may herniate

b. computed tomography (CT)

excellent

c. leukocyte scan

excellent

d. effect of steroids

tests become less positive— can mislead

14. Describe the four stages of cerebral abscess.

G7 p.352:120mm

a. stages

     i. stage 1 e_____ c_____

early cerebritis_____

     ii. stage 2 l_____ c_____

late cerebritis

     iii. stage 3 e_____ c_____

early capsule

     iv. stage 4 l_____ c_____

late capsule

b. number of days

     i. stage 1

1 to 3

     ii. stage 2

4 to 9

     iii. stage 3

10 to 13

     iv. stage 4

14

c. histologic characteristics

     i. stage 1

inflammation

     ii. stage 2

developing necrotic center

     iii. stage 3

neovascularity reticular network, necrotic center

     iv. stage 4

collagen capsule necrotic center gliosis around capsule

15. Conservative management of cerebral abscess is appropriate

G7 p.353:130mm

a. if the abscess is less than_____ cm in diameter

3

b. or it is in the_____ _____ phase.

early cerebritis (where surgery would not be appropriate)

16. List the empiric antibiotics used for cerebral abscess.

Hint: vcmc or r

G7 p.354:60mm

a. v_____

vancomycin

b. c_____

cefotoxime

c. m_____ or

metronidazole (Flagyl)

d. c_____ or

chloramphenicol

e. r_____

rifampin

17. For how long should IV antibiotics be used in cerebral abscess?

6 weeks

G7 p.354:135mm

18. Complete the following regarding Nocardia:

G7 p.356:40mm

a. It arises from the_____.

soil

b. What is the duration of treatment?

many months

c. Is it a fungus?

no, it is a bacterium

19. Complete the following regarding subdural empyema:

G7 p.357:20mm

a. It spreads as a result of_____ _____.

direct extension

b. The leading cause was previously c_____ o_____ m_____.

chronic otitis media

c. The leading cause now is_____0

frontal sinusitis, 65 to 75%

d. Is LP used for diagnosis?

no, rarely positive and it is hazardous

e. Fatal cases are associated with v_____ i_____ of the b_____.

venous infarction of the brain

20. Complete the following regarding herpes simplex:

G7 p.358:150mm

a. HSE stands for_____ _____ _____

herpes simplex encephalitis

b. It has a predilection for the t_____ o_____ l_____ and l_____ s_____.

temporal, orbitofrontal lobes and limbic system

c. Definitive diagnosis requires b_____ b_____ and v_____ i_____.

brain biopsy and virus isolation

d. Treat promptly with_____

acyclovir

21. HSE has the following characteristic:

G7 p.359:70mm

a. CSF:_____-_____

leukocytosis-monocytes

b. EEG: p_____ l_____ e_____ d_____ on electroencephalography

periodic lateralizing epileptiform discharges

c. CT e_____ in t_____ l_____

edema in temporal lobes

d. Hemorrhage on _____ means _____ _____.

CT; poorer prognosis

e. MRI shows t_____ s_____.

transsylvian sign

f. Significance: if bilateral it is highly suggestive of_____.

HSE

22. Transsylvian sign

G7 p.359:105mm

a. indicates temporal lobe e_____

edema

b. that extends across the s_____ f_____.

sylvian fissure

23. General treatment for intracranial pressure (ICP) elevation involves the following:

G7 p.360:60mm

a. e_____ h_____ of b_____

elevate head of bed

b. m_____

mannitol

c. h_____

hyperventilate

24. Complete the following concerning acyclovir treatment:

G7 p.360:85mm

a. The dose is_____

30 mg/kg/day is divided every 8 hours

b. for a duration of_____ days.

14 to 21

c. If you identify HSE before GCS drops you can l_____ m_____.

limit mortality

25. Complete the following about Creutzfeldt-Jakob disease:

G7 p.361:30mm

a. CJD stands for_____ _____ _____.

Creutzfeldt-Jakob disease

b. The prognosis is_____ _____.

invariably fatal

c. The EEG shows_____.

characteristic bilateral sharp waves 0.5 to 2.0 per second

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d. Prion stands for_____ _____ _____.

proteinaceous infectious particles

e. Diagnostic triad Hint: dEm

G7 p.362:160mm

     i. d_____

dementia

     ii. E_____

EEG

     iii. M_____

myoclonus

26. What is the biopsy procedure in suspected CJD?

G7 p.363:150mm

a. Use a_____ cranial saw

manual

b. to avoid_____ of the infection.

Aerosolization

c. Avoid cutting the_____ with the saw.

dura

d. Clearly_____ containers.

label

e. Fix is_____ % phenolized formalin.

