1. Overview of Neurosurgical
patient management

2. Brain
 대뇌 (Cerebrum)
 소뇌 (Cerebellum)
 뇌간 (Brain Stem)
 변연계 (Limbic System)

3. Brain cortex

5. 전두엽 일차운동영역

6. 전두엽 일차운동영역

7. 전두엽
일차운동영역의 분포

8. 전두엽 전운동영역

9. 전두엽 전운동안구영역

10. 두정엽 일차 체성감각영역
체감각연합영역
삼차연합영역

11. 후두엽
일차 시각영역
시각연합영역

12. 측두엽
청각수용영역
Wernicke 영역

13. Diagnostic approach of
dysphasia
 Content
 Fluency
 Comprehension
 Expression
 Repetition

14. Dysphasia
 Broca’s aphasia
 Wernicke’s aphasia
 Global aphasia
 Conductive aphasia

16. Skull

18. Cranial N.
 Cbr: 1,2
 Midbrain:3,4
 Pons:5,6,7,8
 Medulla
oblongata:9,10,11,12

19. Intracranial artery

20. Diagnostic Tool
 Indications of use of CT
`Hounsfield number(Bone>>> lipid>air)
`fisrt line in evaluation of a change in mental status
`Test of choice for those with implantable devices
`shows acute and sub acute blood(ICH/SAH,SDH)
`Bony abnormalities,i.e Trauma or Fracture
`Edema/mass effect
`Abnormalities in size and shape of structures
(brain atrophy,gyri effacement with swelling)
`Hydrocephalus
`Ischemic stroke

21. Diagnostic Tool
 Indications of use of MRI
`Use with caution with people with claustrophobia,implantable
devices or programmable shunts
`Provide better soft tissue differentiation than CT
`Tumor
`Abscess
`Edema/mass effect
`Stroke
`Hydrocephalus
`Stereotactic surgical planning

22. Plane

23. Plane

24. Plane

25. Plane

26. How things appear on a CT
 Acute blood/Calcifications -White
 Chronic blood collection -Low density
black to gray as increasing density
 CSF/Air-Black
 White matter- Less dense than gray matter
 Ischemia-lower density and therefore will be
darker and may not appear for 12hours

28. Types of MRI
 Gadilinium enhancement(tumor/infection)
 T1/T2
 Diffusion- can assess an acute infarct within the last 2 weeks
 MRV-Assess patency,stenosis or occlusion of the venous system
 MRA
 Flair/Echo gradient-Similar studies(Echo gradient may see a smaller
bleed clearer
 Functional MRI-Asked to do sensory,motor and cognitive tasks.
Shows increasing signals with cerebral activity

29. MRI overview (T1/T2)
 T1
CSF appears black
White matter brighter than gray matter
 T2
CSF apperars white

34. Tumor??

35. Pneumocephalus

36. Meningioma

37. Meningioma

38. Hydrocephalus

39. Basal ganglia ICH
Thalamic ICH

40. Lt.F infarction
(Broca area)

41. Rt.Cbll infarction

42. Pontine ICH

43. Lt.MCA infarction
SAH
(Subarachnoid hemorrhage)

44. CT angiography

45. Trauma

46. Chronic SDH

48. EDH c skull Fx.

49. T12 bursting Fx.

50. Brain death(Reversal sign)

51. Orbital wall Fx.

52. Spine

53. Cord

54. Dermatome

55. Compression Fx.(L1)

56. HNP

57. Spinal stenosis

58. Spondylolysis

59. Spine
injury

60. Spinal cord injury
 Methylprednisolone(Within 8hrs)
1.concentration:62.5mg/ml
2.bolus:30mg/kg initial bolus over
15minutes
3.followed by a 45 minutes pause
4.maintenance:then 5.4 mg/kg/hr
if<3hrs:23hrs, >3~8hrs:47hrs

61. Spinal cord injury
(Frankel Scale)
Grade Description
1(A) complete motor and sensory paralysis below lesion
2(B) Complete motor paralysis,but some residual sensory
perception below lesion
3(C) Residual motor function,but of no practical use
4(D) Useful but subnormal motor function below lesion
5(E) normal

62. Glasgow coma scale(≥4yrs)
Points Eye opening verbal motor
6 - - obeys
5 - oriented Localizes pain
4 Spontaneou Confused Withdrawals to pain
s
3 To speech Inappropriate Flexion
2 To pain Incomprehesible Extenson
1 None None none

63. Glasgow coma scale(≤4yrs)
Points Eye opening verbal motor
6 - - obeys
5 - Smile,interact Localizes pain
s
4 Spontaneous Consolable , Withdrawals to
inappropriate pain
3 To speech moaning Flexion
2 To pain Inconsolable, Extenson
restless
1 None None none

65. Alteration in consciousness
 Alert
 Confusion
 Obtundation
 Drowsy(Lethargy)
 Stupor
 Coma

66. Vegetative state
 Preservation of autonomic function and
primitive reflex.
 No meaingful interaction for external
stimuli.

