(BQ) Part 2 book “Neurosurgery rounds - Questions and answers” has contents: Cranial neurosurgery, radiation therapy, spinal anatomy and surgical technique, peripheral nerves, upper extremity, lower extremity, infectious and inflammatory,… and other contents.
5 Cranial Neurosurgery General History and Physical Examination Techniques Operative Anatomy Preoperative Assessment Trauma and Emergencies Trauma Emergencies Neoplasms Endocrine Radiation Therapy Infections Vascular Congenital and Pediatric Pain and Functional Cases p 154 p 154 p 163 p 170 p 173 p 175 p 175 p 181 p 187 p 207 p 213 p 215 p 218 p 240 p 252 p 255 153 154 II Clinical Neurosciences General ■ History and Physical Examination What is the most common type of headache? Tension headache What lesions can produce a head tilt? Trochlear (IVth) nerve palsy, anterior vermis lesion, tonsillar herniation In myasthenia gravis, the head tilts back.1 What is the term for the vermicular movement of the face in a patient with pontine demyelination? Myokymia2 What disorders can benefit from deep brain stimulation (DBS) of the ventral intermediate (VIM) thalamic nucleus? Essential tremor and parkinsonian tremor3,4 What region of the internal capsule may be affected in a patient with dysarthria and clumsy-hand syndrome?5 The genu Dilute pilocarpine (0.1–0.125%) may constrict what type of pupil? An Adie pupil This is possibly because of denervation supersensitivity as the normal pupil reacts only to 1% pilocarpine A pharmacologic pupil (dilated for the purpose of examination by an ophthalmologist) will not constrict with 1% pilocarpine; however, a pupil that is dilated from a compressive third cranial nerve palsy may constrict with 1% pilocarpine.6 What is the term given when the consensual light reflex is stronger than the direct light reflex? Afferent pupillary defect The lesion is ipsilateral to the side of the impaired direct reflex.7 What is the most common cause of spontaneous diplopia in middle-aged people? Orbital Graves disease is the most common cause of spontaneous diplopia in this age group It can present with nor- 5 Cranial Neurosurgery: General 155 mal thyroid function tests The inferior and medial rectus muscles are involved first The patient may present with marked lid edema, lid retraction, and ophthalmoplegia Dysthyroid disease may occur unilaterally and with normal thyroid function tests, which makes this diagnosis difficult Steroids are helpful in the acute setting.8 Which Parkinson-like disease manifests with vertical gaze palsy? Progressive supranuclear palsy (also known as SteeleRichardson-Olszewski syndrome)7 10 In one-and-a-half syndrome, which eye movement is preserved? Abduction of the unaffected eye9 11 How can one differentiate an oculomotor palsy from an aneurysm versus an oculomotor palsy from diabetic neuropathy? An oculomotor palsy in diabetes usually occurs with pain and may occur with pupillary sparing, which helps to distinguish it from an aneurysmal cause Anatomically, the parasympathetic fibers on the oculomotor nerve are at the periphery; therefore, a compressive lesion such as an aneurysm will compromise these fibers first.10 12 What disease is characterized by ataxia, myoclonus, positive immunoassay for 14–3-3 protein, and bilateral sharp waves on electroencephalogram (EEG)? Creutzfeldt-Jakob disease (CJD)11 13 What tests can be performed to differentiate an actual seizure from a pseudoseizure? EEG, serum prolactin level, and muscle enzyme studies11 14 What type of electrical activity occurs with an absence seizure? Hz per second spike and wave12 15 How does the diplopia of myasthenia gravis differ from the diplopia of a compressive lesion? The diplopia of myasthenia is intermittent, whereas the diplopia of a compressive lesion is constant or worsening.7 