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The pons and cere- bellum cheap 17.5mg nicotinell fast delivery quit smoking zap, considered together order 35 mg nicotinell amex quit smoking 70 days, are the third most common site for hypertensive hemorrhage trusted 52.5mg nicotinell quit smoking 5 as, after the putamen/external capsule (first) and the thalamus (second) cheap 52.5mg nicotinell free shipping quit smoking kaiser. Initially, but for a very short time, a parenchy- sociated vasogenic edema and mass effect in the acute stage. The mal hemorrhage contains oxygenated hemoglobin and is seen as a third patient illustrates a subacute, extracellular methemoglobin fluid collection, with slight hyperintensity on a T2-weighted scan. There is a small amount of associated vaso- rim, with low signal intensity, already present on the T2-weighted genic edema and marked mass effect upon the right lateral ventricle. This large, acute, left external capsule hema- case emphasizes the importance of looking for the cause of a hem- toma evolves from a fluid collection containing deoxyhemoglobin orrhage, as the post-contrast scan reveals the associated enhancing (white asterisk, with low signal intensity on T2-weighted scans), to metastasis (black arrows). One arachnoid hemorrhage due either to a time delay (a few key to the recognition of parenchymal hemorrhage, not days) between the hemorrhage and imaging or the small discussed in detail, is the presence of edema surrounding quantity of blood present. Depending on the amount of blood however not specific for subarachnoid hemorrhage, and 1 Brain 29 of methemoglobin. By 3 days following presentation, high signal intensity is commonly seen on T1-weighted scans, a finding that typically persists for days to weeks. High signal intensity Superficial Siderosis on both T1- and T2-weighted scans is consistent with extracellular methemoglobin, in this late subacute hypertensive hemorrhage. The cause is recurrent subarachnoid hemorrhage, typi- cally due to a hemorrhagic neoplasm, ruptured aneurysm, or vascular malformation that has bled. The surface of the can be seen in any disease process that leads to a subtle cerebellum is the most common site (Fig. Meningitis symptoms occur rarely, and only when there is substan- produces this appearance, with administration of 100% O2 tial deposition of hemosiderin. Possible symptoms include in anesthetized ventilated patients another known cause. Any sequence that improves the sensitivity to specific for acute subarachnoid hemorrhage (Fig. On initial inspection, the T2-weighted scan appears normal (other than a small external capsule chronic lacunar infarct). There are three com- mon locations (given in order from the most to the least common, which also parallels the degree of severity of the injury from least to most): the gray–white matter junc- tion, the corpus callosum (splenium), and the brainstem (Fig. Most commonly these involve the frontal cerebellar folia, due to superficial hemosiderin deposition from re- lobe. Suscep- tibility weighted imaging offers a further improvement in sensitivity to T2* effects, and in cases with hemorrhage ■ Trauma will demonstrate more extensive injury. A cortical contusion is simply a bruise of This injury and the subsequently described injury of the the brain’s surface. The inferofrontal and anteroinferior brainstem are usually not seen in isolation but with ex- temporal portions of these two lobes of the brain are par- tensive shear injury at the gray–white matter junction. The term “coup” is used to the brainstem, lesions are seen most often in the pons and reference an injury that lies directly beneath the area of the dorsolateral midbrain. The term “contrecoup” is used for an injury that very poor prognosis, often with a fatal outcome. High veloc- ity contusion injuries are illustrated in two dif- ferent patients, showing characteristic areas of the brain involved. In the first, there is a large hemorrhagic contusion, with the area of hem- orrhage surrounded by low density (edema), overlying the right petrous apex. In the second patient, low-density regions are noted in the low frontal lobes bilaterally, cor- responding to nonhemorrhagic parenchymal contusions. Encephalomalacia, with both gliosis and cystic changes, will be seen in areas of prior contusion. Epidural Hematoma The dura is the periosteum of the inner table, and is strongly adherent to the skull. An epidural hematoma accumulates between the inner table of the skull and the dura, and is typically due to a skull fracture with lac- eration of a blood vessel. The most common location is temporal/parietal, due to laceration of the middle men- ingeal artery. Less