PIC (?)
Ny. X, 54 tahun dibawa ke UGD setelah jatuh pingsan saat bekerja . Dia tersadar dan dapat
berkomunikasi, dg sakit kepala berat, fotopobia, nuchal kaku dan pandangan buram. CT atas otak mengungkapkan adanya darah subaraknoid menyebar pada cistern basal, Hidrosepalus ringan dan tidak tampak hematoma intraparenkimal. Angiogram pasien di bawah ini (utk soal 1-5):
- GRADE HUNT dan HESS klinis berapa pasien ini?
A. Gr I C. Gr III E. Gr V
B. Gr II D. Gr IV
B
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs.
- Beberapa aneurisma arteri komunikan posterior (PComA) tidak menimbulkan defisit saraf ketiga manapun. Mengapa perlu diberikan perhatian khusus kepada angiogram untuk kasus-kasus ini?
A. Jika aneurisme memproyeksi lebih secara posterolateral alih-alih pada posisi medial yanglebih lazim, ada peningkatan risiko cedera pembuluh-pembuluh perforasi dari PComA selama mikrosiseksi.
B. Sebuah aneurisma yang terproyeksi secara lateral kepada tepi tengah lobe temporal akan melawan retraksi prematur dari lobe temporal.
C. Angiogram ini mungkin saja lebih mengungkapkan aneurisma dinding karotid ventral alih-alih luka pada PcomA, yang sering lebih baik jika dikelola dengan perawatan.
D. Untuk mencari aneurisma lainnya dan/atau vasospasma terkait.
E. Mungkin dapat membantu rencana bedah, karena luka yang terproyeksi secara medial akan lebih baik didekati melalui Segitiga karotid-okulomotor.
B
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[
- Pasien kemudian dibawa ke ruang bedah untuk kliping aneurisme. Kontrol terhadap bagian proksimal dan distal arteri karotis interna diperoleh dengan penempatan klip sementara sebelum diseksi leher aneurismal. Meskipun demikian, tetap terjadi ruptur saat dilakukan mikrodiseksi pada aneurisma dan terjadi perdarahan yang cukup banyak, sehingga menghalangi
pandangan. Tindakan preventif apa yang sebaiknya dilakukan saat sebelum terjadinya
ruptur agar jumlah perdarahan selama operasi berkurang ?
A. Mikrodiseksi bedah tumpul
B. Dapatkan kontrol dekat atas arteri karotid dalam di leher.
C. Lepaskan kubah aneurisma dari lobe temporal sebelum penempatan penjepit sementara untuk mencegah retaknya fundus.
D. Sedapat mungkin pastikan arteri komunikasi posterior medial dari arteri karotid interna untuk menempatkan penjepit sementara
E. Penempatan penjepit sementara pada arteri optalamik untuk mencegah pendarahan balik dari orbit.
D
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs.
- Pasca bedah, pasien sadar dalam kontralateral parese dan parestesi dan hemianopsia homonim. CT scan otak menunjukkan infark pada bagian belakang kapsul interna dan substansia alba di dekatnya (di atas kornu temporalis ventrikel lateral), Komplikasi ini kemungkinan bisa dihindari dengan :
A. Memastikan terlebih dahulu arteri koroidal sebelum penjepitan aneurismal untuk mencegah kerusakan atau menyatunya pembuluh ini ke dalam konstruk penjepit
B. Meningkatkan waktu oklusi sementara untuk mencegah mikrodiseksi yang tergesa-gesa.
C. Membatasi diseksi celah sylvian sampai ke bagian spenoidal untuk mencegah adanya diseksi yang tidak perlu di dekat perforator arteri PcomA, yang memasok batang tubuh belakang kapsul internal,
D. Mendapatkan angiogram pasca-bedah untuk meyakinkan kembali apakah penempatan penjepit sudah benar.
E. Memastikan dan mempertahankan arteri balik Heubner.
A
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs.