156 II Clinical Neurosciences 16 What extraocular muscle may be involved if a horizontal object appears slanted? Superior oblique muscle13 17 How does one differentiate the hypertension from a pheochromocytoma versus essential hypertension? Clonidine suppression test (reduces only essential hypertension) If no decrease in plasma catecolamine levels is detected after giving a 0.3 μg/kg oral test dose the study is considered positive (pheochromocytoma).14 18 What lesions of the bilateral hippocampi produce? Recent memory impairment15 19 In what percentage of left-handed subjects is the left hemisphere dominant? Over 75%16 20 What are the clinical symptoms of normal pressure hydrocephalus (NPH)? The chief feature is gait disturbance; the other two major components are memory loss, usually for recent events, and urinary incontinence These features are similar to Alzheimer disease, but in Alzheimer disease the memory loss is out of proportion to the gait disorder A good clue to NPH is that gait disturbance is usually the first symptom to appear and may precede the other symptoms by months to years If rigidity and tremor occur, these patients can be diagnosed incorrectly with Parkinson disease Other diseases in the differential diagnosis are depression and multiinfarct dementia A computed tomography (CT) scan of the brain in NPH shows large ventricles out of proportion to atrophy The cerebrospinal fluid (CSF) pressure measured by lumbar puncture is not high for unknown reasons A good test to show that an NPH patient may improve with a ventriculoperitoneal shunt is to place a lumbar drain for a few days and watch for any improvement (especially of gait, which is very predictive).17 21 What is the name of the area involved with cortical inhibition of bladder and bowel voiding that is damaged in NPH? The paracentral lobule17 5 Cranial Neurosurgery: General 157 22 What other diseases must first be ruled out to be confident about the diagnosis of NPH? Vascular dementia, Parkinson disease, Lewy body dementia, cervical spondylotic myelopathy, and peripheral neuropathy17 23 What are the synapses that occur in the pupillary reflex?18 • An afferent impulse through the optic nerve to the superior colliculus • The superior colliculus to the Edinger-Westphal nuclei bilaterally • From the Edinger-Westphal nucleus through the third cranial nerve to the ciliary ganglion • From the ciliary ganglion via the short ciliary nerves 24 If there is a problem with pupillary response, where is the lesion in relation to the lateral geniculate body? Anterior to the lateral geniculate body19 25 What are some causes of circumoral paresthesia? Hypocalcemia, hyperventilation, syringobulbia, and neurotoxin fish poisoning20 26 What is significant about the pitch of tinnitus? Low-pitch tinnitus is seen in conductive deafness and Ménière disease; high-pitch tinnitus is seen with sensorineural deafness.21 27 What is the significance of a “transverse smile” in a patient with myasthenia gravis? A myasthenic snarl (or transverse smile) may be seen with bulbar muscle involvement in myasthenia gravis.22 28 What diseases may manifest as facial myokymia? Intrinsic brainstem glioma or multiple sclerosis (MS)2 29 What maneuver can elicit nystagmus characteristic of benign positional vertigo? The Dix-Hallpike maneuver The examiner turns the head of the seated patient to one side and pulls the patient backward into a supine position with the head hanging over the edge of the examining table; the patient then 158 II Clinical Neurosciences looks straight ahead and the examiner observes for positional nystagmus, which is indicative of benign positional vertigo.23 30 What are some characteristics of benign positional vertigo? Fatigability is often seen and nystagmus is characteristic with