15%

27. Name four conditions in AIDS producing focal CNS lesions.

G7 p.364:75mm

a. t_____

toxoplasmosis

b. l_____

lymphoma

c. p_____ m_____ l_____

progressive multifocal leukoencephalopathy (PML)

d. C_____

Cryptococcus

28. Complete the following about the neurologic manifestations of AIDS:

G7 p.364:95mm

a. What is the most common lesion causing mass effect in AIDS patients?

toxoplasmosis

b. Does this occur early or late in the course of HIV infection?

late

c. Central nervous system (CNS) lymphoma is associated with what virus?

Epstein-Barr virus

d. PML is associated with what virus?

polyoma or J-C virus (not to be confused with Creutzfeldt-Jakob)

29. An imaging characteristic of toxoplasmosis in AIDS patients is

G7 p.365:170mm

a. number

multiple

b. density

low

c. located

basal ganglia

d. enhancement

ring—”multiple enhancing lesions in the basal ganglia”

30. Complete the chart by listing the CT and MRI findings in each of the following:

G7 p. 365:171mm

a. toxoplasmosis

     i. number

more than 5

     ii. enhance

ring

     iii. Location

basal ganglia

     iv. mass effect

moderate

     v. miscellaneous

edema

b. lymphoma

     i. number

less than 5

     ii. enhance

homogeneous

     iii. location

subependymal

     iv. mass effect

mild

     v. miscellaneous

may cross corpus callosum

c. PML

     i. number

multiple

     ii. enhance

no

     iii. location

white matter

     iv. mass effect

none

     v. miscellaneous

high on T2 and low on T1

31. Complete the following about the neurologic manifestations of AIDS:

G7 p. 366:135mm

a. treatment for toxoplasmosis

     i. p_____

pyrimethamine

     ii. s_____

sulfadiazine

b. How promptly should we see improvement clinically and radiologically?

2 to 3 weeks

G7 p. 367:68mm

c. If successful how long should toxoplasmosis be controlled?

for patient’s lifetime if meds are continued

d. Biopsy should be considered if there is no response in _____ _____.

3 weeks (some say 7 to 10 days)

G7 p. 367:82mm

32. Complete the following about the neurologic manifestations of AIDS:

G7 p.366:160mm

a. Can toxoplasmosis be radiologically distinguished from

     i. lymphoma?

no

     ii. PML?

usually

b. Therefore check

     i. for toxo_____ _____ _____

serum toxo titers

     ii. for lymphoma_____ study for c_____, PCR a_____ of v_____ D_____

LP (if no mass effect); cytology; amplification of viral DNA

33. Considerations for performing a biopsy of a brain lesion in a HIV+ patient

G7 p.367:15mm

a. if toxo titers are_____

negative

b. if no response to toxo meds in_____

3 weeks

c. True or False. Biopsy is equally valuable in lesions that enhance or don’t enhance.

false (more valuable in enhancing lesions to differentiate toxoplasmosis from lymphoma)

G7 p.367:113mm

d. technique for biopsy_____

stereotactic

e. What two areas should be sampled?

enhancing rim and the center

f. Positive biopsy can be expected in

96%

G7 p.367:120mm

34. Indicate the survival times for AIDS patients with the following conditions:

G7 p.367:160mm

a. CNS toxo_____

15 months

b. PML_____

15 months

c. lymphoma_____

3 months versus 1 month without treatment

d. lymphoma in nonimmunosuppressed patient _____

13.5 months

35. Complete the following regarding Lyme disease:

G7 p.368:30mm

a. It is caused by a_____.

spirochete transmitted by a tick

b. The hallmark skin lesion is called e_____ c_____ m_____.

erythema chronicum migrans

c. The clinical triad consists of

     i. c_____ n_____

cranial neuritis

     ii. m_____

meningitis

     iii. r_____

radiculopathy

d. On clinical exam, don’t be misled into diagnosing_____ _____.

Bell palsy (The seventh nerve weakness in Lyme disease is common.)

e. On CSF exam, don’t be misled into diagnosing_____ _____.

multiple sclerosis (MS) (from the oligoclonal bands that also occur in Lyme disease)

f. What is the most common cause of bilateral Bell palsy?

Lyme disease cranial neuritis

G7 p.368:110mm

36. Complete the following about Lyme disease neurologic manifestations:

G7 p.369:100mm

a. What two conditions share an uncommon CSF finding?

MS(multiple sclerosis) and Lyme disease

b. The CSF component they share is_____ _____.

oligoclonal bands

37. Cysticercosis is a disease caused by

G7 p.370:60mm

a. Which organism?