- Pasca-bedah, pasien menderita kerusakan pada cabang frontal nervus fasialis. Manakah yang menjadi penyebabpaling mungkin dari cedera cabang frontal nervus fasialis ini ?
A. Saraf supraorbital tidak dipastikan saat mengangkat kulit kepala dari rim supraorbital.
B. Insisi dimulai dengan jarak kurang dari satu cm ke sebelah depan tragus
C. Ada neuropraksia saraf karena robekan pasca-bedah.
D. Saraf pada bantalan lemak subgaleal cedera selama diseksi bedah.
E. Saraf antara lapisan luar dan dalam dari faskia temporalis cedera dengan monopolar cautery.
D
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs.
Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:
- Diagnosis mana yang paling mungkin?
A. Sindroma celah orbital atas
B. Meningioma incidental yang berasal dari aspek tengah dari tepi sphenoid
C. Fistula venus-arterial
D. Oklusi arteri karotid dalam di dekat origin arteri optalamik
E. Cavernous sinus thrombosis
C
Carotid-cavernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous types. They are direct shunts between the ICA or EC.-\ and cavernous sinus and usually occur after trauma or spontaneous aneurysmal rupture. Traumatic CCFs often present in a delated fashion: like spontaneous fistulas, they often present with retro-orbitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia
Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:
- Tanda-tanda / gejala-gejala dari proses penyakit ini hampir sepenuhnya tergantung
kepada:
A. Ukuran dan lokasi tumor dibandingkan dengan saraf optik
B. Arah drainase Venus dan kecepatan aliran darah melalui shunt
C. Sejauh mana reaksi peradangan di dekat cavernous sinus
D. Sejauh mana reaksi peradangan di dekat celah orbital atas
E. Sejauh mana aliran kolateral dari arteri karotid balik dan Pengumpan-pengumpan meningeal luar
B
Carotid-cavernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous types. They are direct shunts between the ICA or EC.-\ and cavernous sinus and usually occur after trauma or spontaneous aneurysmal rupture. Traumatic CCFs often present in a delated fashion: like spontaneous fistulas, they often present with retro-orbitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia
Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:
- Untuk pasien ini, pilihan terapi manakah yang seharusnya ditempuh?
A. Enam minggu pemberian antibiotika dan diikuti dengan angiografi ulangan
B. Embolisasi perekat dari Pengumpan-pengumpan arteri utama diikuti oleh reseksi tumor
C. Pembuangan arteri karotid
D. Embolisasi balon transarterial detachable
E. Infus heparin
D
Carotid-cavernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous types. They are direct shunts between the ICA or EC.-\ and cavernous sinus and usually occur after trauma or spontaneous aneurysmal rupture. Traumatic CCFs often present in a delated fashion: like spontaneous fistulas, they often present with retro-orbitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia
Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:
- Jika strategi terapi yang dikehendaki ternyata gagal, apakah pilihan terapi lainnya ?
- Debridemen bedah atas infeksi
- Paking bedah langsung atas cavernous sinus dengan Gelfoam, Surgicel, kawat platina, atau serat katun.
- Embolisasi perekat praoperasi yang dilanjutkan dengan reseksi tumor.
- Prosedur endovaskuler untuk membuang arteri karotid dalam.
C. 2 dan 4
Carotid-cavernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous types. They are direct shunts between the ICA or EC.-\ and cavernous sinus and usually occur after trauma or spontaneous aneurysmal rupture. Traumatic CCFs often present in a delated fashion: like spontaneous fistulas, they often present with retro-orbitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia
PIC (Dx: DAVF)