common are posterior fossa lesions, due to an occipital skull fracture with secondary lacer- ation of the transverse sinus. In 50% of cases there will be an intervening lucid interval after the initial trauma, with subsequent rapid progressive deterioration. The imaging appearance is that of a biconvex, elliptical fluid collection, which can cross the midline (falx) and the ten- torium, with the venous sinuses displaced away from the skull (Fig. Note also the extracranial soft tissue brain injuries, as well as subacute hemorrhage. Edema (high signal intensity) of the splenium of the corpus callosum reveals edema therein and petechial hemorrhage (low signal intensity) are seen on T2- (black arrow), a less frequent and more clinically significant in- weighted scans at the gray–white matter junction of the fron- jury. A large, extra-axial, high-density fluid collection (acute hemorrhage) is seen on the right, overlying the temporal and parietal lobes (part 1). On the image win- dowed for bone, an underlying, mini- mally displaced, skull fracture (small white arrow) is noted. In a second pa- tient (part 2), a smaller epidural he- matoma is noted overlying the right frontal lobe (large black arrow). With some chronic subdural hematomas there may be sufficient resorption of blood products to make differentiation from a hygroma, on the Subdural Hematoma basis of signal intensity, difficult. Findings include skull fractures, sub- intracellular methemoglobin to extracellular methemo- dural hematomas, and contusions. Otherwise, children in whom this entity is tually remove the blood products therein. Territorial infarcts and/or global hypoxic hypointense with brain on T1-weighted images, with high injury may also be present. A subdural hygroma, T2*-weighted scans is in part for the detection of chronic 1 Brain 33 Fig. A small subdural hematoma is seen on the right, with a much larger subdural hematoma on the left. The large subdural hema- toma exhibits many adhesions, best seen on the T2*-weighted gradient echo scan, important information to communicate to the neurosurgeon since drainage will likely require lysis of these adhesions. The ipsilateral ventricle will be compressed and displaced toward the Penetrating Injuries midline. The herniated anterior cerebral artery In addition to the defecThat the entry site, there may be can also be compressed against the free margin of the extensive skull fractures. The location of metal fragments falx, and thus occluded with subsequent infarction of the from the bullet will be readily evident. Parenchymal hemorrhage is almost always pres- Descending transtentorial herniation is the second ent and subdural hematomas common. The uncus of the temporal lobe will be ■ Herniation displaced medially and encroach upon the suprasellar cistern. On imaging, both the ipsilateral ambient cistern Subfalcine herniation is the most common brain hernia- (which lies lateral to the midbrain) and lateral portion tion, and is caused by a supratentorial mass on one side of the prepontine cistern may be widened. Herniation of brain mass effect, the uncus and hippocampus can both herniate occurs across the midline under the inferior or “free” through the tentorial incisura. There are subdural hematomas of four differ- ent time frames (numbered 1 to 4, each with a characteristic signal intensity) in this infant, a pathognomic appearance for nonaccidental trauma.

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Failure of the heart rate to rise above Guidelines for Chest Compressions 80 beats/min is an indication for chest compres- Indications for chest compressions are a heart rate sions discount 35mg nicotinell with visa quit smoking banner. Indications for endotracheal intubation that is less than 60 beats/min or 60–80 beats/min include inefective or prolonged mask ventilation and not rising afer 30 s of adequate ventilation with and the need to administer medications order nicotinell 35mg on line quit smoking techniques. Intubation ( Figure 41–6) is performed with a Cardiac compressions should be provided Miller 00 generic 17.5 mg nicotinell overnight delivery quit smoking you fool, 0 cheap nicotinell 35 mg on line quit smoking results timeline, or 1 laryngoscope blade, using a 2. Correct ferred because it appears to generate higher endotracheal tube size is indicated by a small leak peak systolic and coronary perfusion pressures. Right endobronchial Alternatively, the two-fnger technique can be used intubation should be excluded by chest ausculta- (Figure 41–8). The correct depth of the endotracheal tube be approximately one third of the anterior–poste- (“tip to lip”) is usually 6 cm plus the weight in kilo- rior