rotatory movement in one eye and vertical movement in the other eye Patients describe a “critical position” that either elicits the vertigo or alleviates the vertigo.23 31 What are some characteristics of Ménière disease? Spontaneous bouts of prolonged vertigo, fluctuating hearing loss (poor speech perception), tinnitus, excessive endolymph within the scala media It may mimic an acoustic neuroma.21 32 What are the major signs and symptoms of lateral medullary infarction? Vertigo, nausea, vomiting, intractable hiccups, diplopia, dysphagia, dysphonia, ipsilateral sensory loss of facial pain and temperature, ipsilateral Horner syndrome, contralateral pain, and temperature loss of the limbs and trunk This is also known as Wallenberg syndrome.24 33 What differentiates ptosis from third cranial nerve palsy from ptosis in Horner syndrome? Horner syndrome ptosis is partial and disappears on looking up.25 34 What localizing value is the presence of anhidrosis in Horner syndrome? If the lesion is proximal to the internal carotid artery (ICA) origin or involves the external carotid artery circulation then the anhidrosis is present along the face due to dysfunction of cervical sympathetic output If the lesion is more proximal (along the first or second order neuron level) then the anhidrosis may involve a greater portion of the hemi-body.25 35 What are some causes of partial ptosis from a firstorder Horner syndrome? A first-order Horner syndrome involves the nerves from the posterolateral hypothalamus to the intermediolateral cell column (at C8–T2) Its causes include an Arnold-Chiari 5 Cranial Neurosurgery: General 159 malformation, basal meningitis, basal skull fracture, lateral medullary syndrome, demyelinating disease, an intrapontine hemorrhage, neck trauma, pituitary tumor, and syringomyelia.25 36 What pharmacologic test can be used to determine if Horner syndrome is second order or third order? Hydroxyamphetamine drops placed in the eye of a patient with Horner syndrome with intact postganglionic fibers (i.e., first- or second-order neuron lesions) dilates the pupil to an equal or greater extent than a normal pupil, whereas in an eye with damaged postganglionic fibers (third-order neuron lesions) the pupil does not dilate as well as a normal pupil after hydroxyamphetamine drops.25 37 What is Bell phenomenon? On attempting to close the eyes and show the teeth, one eye does not close and the eyeball rotates upwards and outwards.26 38 What are some nutritional causes of dementia? Wernicke-Korsakoff syndrome (thiamine deficiency), vitamin B12 deficiency, and folate deficiency 39 What is the name of the inherited disorder that presents with migraine (often hemiplegic) in early adult life, progressing through transient ischemic attacks (TIAs) and subcortical strokes to early dementia? CADASIL The disease CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a recently identified cause of stroke and vascular dementia CADASIL is identified by finding mutations in a gene called Notch3, which influences how cells in blood vessels grow and develop.27 40 What tests or procedures can one perform to determine if a patient with NPH will benefit from a shunt?18 • The presence of β waves can be noted with intracranial pressure (ICP) monitoring for more than hours over a 24-hour period • After lumbar CSF drainage for a few days, there is clinical improvement 160 II Clinical Neurosciences 41 What is the most common cause of cardioembolic stroke? Atrial fibrillation28 42 What arteries supply macular vision? Posterior cerebral artery (PCA) and middle cerebral artery (MCA)29 43 What are symptoms of color desaturation in MS? Patients complain about their perception of color; for example, the perception of red color as different shades of orange or gray.30 44 In acoustic