10. Temuan proses patologis apakah yang tampak pada angiogram di bawah ini dan perlu terapi segera?
A. Drainase Vena kortikal retrograde
B. Pengumpan artero meningeal majemuk
C. Pasokan arteri karotid dalam dan luar berganda
D. stroke embolik
E. Oklusi sinus Venus
A. Retrogade cortical venous drainage
The natural history of DAVF is variable and includes spontaneous resolution, recruitment of meningeal arterial feeders, and the development of intracranial hypertension. DAVF can present with pulsatile tinnitus, visual symptoms, papilledema, hydrocephalus, and intracranial hemorrhage. The presence of retrograde cortical venous drainage indicates the potential for intracranial hemorrhage and mandates urgent treatmen.t of the DAVF. Intracranial hemorrhage from a DAVF in the absence of retrograde cortical venous drainage has not been reported. Hemorrhage from a DAVF is associated with a high morbidity and mortality (approximately 30%). Ectatic dilation or venous occlusion of the invoked sinus, multiple or dual ICA/ECA arterial feeders, or embolic stroke, in the absence of retrograde cortical venous drainage has not been reported to increase hemorrhage rates of DA 'Fs ( Kaye and Black, pp. 1125-1135; Greenberg, p . 811; Youmans, p p . 2 1 7 1-2 173; Wilki ns, p p . 2523-2527).
Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
- Manuver bedah yang bisa menambah eksposure dari percabangan letak tinggi (high-riding) arteri karotid saat endarterektomi karotid meliputi semua hal di bawah ini, KECUALI
A. Mobilisasi medial dari servikalis ansa
B. Membagi perut belakang dari otot digastris
C. Osteotomi mandibular atau disartikulasi mandibel pada sendi temporomandibular
D. Judicious cautery dan lligasi pembuluh-pembuluh terpilih (arteri okipital, pembuluh wajah biasa) yang menghambat paparan
E. Diseksi trasversal kepala klavikular dari otot sternokleidomastoid pada setinggi tulang hyoid untuk memperoleh visualisasi yang lebih baik arteri karotid lateral dari vena jugular.
E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nerve at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprmement if flow is re-established within 4 5 minutes. For later-onset deficits, workup ( i.e . C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
- Saraf kranial mana yang paling berisiko terkena cedera pada saat mengekspose pencabangan letak tinggi (highriding) arteri karotid ?
A. VII B. IX C. X
D. XI E. XII
E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the jaw at the temporomandibular joint. This type oi exposure places the hypoglossal nerve at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprmement if flow is re-established within 4 5 minutes. For later-onset deficits, workup ( i.e . C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
13. Bagaimana urutan penempatan klem pada arteri selama endarektomi karotid? A. Luar, dalam, biasa B. Internal, Utama, Eksternal C. Luar, biasa, dalam D. Biasa, luar, dalam E. Biasa, dalam, luar
B
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the jaw at the temporomandibular joint. This type oi exposure places the hypoglossal nerve at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprmement if flow is re-established within 4 5 minutes. For later-onset deficits, workup ( i.e . C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
- Setelah penempatan klem dan arteriotomi, ahli bedah melihat pendarahan terus menerus dari dinding belakang arteri karotid, yang sangat mengganggu penglihatan selama prosedur bedah. Apakah dasar utama terjadinya pendarahan terus menerus ini ?
A. Pemasangan klem yang tidak tuntas terhadap arteri karotid biasa
B. Pendarahan balik dari arteri temporal permukaan
C. Pendarahan dari arteri asending paringeal
D. Pendarahan Venus dari adventitia arteri karotid dalam
E. Kelainan penebalan dari infuse heparin
C
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the jaw at the temporomandibular joint. This type oi exposure places the hypoglossal nerve at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprmement if flow is re-established within 4 5 minutes. For later-onset deficits, workup ( i.e . C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
- Saat diseksi di sekitar arteri karotid, akhli anestesi melihat bahwa pasien menjadi hipotensi dan bradikardia. Langkah pengelolaan selanjutnya yang perlu ditempuh adalah:
A. Dapatkan gas arterial intermedier (ABG) untuk memastikan apakah pasien menderita embolus pulmonaris.
B. Periksa enzim jantung, karena sepertinya pasien menderita infarksi dinding miokardial depan.
C. Persarafan sinus karotid (saraf Hering) perlu dianestesi dengan 0,5mL dari lidokain 2%.
D. Memulai dubotamin, periksa tekanan pembuluh vena pusat, dan dapatkan kadar laktat, karena pasien sepertinya mengalami deplesi volume laktat
E. Perlu dilakukan infuse 100 IU/kg heparin secara intravena untuk mencegah berlanjutnya emboli.
C
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
- Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.