diameter of the chest and enough to generate grams. Compressions should be interposed with venti- Capnography is also very useful in confrming lation in a 3:1 ratio, such that 90 compressions and endotracheal intubation. The heart rate sensors are useful for measuring tissue oxygenation should be checked periodically. Less common causes of hypotension include hypocalce- mia, hypermagnesemia, and hypoglycemia. Epinephrine may chest compressions: two fingers are placed on the lower be given in 1 mL of saline via the endotracheal tube third of the sternum at right angles to the chest. The tip of the catheter should be just below precipitated in babies of mothers who chronically skin level and allow free backfow of blood; further consume prescribed or illicit opioids. Other Drugs even the endotracheal tube can be used as an alter- Other drugs may be indicated only in specifc nate route for drug administration. Sodium bicarbonate (2 mEq/kg of a Cannulation of one of the two umbilical arteries 0. It may also be administered during continuous Pa o or oxygen saturation monitoring as prolonged resuscitation (>5 min)—particularly if 2 well as blood pressure. The infusion rate should not exceed 1 mEq/kg/min to avoid hypertonicity and intracranial hemorrhage. Volume Resuscitation As noted above, in order to prevent hypertonicity- Some neonates at term and nearly two thirds of induced hepatic injury, the umbilical vein catheter premature infants requiring resuscitation are hypo- tip should not be in the liver. Diagnosis is based on physical 100 mg/kg (CaCl2, 30 mg/kg) should be given only examination (low blood pressure and pallor) and a to neonates with documented hypocalcemia or poor response to resuscitation. Neonatal blood pres- those with suspected magnesium intoxication (from sure generally correlates with intravascular volume maternal magnesium therapy); these neonates are and should therefore routinely be measured. Normal usually hypotensive, hypotonic, and appear vasodi- blood pressure depends on birth weight and varies lated. Glucose (8 mg/kg/min of a 10% solution) is from 50/25 mm Hg for neonates weighing 1–2 kg to given only for documented hypoglycemia because 70/40 mm Hg for those weighing over 3 kg. A low hyperglycemia worsens hypoxic neurological def- blood pressure suggests hypovolemia. Dopamine may be started at 5 mcg/kg/min limiting both insufflation pressure and duration of to support arterial blood pressure. Long- may be given through the endotracheal tube to pre- term detrimental effects relate to possible terato- mature neonates with respiratory distress syndrome. Three stages of susceptibility are generally Appendicitis in a Pregnant Woman recognized. In the first 2 weeks of intrauterine life, A 31-year-old woman with a 24-week gestation teratogens have either a lethal effect or no effect presents for an appendectomy. The third to eighth weeks are the How does pregnancy complicate the most critical period, when organogenesis takes management of this patient? From the Nearly 1–2% of pregnant patients require sur- eighth week onward, organogenesis is complete, gery during their pregnancy. Teratogen exposure procedure during the first trimester is laparoscopy; during this last period usually results in only minor appendectomy (1:1500 pregnancies) and chole- morphological abnormalities but can produce sig- cystectomy (1:2000–10,000 pregnancies) are the nificant physiological abnormalities and growth most commonly performed general surgical proce- retardation. Cervical cerclage may be necessary in some of anesthetic agents have been extensively studied patients for cervical incompetence. The physiologi- in animals, retrospective human studies have been cal effects of pregnancy can alter the manifestations inconclusive. Past concerns about possible terato- of disease process and make diagnosis difficult. The physiological changes to all anesthetic agents should be kept to a minimum associated with pregnancy (see Chapter 40) further in terms of the total number of agents, dosage, and predispose the patient to increased morbidity and duration of exposure. Moreover, both the operation and the those agents that are required—and in our practice, anesthesia can adversely affect the fetus. What would be the ideal anesthetic technique The procedure can have both immediate in this patient? Maternal hypotension, hypovolemia, severe ane- Toward the end of the second trimester (after mia, hypoxemia, and marked increases in sympa- 20–24 weeks of gestation), most of the major thetic tone can seriously compromise the transfer physiological changes associated with pregnancy of oxygen and other nutrients across the uteropla- have taken place. Regional