schwannomas, when tumors are greater than cm the trigeminal nerve may be involved causing facial pain, numbness, and paresthesias What sign on CN examination may be an early manifestation of this phenomenon? Depression of the corneal reflex on the side of the tumor is an early sign Facial weakness is surprisingly uncommon despite marked CN VII compression 45 At what diameter of the carotid vessel lumen does a carotid bruit manifest on auscultation? Carotid artery bruits, often atherosclerotic in nature, become audible when the residual vessel lumen diameter approaches 2.5 to mm; they later disappear as the lumen is thinned to 0.5 mm.31,32 46 What are some features of Cushing syndrome? Moon face, acne, hirsutism and baldness, buffalo-type obesity, purple striae over flank and abdomen, bruising, muscle weakness and wasting, osteoporosis, hypertension, susceptibility to infection, and diabetes mellitus 47 What are conditions that may result in upgaze palsy? Tumor on the quadrigeminal plate or pineal region (Parinaud syndrome), hydrocephalus or other causes of elevated ICP, Guillain-Barré syndrome, myasthenia gravis, botulism, hypothyroidism 5 Cranial Neurosurgery: General 161 48 In what percentage of patients will phenytoin result in a skin rash? About to 10%33,34 49 What is the diagnosis (until proven otherwise) of an adult patient who presents with recurrent meningitis without any other predisposing conditions? CSF fistula Recurrent meningitis in an infant may be a manifestation of basal encephalocele 50 What is the other name of the disease known as cupulolithiasis? Benign positional vertigo35 51 What causes horizontal diplopia? Paresis of one or both of the sixth CNs This may occur, for example, with pseudotumor cerebri as a false localizing sign The firm attachment of the abducens nerve at the pontomedullary junction and its attachment to the dural elements as it passes into the Dorello canal make it susceptible to stretch forces in cases of high ICP.36 52 A cherry red spot in the retina is seen in which conditions? • Tay-Sach disease • Niemann-Pick disease • Pseudo-Hurler syndrome (GM1 ganglioside) 53 Retinitis pigmentosa is seen in which conditions? • • • • Friedreich ataxia Refsum disease Cockayne syndrome Kern-Sayre syndrome 54 What is cerebellar mutism? Mutism seen in children usually 1–4 days after a vermian lesion resection that may take weeks to months to resolve 162 II Clinical Neurosciences 55 What is the House-Brackman classification of a seventh cranial nerve injury? • Grade I: Normal • Grade II: Mild deformity and mild synkinesis • Grade III: Moderate damage, good eye closure, forehead function is preserved • Grade IV: No forehead function, partial eye closure • Grade V: No eye closure • Grade VI: Total paralysis, no tone37,38 56 Which questions should be asked regarding seventh cranial nerve palsy? • Ask about history of diabetes mellitus, pregnancy, autoimmune disorders, and ear/parotid surgery • Also inquire about otalgia, otorrhea, vertigo, and blurred vision as well as taste 57 What is Melkersson-Rosenthal syndrome? Triad of recurrent orofacial edema, recurrent seventh cranial nerve palsy, and lingua plicata39 58 What is Ramsay-Hunt syndrome? • Herpes zoster oticus • Third most common cause of seventh cranial nerve palsy 59 What is Heerfrodt syndrome? • Uveoparotid fever • Seventh cranial nerve palsy in sarcoidosis40 60 Bilateral seventh cranial nerve palsy is indicative of which disease? Lyme disease 61 What is Millard-Gubler syndrome? Ipsilateral sixth and seventh cranial nerve palsy and contralateral hemiparesis41 62 What is Brissaud-Sicard syndrome? Ipsilateral CN VII hemispasm and contralateral hemiparesis41 454 Index House-Brackman classification, 162 H-reflex, 254, 329, 366 Human immunodeficiency virus (HIV) See