Pasca-bedah, pasien terbangun dengan hemiplegia sisi kanan dan letargi. Langkah pengelolaan logis selanjutnya perlu mencakup:
A. Segera lakukan CT Angiografi untuk menilai kemantapan arteri karotid kanan
B. Segera lakukan angiografi selektif atas arteri karotid kanan
C. Lakukan terapi antiplatelet selama satu minggu, yang diikuti oleh angiografi ulangan
D. Tempatkan stent pada lokasi arteriotomi untuk memperkuat penutupannya
E. Segera lakukan reeksplorasi bedah untuk dilakukannya trombektomi
E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves VII, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .
Nn. X, 15 tahun menjalani reseksi tanpa komplikasi atas luka yang ditunjukan di bawah ini 4 hari kemudian dia menderita Letargi, demam, meningismus, dan fotopobia. Sampel cairan serebospinal (CSF) mengungkapkan kadar protein sebesar 86 mg/d (Rentang baku 12 - 60 mg/dL), gula darah 61 mg/dL (40 – 70 mg/dL), erytrosit 16/mL, dan lekosit 126/mL, dengan diferensial 11% netropil, 82% limposit dan 7% histiosit. Tes dan kultur grain dari CSF adalah steril dan tetap demikian untuk keberadaan organisme tersebut.
- Manakah yang menjadi riwayat lazim
masalah di atas?
A. Pemberian antibiotika selama 10 hari, meski pun kulturnya negatif karena perlunya mencegah spesies-spesies bakterial yang pertumbuhannya lambat
B. Pasien seringkali memerlukan terapi steroid yang dilanjutkan dengan lumbar puncture ulangan
C. Biasanya pulih dengan sendirinya dan tidak perlu perawatan
D. Setelah shunting, pasien biasanya menunjukkan pemulihan yang drastis
E. Biasanya akan segera pulih setelah materi sintetis apa pun selama pembedahan (misalnya, dural graft) diangkat kembali.
C Aseptic meningitis (AM) is a well-recognized complication after posterior fossa surgery but is typically self-limited and requires no treatment. It has generally been attributed to one or more irritants released into the subarachnoid space during surgery, including blood breakdown products, tumor, muscle, and brain . Lowering of i n tracranial pressure with lumbar puncture and dexamethasone is the mainstay of treatment in certain patients with continued, problems. Bacterial meningitis and postmeningitic syndrome are unlikely, considering that an organism was not isolated from the CSF, although this is not always the case. .\!orem•er. the CSF profile was more consistent with aseptic meningitis than bacterial meningitis. Hydrocephalus is unlike[,•. since fe,•er. meningismus, and photophobia rarely accompanv this diagnosis, and encephalitis would be very uncommon in this situation (Carmel et a l . , pp. 2 76-280; Youmans. pp. 3645, 3659; Kaye and Black, p . 868; Wilkins, p . 3965 ) 3227-3233).
Nn. X, 15 tahun menjalani reseksi tanpa komplikasi atas luka yang ditunjukan di bawah ini 4 hari kemudian dia menderita Letargi, demam, meningismus, dan fotopobia. Sampel cairan serebospinal (CSF) mengungkapkan kadar protein sebesar 86 mg/d (Rentang baku 12 - 60 mg/dL), gula darah 61 mg/dL (40 – 70 mg/dL), erytrosit 16/mL, dan lekosit 126/mL, dengan diferensial 11% netropil, 82% limposit dan 7% histiosit. Tes dan kultur grain dari CSF adalah steril dan tetap demikian untuk keberadaan organisme tersebut.