anesthesia, when fea- cental circulation and promote intrauterine fetal sible, is preferable to general anesthesia in order asphyxia. The stress of the operative procedure to decrease the risks of pulmonary aspiration and and the underlying process may also precipitate failed intubation and to minimize drug exposure preterm labor, which often follows intraabdomi- to the fetus. On the immature liver of the fetus may have a limited abil- other hand, general anesthesia guarantees patient ity to metabolize the cyanide breakdown product. Elective use of circulatory arrest dur- of a halogenated anesthetic is reported to reduce ing pregnancy is not recommended. Spinal anesthesia is usually satis- Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary factory for open appendectomies, whereas gen- Resuscitation and Emergency Cardiovascular Care. A prospective regular organized uterine activity is detected, early cohort study: Maternal intrapartum temperature. Magnesium Loubert C, Hinova A, Fernando R: Update on modern sulfate and oral or rectal indomethacin may also be neuraxial analgesia in labour: A review of the used as tocolytics. Controlled (deliberate) hypotensive Toledo P: What’s new in obstetric anesthesia: The 2011 anesthesia has been utilized to reduce blood loss Gerard W. Int J Obstet Anesth during extensive cancer operations; nitroprusside, 2012;21:68. The associated with delayed awakening from combination of these two characteristics anesthesia, cardiac irritability, respiratory promotes chest wall collapse during depression, increased pulmonary vascular inspiration and relatively low residual lung resistance, and altered drug responses. These anatomic features make halogenated agents is greater in infants neonates and infants obligate nasal breathers than in neonates and adults. A programmable infusion 8 pump or a buret with a microdrip chamber Unlike adults, children may have profound is useful for accurate measurements. Drugs bradycardia and sinus node arrest following can be flushed through low dead-space the first dose of succinylcholine without tubing to minimize unnecessary fluid atropine pretreatment.

Changes of signal intensity are absent in the ad- as rims of hypointensive signal on T2-weighted images or on jacent structures generic 17.5 mg nicotinell with amex quit smoking government programs. Tere is an opinion that cases of acquired diabetes in- sipidus may be a result of viral infection of the supraoptic and Saccular aneurysms in the chiasmal–sellar region may origi- the paraventricular nuclei of the hypothalamus (Daughaday nate from the cavernous segment of the internal carotid ar- 1985) generic 52.5mg nicotinell otc quit smoking encouraging words. Tuberculosis and syphilis that were frequently encoun- tery as well as from its supraclinoid segment of it order 35 mg nicotinell overnight delivery quit smoking banner. Sometimes tered in the chiasmal–sellar region in the past due to high aneurysms of the anterior and posterior communicating and incidence in the common population are now rare nicotinell 52.5 mg discount quit smoking 40. Diferential diagnosis should be made abscesses of the parasellar region have been followed-up in from tumours of the chiasmal–sellar region. Т2-weighted image (а) and Т1-weighted image (b) in the sagittal plane reveal the arachnoid cyst of the suprasellar region, which deforms adjacent brain structures. Giant saccular aneurysm of the sellar and suprasellar region is seen 608 Chapter 6 Fig. Т2-weighted imag- ing (а,b) reveals a signal void efect and the pulsatile artefact of blood fow in the phase-encoding direction typical for saccular aneurysm. A signal-void efect typical for saccular aneurysm is seen on the medial wall of the siphon of the internal carotid artery. Т2-weighted image (а) and the relationship between the functioning part of the aneurysm and Т1-weighted image (b). Direct angiogram clearly identifes a large functioning aneurysm (h) 612 Chapter 6 Fig. The most common clinical mani- is usually seen during late pregnancy or the postnatal period. Females complain of headache, ment is seen on periphery, and the hypointensive area remains memory loss, postnatal amenorrhea, lactation impairment, or in the centre (Fig. Brain base meninges and menin- Sarcoidosis is a chronic polysystemic infammatory disor- ges covering the suprasellar cistern are sensitive to tubercu- der of unknown aetiology. Parasitic are most frequently afected, which are followed by the skin cysts may also be situated in the cistern, especially cysticer- and eyes. Tis disorder afects both sexes and may thrombosis is a dangerous complication of periorbital or the be seen a little more frequently in females than