Taenia solium

b. At which life cycle stage?

larval stage

c. The life cycle stages (4) include the following:

Hint: eael

     i. e_____

embryo

     ii. a_____

adult

     iii. e_____

eggs

     iv. l_____

larva

d. The current best test is_____-_____ _____ _____.

enzyme-linked immunoelectrotransfer blot

38. Complete the following statements about parasitic infections of the CNS:

G7 p.370:65mm

a. Cysticercosis is caused by

     i. the p_____ t_____

pork tapeworm

     ii. T_____ s_____

Taenia solium

b. Echinococcus is caused by

     i. the d_____ t_____

dog tapeworm

     ii. E_____ g_____

Echinococcus granulosa

G7 p.373:80mm

c. What is hydatid sand?

germinating parasitic scoleces

G7 p.373:120mm

d. Caution is advised during removal not to_____.

rupture the Echinococcus cyst and contaminate adjacent tissues

G7 p.373:135mm

39. Describe the life cycle of cysticercosis.

G7 p.370:85mm

a. Pig contains_____ _____ in its flesh.

encysted embryo

b. Humans eat undercooked_____ with_____ in it.

pork with embryo

c. Embryo matures to an_____.

adult

d. The_____ produces eggs.

adult

e. Eggs are released in the_____ of the human.

feces

f. The same or a different human_____ the _____.

ingests the eggs (from contaminated fingers, vegetables, or water)

g. Eggs in this host release_____

larvae

h. which burrow through the_____ _____ _____to _____.

small bowel wall to circulation

i. Larva lands and develops a_____ _____.

cyst wall

j. and becomes an_____ _____

encysted embryo

k. in_____ months.

4

40. Answer the following concerning neurocysticercosis:

G7 p.371:107mm

a. What is the permanent host for the adult tapeworm?

human

b. What is the intermediate host?

human or animal (pig)

41. Answer the following concerning neurocysticercosis:

G7 p.371:175mm

a. What is the significance of CT scan with

     i. low-density cysts with eccentric punctate high-density spots in an enhancing ring?

living cysticerci

     ii. above plus edema?

dying cysticerci

     iii. intraparenchymal punctate calcifications?

dead parasites

b. What may soft tissue x-rays show?

calcifications in thigh or shoulder

c. What might MRI show?

intraventricular or cisternal cysts

42. Complete the following regarding CT in cysticercosis:

G7 p.372:20mm

a. Ring-enhancing cysts suggest_____ _____.

living cysticerci

b. Intraparenchymal punctate calcifications suggest_____ _____.

dead parasites

c. Ring-enhancing cyst with edema suggests

     i. _____ with

recently dead or dying parasite

     ii. _____

inflammatory reaction

43. What organism can cause a cerebral abscess in an organ transplant patient?

Aspergillus fumigatus

G7 p.374:80mm

44. Name the most common fungal infection of the CNS diagnosed in the living patient.

cryptococcosis

G7 p.374:100mm

45. Describe amoebic infections of the CNS.

G7 p.375:120mm

a. The only amoeba known to cause infection is_____ _____.

Naegleria fowleri

b. Infection occurs 5 days after exposure in warm_____

freshwater

c. The amoeba gains entry to the CNS via the_____ _____.

olfactory mucosa

d. 95% die within_____ _____

1 week

e. due to_____.

↑ICP

f. Prescribe with_____ _____.

amphotericin B

46. Describe spinal epidural abscess.

G7 p.367:140mm

a. Most common site for spinal epidural abscess is the_____ at_____%.

thoracic level at 50%

b. The next most common is

     i. _____ at _____%

lumbar at 35%

     ii. _____ at _____%

cervical at 15%

c. Symptoms of epidural abscess are

     i. s_____ p_____

severe pain over the area

     ii. p_____ upon p_____

pain upon percussion

     iii. f_____

fever

47. What is the pathophysiology of cord in spinal epidural abscess?

G7 p.377:45mm

a. compression by

     i. m_____ of a_____

mass of abscess

     ii. b_____ by c_____ of o_____ v_____ b_____

bone by collapse of osteomyelitic vertebral body

b. infarction by v_____ t_____

venous thrombophlebitis

c. direct spread to cord can cause_____

myelitis

48. Complete the following regarding causes of spinal epidural abscess:

G7 p.377:100mm

a. hematogenous—most commonly from

     i. f_____

furuncle

     ii. IV_____ _____

drug abuse

b. direct extension from a p_____ a_____

psoas abscess

c. spinal procedures

     i. d_____

discectomy (incidence of SEA 0.67%

     ii. n_____

needles (catheters)