also Acquired immunodeficiency syndrome (AIDS) brain lesions in, 194 dementia in, 216 empiric medications for CNS mass lesions in, 215 lymphoma in, 401 myelopathy in, 401 peripheral neuropathy in, 361 Hunter syndrome, 408, 409t Hunt-Hess grades, 257–258 Hurler disease, 408, 409t Hutchinson triad, 399 Hydatid disease, 401 Hydranencephaly, 407 Hydrocephalus communicating, 201 in Latin America, 217 myelomeningocele and, 251 non-communicating, 201 normal pressure, 156–157, 159, 392 obstructive, 229 third ventriculostomy for, 174 Hydrocodone, 139t Hydromorphone, 139t Hydromyelia, 342–343 Hydrosyringomyelia, 343 Hydroxyamphetamine drops, 159 Hydroxyproline, in Paget disease, 285 Hyoid bone, 43, 288 Hyperalgia, 77 Hyperbilirubinemia, in infants, 410 Hypercalcemia, from bone metastases, 318 Hyperdense artery sign, 222 Hyperemia, of brain, 182 Hyperextension injury, 307 Hyperhidrosis, 308, 375 Hyperostoses, 196 Hyperpathia, 369, 411 Hyperreflexia, autonomic, 308, 318 Hypertension high intracranial pressure and, 145 in pheochromocytoma vs essential, 156 Hypertensive cerebral hemorrhage, 185 Hyperventilation, 73, 178 Hypocalcemia, 73 Hypoglossal canal, 13f Hypoglossal nerve, 20f, 40 Hypoglossal triangle, 20f Hyponatremia, 87 Hypotension acute intracranial, 426 spontaneous intracranial, 175 Hypothalamic hamartoma, 199 Hypothalamus in autonomic system, 21, 21f thermoregulation by, 29, 29f vasopressin synthesis in, 28, 29f Hypsarrhythmia, 69 I Ibuprofen, 136t ICA See Internal carotid artery (ICA) Ideomotor apraxia, 85 Iliac crest bone harvesting, 365, 365f Iliohypogastric nerve, 381, 381f Iliopsoas, 379 Inadvertent dural breach, 303–304 Inborn errors of metabolism, 409t India ink stain, 397 Indications, surgical for adult spine stenosis, 294 cervical spine, 293 lumbar spine, 293 for primary spine tumor, 294 for revision surgery, 294 Index 455 Indusium griseum, 26, 26f Infantile spasms, 395–396 Infections, 215–217 Inferior alveolar point, 12f Inferior anastomotic vein, 5, 5f, Inferior cerebellar peduncle, 34 Inferior colliculus, 20f Inferior frontal gyrus, 30 Inferior olivary nerve, 20f Inferior orbital fissure, 16 Inferior parietal lobule, 29 Inferolateral trunk, Infraspinatus weakness, 374 Infundibulum, 427 Inhalational anesthetics, 173 Inion, 12f Innominate artery occlusion, 221 Intensive care, 145–148 Intercristal line, 286 Intermediate nerve, 22 Intermediolateral nucleus, 293 Internal acoustic meatus, 13f, 14, 15f Internal arcuate fibers, 37, 38f Internal auditory canal, 164, 164f Internal capsule arterial supply of, 11 organization of, 28 Internal carotid artery (ICA) branches, 6f dissection, 59–60, 59f external vs., occlusion, stroke and, 224 supraclinoid, 171 Internal hamstring reflex, 379 International Study of Unruptured Intracranial Aneurysms (ISUIA), 223, 231 International Subarachnoid Aneurysm Trial (ISAT), 223 Interpeduncular cistern, 21, 25 Intertransverse ligaments, 292 Intertransverse procedure, 298 Interventricular antibiotics, 143 Intracerebral aneurysm, 233 Intracranial artery dissection, 430 Intracranial hypotension, 426 Intracranial pressure hypertension and, 145 spontaneous low, 175 Intrafacial triangle, 20f Intraneural ganglion cyst, 384 Intraoperative antibiotics, 304 Intrathecal antibiotics, 143 Intrathecal baclofen pump, 135, 299 Intrathecal baclofen withdrawal syndrome, 135 Intraventricular hemorrhage (IVH), 237–238 Intubation awake fiberoptic, in cervical spine injury, 323 in basal skull fracture, 181 Ipsilateral nucleus solitarius, 27 Ipsilateral sixth nerve palsy, Iron toxicology, 149 Irradiation prophylaxis, cranial, in lung cancer, 190 ISAT See International Subarachnoid Aneurysm Trial (ISAT) Ischemic penumbra, 27, 67, 219 ISUIA See International Study of Unruptured Intracranial Aneurysms (ISUIA) IVH See Intraventricular