in males. Involvement of the hypo- Mucocele is a mass lesion located in the paranasal sinuses thalamic–pituitary system is usually manifested by diabetes (Delfni 1993). If located in the sphenoidal sinus the diferen- insipidus, or by defciency of a single or many other hormones tial diagnosis should be made from tumours of the chiasmal– of the anterior part of the pituitary. It is seen in children younger than 10 years but the disease completely depend on the afected site. Tis disorder tion of mucus developing afer occlusion of a sinus, usually usually responds well steroid treatment. If the content of muco- and the bottom of the third ventricle, and thickening and de- cele is infected, it is then called a mucopyocele. Frequently it is the sphenoid sinus, which may marked- which is why precise diferential diagnosis is difcult, unless ly enlarge in size. In our observations, mucocele had hyperintensive signal on Tolosa-Hunt syndrome is an idiopathic infammatory dis- T1- and T2-weighted images, which was probably connected order of the cavernous sinus. Its clinical manifestations are with high protein level and elements of blood decay in its con- prominent retro-orbital pain, and neuropathies of the third, tent (Fig. The sphenoid bone is flled with a hypodensive structure, with elements of partial bone de- struction of the lateral walls. Abnormal hyperintensity is seen in the lef half of the sphenoidal sinus due to high protein content in the cyst ffh cranial nerve, with less frequent involvement of the optic pseudotumour in aetiology (Yousem et al. The disor- nerve and the sympathetic ganglions around the cavernous der is responsive to steroid therapy. Symptoms may persist of Tolosa-Hunt syndrome should be made from sarcoidosis, for several days or weeks both, with spontaneous remissions meningioma, lymphoma, metastasis into the cavernous sinus, and relapsing. The expansion of changes onto the apex of the orbit is hypophysis is revealed, and if a haemorrhage is present, then seen, which suggests the similarity of this syndrome to orbital the picture resembles that of infarction of the pituitary. Ann Ophthalmol 10:1161–1168 Neurosurg 100:33–40 Carmel P (1985) The empty sella syndrome. In: Wilkins R, Reganchary Konovalov A, Kornienko V, Ozerova V, Krasnova T (1983) Modern S (eds) Neurosurgery. Vestn Rentgenol Ra- diol 3:5–12 (in Russian) Carmel P, Antunes J, Chang C (1982) Craniopharyngiomas in chil- dren. J Neuro- Konovalov A, Kornienko V, Pronin I (1997) Magnetic-resonance to- surg 74:230–235 mography in neurosurgery clinics. Vidar, Moscow (in Russian) Daningue J, Wilson C (1977) Pituitary abscesses: report of 7 cases Konovalov A, Kornienko V, Qzerova V, Pronin I (2001) Pediatric and review of the literature. Willian’s textbook of Kovacs K, Horvath E, Asa S (1985) Classifcation and pathology of endocrinology. Raven, New York 32:901-906 Kwan E, Wolpert S, Hedges T (1987) Tolosa-Hunt syndrome revis- Dietrich R et al. Neurosurgery 30:173–179 616 Chapter 6 Russell D, Rubinstein L (1989) Pathology of tumours of the nervous Tatler G, Kendall B (1991) The radiological diagnosis of epidermoid system, 5th edn. J Neurosurg 74:535–544 Scott T (1993) Neurosarcoidosis: progress and clinical aspects. Neu- Wester K (1992) Gender distribution and sidedness of middle fossa rology 43:8–12 arachnoid cysts: a review of cases diagnosed with computed im- Selosse P, Mahler M, Klaes R (1980) Pituitary abscess: report. J Comput Assist Tomogr 11:236–241 pituitary necrosis of the anterior lobe of the pituitary gland. Up to 20% of intracranial metastases seen in adults are in the posterior fossa (Lizak and Woodruf 1992; Lavaroni 1993). Infants (children younger than 1 year of age) life, with predomination in boys (2:1 to 4:1). Medulloblastoma are the exception, in whom supratentorial tumours predomi- is a rapidly growing tumour—clinical manifestations devel- nate. The highest frequency of posterior fossa tumours is seen op within several weeks, and rarely, over more than several between 2 and 5 years of age (>60%). Two histo- mours of the cerebellar hemispheres and brainstem; the tu- logical variants are distinguished, medulloblastomas of “clas- mours of the fourth ventricle rank in third place, and then sic” structure and desmoplastic medulloblastomas. The latter follow meningeal tumours, and tumours of cranial nerves and are related to mesenchymal tumours and were called “cere- of skull base structures (Gusnard 1990; Bilanuik 1990; Atlas bellar sarcoma” up until the 1970s. Metastases of medullo- represented by glial tumours of various tissue diferentiations. Primary neuroectodermal tumours are sec- cistern and basal surface of the frontal lobes (Meyers et al.