d. Underlying causes are Hint: idlra

     i. i_____ c_____

immune compromised

     ii. d_____

diabetes

     iii. IV d_____ a_____

IV drug abuse

     iv. r_____ f_____

renal failure

     v. a_____

alcoholism

49. Complete the following concerning psoas abscess:

G7 p.377:160mm

a. Muscle extends from T_____ to L_____

T12 to L5

b. Psoas is the primary hip_____

flexor

c. Innervated by _____

L2, L3

d. Proximity to sources of_____

infection

e. Pain on_____ flexion

hip

f. CT shows_____ of psoas shadow

enlargement

G7 p.378:80mm

g. Inside the_____ wing

iliac

50. Cultures from spinal epidural abscess patients can be expected to show the following:

G7 p.378:100mm

a. Staphylococcus aureus_____%

50%— the main organism

b. no growth_____ %

30 to 50%

c. Streptococcus (frequency)

second-most-common organism

d. tuberculosis (TB) associated with_____ disease _____%

Potts disease; 25%

e. multiple organisms_____%

10%

51. Complete the following regarding spinal epidural abscess (SEA):

G7 p.378:175mm

a. If during the spinal tap you encounter pus, what should you do?

stop advancing needle and send pus for culture

b. The best test if you suspect SEA is _____

MRI

c. Treatment includes

Hint: eabc

     i. e_____

evaluation

     ii. a_____

antibiotics

     iii. b_____

bracing—immobilization

     iv. c_____

compression relief if present

d. If no organism is known, start empiric antibiotics of

Hint: cvr

     i. c_____

cephalosporin third-generation (cefotaxime)

     ii. v_____

vancomycin

     iii. r_____

rifampin

52. Complete the following regarding spinal infections:

G7 p.380:35mm

a. The length of time IV antibiotics should be administered for spinal epidural abscess is_____.

3 to 4 weeks

b. The length of time IV antibiotics should be administered for vertebral osteomyelitis is_____.

6 to 8 weeks

c. Follow with_____.

serial sedimentation (ESR) rates

d. Mortality is_____%.

rates 4 to 31%

e. Recovery of neurologic deficit is_____ _____.

very rare

f. An exception to the rule is_____ _____−_____% improve.

Potts disease—50% improve neurologically

53. Complete the following regarding spine infections:

G7 p.380:85mm

a. vertebral osteomyelitis risk factors

Hint: d³e

     i. d_____

drug abusers

     ii. d_____

dialysis patients

     iii. d_____

diabetes

     iv. e_____

elderly

b. What condition in renal patients can mimic infection on MRI?

destructive spondyloarthropathy

G7 p.1233:30mm

c. Sources of infection are never found in_____%.

37% (consider urinary tract infection [UTI], respiratory tract, teeth)

d. Neurologic deficits occur in _____% of Pott’s disease patients.

10 to 47%

54. Answer the following about spine infections:

G7 p.382:105mm

a. How long does it take for plain x-rays to demonstrate changes in osteomyelitis?

2 to 8 weeks

b. What % of cases can be successfully managed nonoperatively?

90%

55. True or False. Regarding treatment of vertebral osteomyelitis:

G7 p.383:73mm

a. Instrumented fusion is contraindicated.

false

b. It is permitted even in pyogenic infections.

true

56. One differentiates spine destruction from

G7 p.384:45mm

a. infection: i_____ d_____

involves the disc

b. metastases: m_____ d_____

miss the disc and involve the vertebral body

57. What is the MRI triad of infection? Enhancement of

G7 p.384:120mm

a. a_____ p_____ p_____

annulus posterior portion

b. b_____ m_____

bone marrow

c. d_____ s_____

disc space

58. What is the CT triad of infection?

G7 p.384:160mm

a. e_____ p_____ f_____

end plate fragmentation

b. p_____ s_____

paravertebral swelling

c. p_____ a_____

paravertebral abscess

59. Complete the following regarding discitis:

G7 p.385:70mm

a. Cultures are positive

     i. from disc space in _____%.

60%

     ii. from blood in _____%.

50%

b. The usual pathogen is_____.

Staphylococcus aureus

c. Special staining is required to detect _____.

TB in all cases

60. Complete the following about discitis:

G7 p.386:100mm

a. In children discitis manifests itself by the child refusing to_____ or _____ or_____.

walk or stand or sit

b. Postop discitis is suggested when the

     i. Erythrocyte sedimentation rate (ESR) is raised in infection to above _____ and does not come down.

20 mm/hour

G7 p.387:90mm

     ii. CRP reactive protein above _____mg/L at_____ weeks postop.

10; 2

c. Interval between surgery and radiological changes in discitis

G7 p.387:135mm

     i. plain x-rays_____ weeks

12 (1 to 8 months range)

     ii. polytomography_____ weeks

3 to 8

61. The empiric antibiotic treatment for postop discitis is

G7 p.388:30mm

a. v_____

vancomycin

b. r_____

rifampin

c. C_____

Ceftizox