17. Diagnosis manakah yang paling mungkin? A. Meningitis bakterial B. Meningitis aseptic C. Hidrosepalus D. Sindroma pasca-meningitis E. Sinus petrosal atas
B Aseptic meningitis (AM) is a well-recognized complication after posterior fossa surgery but is typically self-limited and requires no treatment. It has generally been attributed to one or more irritants released into the subarachnoid space during surgery, including blood breakdown products, tumor, muscle, and brain . Lowering of i n tracranial pressure with lumbar puncture and dexamethasone is the mainstay of treatment in certain patients with continued, problems. Bacterial meningitis and postmeningitic syndrome are unlikely, considering that an organism was not isolated from the CSF, although this is not always the case. .\!orem•er. the CSF profile was more consistent with aseptic meningitis than bacterial meningitis. Hydrocephalus is unlike[,•. since fe,•er. meningismus, and photophobia rarely accompanv this diagnosis, and encephalitis would be very uncommon in this situation (Carmel et a l . , pp. 2 76-280; Youmans. pp. 3645, 3659; Kaye and Black, p . 868; Wilkins, p . 3965 )
- NY. X, 62 tahun menjalani dekompresi mikrovaskuler karena spasme hemifasial. Pasca-bedah, pasien menderita ketulian ipsilateral total tanpa adanya defisit neurologis lainnya Penyebab yg paling memungkinkan dari defisit ini adalah cederanya salah satu pembuluh darah berasal dari
A. Arteri serebral belakang (PCA)
B. Arteri serebelar Atas (SCA)
C. Arteri serebellar Inferior Anterior (AICA)
D. Arteri serebellar bawah belakang (PICA)
E. Arteri vertebral
C.
20. Remaja puteri usia 14 tahun dengan hilang penglihatan progresif pada mata kanan baru baru ini didiagnosis 2.0 x 3.5 cm Glioma saraf optik kanan yang menjalar ke kiasme optik. Selama pembedahan, porsi tumor pada saraf optik berhasil dibuang tetapi tumor di dekat kiasme optik dibiarkan. Berapa dosis maksimal radiosurgeri fraksi tunggal yang dapat dijalankan dengan aman kepada kiasme optik ini? A. 4 sampai dg 7 Gy B. 9 sampai dg 10 Gy C. 11 sampai dg 13 Gy D. 14 sampai dg 16 Gy E. 21 Gy
B.
The maximal safe dose of single-shot radiosurgery that the optic chiasm can tolerate is approximately 9 to 10 Gy (Alexander, p. 171).
- Seorang dokter akhli bedah memutuskan untuk menggunakan koridor supraselebelar infratentorial untuk mendekati massa daerah pineal. Pembuluh darah manakah yang seringkali diberi kauterisasi dan dibagi agar diperoleh paparan yang lebih baik atas permukaan belakang dari tumor selama pendekatan ini?
A. Pembuluh Galen
B. Pembuluh basal ipsilateral dari Rosenthal
C. Arteri serebral belakang (PCA)
D. Pembuluh serebelar pra-sentral
E. Sinus Petrosal Atas
D.
Cauterizing and dividing the precentral cerebellar vein will often expose the posterior surface of pineal region tumors. The veins of Galen and Rosenthal should be preserved during this operation , as well as the vermian vein, which often can be spared in this approach. The choroidal arteries may supply feeders to the tumor but rarely need to be cauterized and ligated for adequate tumor resection ( Kaye and Black, pp. 815-824; Youmans; pp. 1017-1021, Wilkins, p . 1029) .
- Selama paparan trans-labirintin untuk reseksi Neuroma akustik, dokter akhli bedah terpapar Segitiga Trautmann. Semua struktur di bawah ini akan menegaskan daerah Segitiga tersebut, KECUALI
A. Daerah Segitiga dura pada aspek belakang tulang temporal yang berhadapan dengan sudut serebelopontin
B. Lateralis sinus sigmoid
C. Sinus petrosal atas di atasnya
D. gelembung jugular di bawahnya
E. Foramen magnum di tengahnya
E.