67. Locked in syndrome
 A state quadriplegia with preservation of
cognition
 Consciousness,vertical eye
movements,eyelid blinking
 Destructive lesions in the ventral pons or
ventral midbrain
 Reemergence of horizontal movement
(within 4weeks):Predictive of improved
recovery

68.  Convulsion(Involuntary jerky
movement)
 Seizure(with epileptic discharge,
episodic event,LOC,EBD,drooling
etc.drug,Uremia, encephalopathy)
 Epilepsy(recurrent,chronic)

69. Muscle strength
Grade Strength
0 No contraction
1 Flickering
2 Movement with gravity eliminated
3 Movement against gravity
4 Against resistance(4-,4 ,4+)
5 normal

70. Muscle tone
 Hypotonia
 Flaccidity
 Spasticity( 강직 ):clasp-knife
 Rigidity( 경직 ):Cogwheel ridigity,lead
pipe rigidity

71. CSF pathway

72. CSF dynamics
 1500 cc intracranial space
-140cc(ventricle:23cc,spinal:30cc,
cistern:87cc)
V(CSF)+V(blood)+V(brain)=constant
;Monro-kellie doctrine
 Pressure
60~180 mmH2O(lateral)
200~350 mmH2O(sitting)

73. Cushing’s response
 Hypertension
 Bradycardia
 Irregular respiration

74. Theapeutic modalities for the
reduction of ICP
 CSF vol.
-Acetazolamide,steroid,EVD
 Blood vol.
-Hyperventilation,head elevation,
 Brain vol.
-Osmotic agents,diuretics,
 Surgical decompression

75. Lumbar tapping
 Contra Ix.
-skin infection
-IICP
-Degenerative spondylosis
-bleeding tendency

76. IICP precipitating factor
 Hypercapnia(Paco2>45mmHg)
 Hypoxemia(PaO2<50mmHg)
 Respirtory
procedure(Suction,PEEP,ambu
bagging)
 Position(angulation)
 Valsalva maneuver
 Anxiety,coughing,

77. Cranial N.
I. Olfactory 냄새
II. Optic 시력 , 시야 , 동공대광반사
III. Oculomotor 안구운동 , 동공대광반사
IV. Trochlear 안구운동 ( 하외전 )
V. Trigeminal 안면감각 , 각막반사 , 저작운동
VI. Abducens 안구운동 ( 측방 )
VII. Facial 안면근육운동
VIII. Vestibularcochlear 듣기 , 균형
IX. Glossopharyngeal 구토반사 , 소리내기
X. Vagus 연구개운동 ,
XI. Accessory 머리돌리기 , 어깨움추리기
XII. Hypoglossal 혀내밀기

78. Bell’s palsy

79. Facial weakness
H-B(House-Brackmann grade)
Grade Description
1 Normal function in all areas
2 Slight weakness on close inspection
3 Obvious but not disfiguring
4 Obvious weakness and/or disfiguring
asymmetry
5 Barely perceptible motion
6 No movement

80. Bell’s palsy

81. Ocular movement

82. Disorder of gaze

83. Ischemic CVD
 TIA(transient ischemic attack):24 시간이내에 full
recovery.30% 환자에서 한달이내에 뇌경색
 RIND(Reversible ischemic neurologic deficit):3 주이
내 회복
 Progressive stroke:ischemic cerebral edema
 Completed stroke

84. Ischemic CVD
 Atherothrombotic infarction
 Embolic infarction(Atrial fibrillation)
 Lacunar infarction
 Hemodynamic infarction

85. Acute medical management of
ischemic stroke
 Effective therapy for stroke
-Reduce degree of ischemic change
-Minimize effect of reperfusion injury
*penumbra:
Target of
neuroprotective therapy

86. Thrombolytic agents
 Plasminogen to plasmin
 Degradation of fibrin
 Canal recanalization
* t-PA:only drug approved by FDA

87. t- PA administration
 Inclusion
-18yr older
-Signs of measurable neurological deficit
-Onset≤3hrs

88. t- PA administration
 Exclusion
-Hemorrhage
 ICH,SAH,active internal bleeding
 Platelet count<100,000/mm 3
 Heparin within48hrs,PT>15sec
 Recent lumbar or arterial puncture
 GI bleeding within 21 days

89. t- PA administration
 Exclusion
-Minor or rapidly improving symptoms
-Uncontrolled HTN (SBP>180,DBP<110)
-abnormal blood glucose(<50 or >400)
-Post myocardial infarction
-Seizure at time stroke onset

90. t- PA administration
 Monitor BP every 15min for 2hrs
 Recommneded goal of BP
-less than 185/100
 Aggressive blood pressure reduction
might precipitate further ischemic injury

91. Pain-sensitive structure
 Venous sinuses
 Cortical veins
 Artery
 Dura mater
 Scalp vessels and muscle

92. Classfication(Headache)
 Sinusits
 Migrane
 Cluster headache
 Post traumatic
 Drug-induced HA
 Menigitis
 Hydrocephalus
 Tension HA
 Cervicalgia
 Hemorrhage

93. History taking
 Character,site,mode of onset
 Frequently duration
 Timing
 Associated symptoms
 Precipitating factors

94. Meningeal irritation sign
 Photophobia
 Neck and back pain
 Brudzinski’s sign