hemorrhage (IVH) J Jane procedure, 298 Jefferson fracture, 315, 315f Jugular foramen, 13f, 14, 15f Jugular foramen tumors, 199–200 456 Index Jumped facets, 350, 351f Juvenile pilocytic astrocytoma, 111t K Kawase triangle, 172f Kernicterus, 410 Ketamine, 84 Ketoconazole, 211 Ketorolac, 136t Keyhole, 163 Ki-67, 201 Kinesin, 79 Klippel-Feil syndrome, 343–344 Kyphosis congenital, 344 postlaminectomy, 302f L L4 reflex, 284 Lambda, 12f Lambdoid suture, 13 Lamina terminalis, 170 Laminectomy, 296–297, 300–303, 325 Laminoplasty, 300–301 Laminotomy, 300 Lasègue sign, 283 Lateral geniculate nucleus (LGN), arterial supply of, Lateral mass screws, 298 Lateral medullary infarction, 158 Lateral medullary syndrome, Lateral meniscus, 39 Lateral pectoral nerve, 289 Lateral recess stenosis, 284–285 Lateral triangle, 172f Lateral ventricle parts of, 17, 18f walls of, 19 LBP See Low back pain (LBP) Lead poisoning, 52, 149 Left-handedness, 156 Lenticulostriates, 227 Leptomeninges, 24, 24f Lesser petrosal nerve, 23f Leukemia, 245 Levetiracetam, 134 Levodopa, 131, 201 Lewy body disease, 232, 392 L’Hermitte phenomenon, 286 Lhermitte-Duclos disease, 205, 431 Ligament of Struthers, 53 Ligamentotaxis, 297 Ligamentous injury, in children, 316 Ligamentous instability, 316 Light reflexes, 154 Liliequist membrane, 21 Lindegaard ratio, 226 Lingual artery, 2f Lissencephaly, 105, 407 Local anesthetic infiltration, 67 Locked facet subluxation in, 311 unilateral vs bilateral, 310, 310f Locked-in syndrome, 392 Locus ceruleus, 22 Longitudinal striae, 26f Lorazepam, 130t, 133, 182, 394 Low back pain (LBP), 282, 321 Lower extremity, 379–384 Lower root injury, 377 Lower subscapular nerve, 289 Lumbar brace, 282 Lumbar corpectomy, 302 Lumbar disk herniation, 285 Lumbar laminectomy, 303, 325 Lumbar nerves, 290 Lumbar peduncle, 291–292 Lumbar plexus, 381, 381f Lumbar radiculopathy, 331 Lumbar spinal stenosis, 324–325, 324f–325f Lumbar spinal surgery indications, 293 Lung cancer metastatic tumor from, 115t paraneoplastic syndromes in, 194 prophylactic cranial irradiation in, 190 Luxury perfusion, 219 Index 457 Lyme disease, 162, 399 Lymphoma AIDS, 202 in HIV, 194, 401 metastatic tumor from, 115t Reed-Sternberg binucleated cells in, 122 reticulin stain in, 119 surgery in primary CNS, 195 M Macula, 80–81, 81f Macular vision, 160 Magnesium, 64 Magnetic resonance imaging (MRI) acute intracranial hypotension on, 426 arachnoid cyst on, 428 carotid-cavernous fistula on, 427 cavernous malformation on, 429 complex partial epilepsy on, 425 Dandy-Walker malformation on, 427 diffuse axonal injury on, 426–427 dissemination in space lesions on, 431 dissemination in time lesions on, 432 epidermoid cyst on, 428 hemangioblastoma on, 425 infectious spondylitis on, 433 intracranial artery dissection on, 430 Lhermitte-Duclos disease on, 431 “Medusa head” on, 428–429, 428f Modic changes on, 435 multiple sclerosis on, 427–428, 431–432 presellar vs postsellar tumors on, 426 recurrent disk herniation on, 436, 436f Sturge-Weber syndrome on, 427 traumatic extracranial arterial dissection on, 427 Wilson disease on, 429 Malignant hyperthermia, 84 Malnourishment, 284 Mandible, 12, 288 Mannitol, 173 MAP See Mean arterial pressure (MAP) Markers, tumor, 120, 201 Martin-Gruber anastomosis, 371, 371f Masseter, 12 Mastoiditis, 216 Maternal serum alpha fetoprotein (MSAFP), 406 Matrix metalloproteinases, 68 Maxillary artery, 2f MCA See Middle cerebral artery (MCA) McCune-Albright syndrome, 250 McDonald criteria, 403 McGregor line, 437, 438f Mean arterial pressure (MAP) calculation of, 177 Medial antebrachial cutaneous nerve, 363 Medial lemniscus, 20f Medial longitudinal fascicle, 20f Median nerve, 289, 363, 372 Median sulcus, 20f Medullary glioma, 193 Medulloblastoma, 204, 247, 338, 404 “Medusa head,” 428–429, 428f