There are two goals of the translabyrinthine approach for acoustic neuroma resection that may help achieve maximal tumor resection. The first is to remove enough bone to identify the nerves lateral to the tumor as they course through the IAC, and the second is to expose the dura of the posterior aspect of the temporal bone that faces the cerebellopontine angle (CPA). This triangular patch of dura facing the CPA is called Trautmann’s triangle and extends from the sigmoid sinus laterally, the superior petrosal sinus above, and the j ugular bulb below. The foramen magnum is not included in Trautmann’s triangle ( Kaye and Black, pp. 851-860; Youmans, pp. 1155-1156; Wilkins, pp. 1067- 1071) .
- Salah satu prosedur paling dini yang dilakukan untuk penyakit Parkinson adalah ligasi pembuluh darah yang mana?
A. Arteri koroidal anterior
B. Arteri koroidal belakang tengah
C. Arteri balik Heubner
D. Arteri tentorial Bernasconi dan Cassarini
E. Arteri lentikulostriata media
A.
Neurosurgical therapies for Parkinson’s disease (PD) have been utilized in patients with progressi\•e disease despite maximal medical therapy. An early procedure performed for PD was ligation of the anterior choroidal artery, with subsequent infarction of the pallidum. Due to the variable distribution of this vessel outside the confines of the pallidum, results were too unpredictable and this procedure lost favor. In the 1 9 50s, anterodorsal pallidotomy became an accepted procedure, but the long-term benefits were mostly for rigidity, while tremor and dyskinesia did nor improve. Subsequently, the ventrolateral thalamus became the preferred target for lesioning, but this procedure also lost favor, as patients were often still left with bradykinesia ancl/or rigidity. Moreover, this procedure reduced tremor only in the contralateral half of the body, and bilateral thalamotomies were not recommended due to an unacceptably high risk of postoperative dysarthria and gait disturbances. Thalamotomy procedures fell off dramaticalh• in the late 1960s with the i ntroduction of L-DOPA. More recently, dramatic and beneficial effects of both -ubthalamic nucleus (STN) and globus pallidus interna CHAPTER 6 Neurosurgery Questions 2 0 1 (Gpi) deep brain stimulation (DBS) have been consistently observed. Both interventions appear to result in significant improvements in both motor fluctuations and dyskinesias. The DBS study group, in a large multicenter study, reported that on time without dyskinesia during the waking hours increased from 25 to 30% at baseline to 65 to 75% 6 months postoperatively. In a complementary fashion, these procedures also markedly decreased off time and on time without dyskinesia. Although some preliminary studies suggest STN DBS may be a superior intervention, no large randomized controlled trial comparing STN and Gpi DBS has been conducted to compare the efficacy of these treatments. The most consistent finding has been the reduction in antiparkinson medication following STN DBS compared to Gpi DBS. (Greenberg, p . 751; Tarsy, p . 191).
- Stimulasi saraf vagal dicadangkan untuk memilih pasien dengan epilepsi. Mengapa dilakukannya pada sisi kiri?
A. Untuk menghindari kemungkinan cedera pada saraf laringeal balik, yang mengikui
jalur ke arah kanan yang lebah rawan kerusakan
B. Untuk menghindari kemungkinan rusaknya saraf laryngeal atas dominan di sisi kanan.
C. Untuk menghindari kemungkinan rusaknya saraf kranial X, yang memasok jantung terutama dari sisi kanan
D. Untuk menghindari kemungkinan cedera pada saluran torak
E. Lebih kecil peluang terjadinya paralisis dan seraknya urat suara dari kiri
C.
Vagal nerve stimulation must be performed on the left side so that the cardiac innervation of CN X is unaffected (Youmans, pp. 2644-2645 ) .