Melanoma markers for, 120 metastatic tumor from, 115t, 199 Parkinson disease and, 201 Melkersson-Rosenthal syndrome, 162 Ménière disease, 158, 393 Meninges, 24–25 458 Index Meningioma benign, recurrence of, 195 chromosome alteration and, 121 chromosome 14 deletion and, 121 chromosome 22 monosomy and, 121 convexity, 196 defining feature, 339 foramen magnum, 196 hormone receptors in, 196 intraventricular, 204 locations of CNS, 196 origin of, 195 rate of malignant change in, 196 S-100 staining in, 120 secretory, 120 sites for spinal, 338, 338f skull abnormalities in, 196 staining in, 120 Meningitis bacterial, 143, 398t cerebrospinal fluid profile in, 398t fungal, 398t syphilis, 334 viral, 397, 398t Meningocele, 345 Meningohypophyseal trunk, 5–6, 6f Menton, 12f Meperidine, 139t Meralgia paresthetica, 50 Mercury poisoning, 149 Mesencephalic nucleus, 38, 39f Mesencephalic vein, 20f Mesial temporal lobe epilepsy, 396 Mesial temporal lobe sclerosis, 106, 106f Metabolism, inborn errors of, 409t Metastatic tumors, 112, 114f, 115t, 199, 318, 438 Methotrexate, 316 Metopic suture, 248 Meyer’s loop, lesion of, 27 MGMT, 82 Midazolam, 130t, 134 Midbrain, 98, 98f Midbrain glioma, 193 Middle cerebellar peduncle, 34, 34f, 170 Middle cerebral artery (MCA), 160 Middle cerebral artery (MCA) aneurysm, 224 Middle cerebral artery (MCA) occlusion, 227 Middle frontal gyrus, lesion of, 27 Migraine trauma-triggered, 178 treatment of acute, 185 Millard-Gubler syndrome, 36, 36f, 162 Milrinone, 146 Modic changes, 435 Monosomy 22, 196 Moquio syndrome, 344 Morphine, 139t, 140 Motor strength assessment scale, 319 Motor strip, 11, 11f Motor unit potential, neurogenic vs myogenic, 366 Mt Fuji sign, 251 Moyamoya disease, 238–239, 239f, 429, 430f MRI See Magnetic resonance imaging (MRI) MS See Multiple sclerosis (MS) MSA See Multisystem atrophy (MSA) MSAFP See Maternal serum alpha fetoprotein (MSAFP) Mucor, 400 Mucormycosis, 400 Multidrug resistant ventriculitis, 144 Multiple myeloma, 188, 335 Multiple sclerosis (MS), 157, 194, 253, 286, 403, 427–428 dissemination in space lesions in, 431 dissemination in time lesions in, 432 on MRI, 431–432 Index 459 Multisystem atrophy (MSA), 412 Muscle spindle, 79, 80f Muscular dystrophy Becker-type, 410 Duchenne, 408, 410 Musculocutaneous nerve, 289, 373 Myasthenia gravis, 155, 367 Myelomeningocele, 240, 251, 342–343, 345, 405 Myelopathy cervical, 283, 286 in HIV, 401 thoracic, 288 Myocardial infarctions cerebrovascular accident and, 222 perioperative, 173 presentation of, 375 Myogenic motor unit potential, 366 Myokymia, 154, 157, 254 Myotonic dystrophy, 411 Myoxopapillary ependymoma, 338 Myxedema coma, 183 N NAA See N-acetyl-aspartate (NAA) N-acetyl-aspartate (NAA), reduced, 193 Nasal drainage, of CSF, 175 Nasal polyp, 246 Nasal septum, osseous, 13, 14f, 170 NASCET See North American Symptomatic Carotid Endarterectomy Trial (NASCET) NASCIS See National Acute Spinal Cord Injury Studies (NASCIS) National Acute Spinal Cord Injury Studies (NASCIS), 316 NC See Neurogenic claudication (NC) Neck fracture, 315, 315f Negri bodies, 399 Nelson syndrome, 211 Neostriatum, 27 Nerve block occipital, 252 suprascapular, 364 sural, 362–363 tibial, 363 Nerve root avulsion, 252 Nerve roots, 285, 289 Neural tissue repair, in fetus vs adult, 100 Neural tube defects, 342, 404–406 Neurocysticercosis, 217, 397 Neurofibrillary tangles, 124 Neurofibroma, 204t, 244, 334 Neurofibromatosis type I (NF1), 198, 243–244, 334 Neurofibromatosis type II (NF2), 197–198, 244, 334 Neurogenic claudication (NC), 340–341 Neurogenic motor unit potential, 366 Neurogenic pulmonary edema, 185 Neuroleptic malignant syndrome, 132, 184 Neuropathic pain, 53, 320, 367 Neuropore closure, 342, 405 Neuroprotective drugs, 178 Neuroradiology cranial, 424–432 spinal, 433–439 Neurosyphilis, 334, 413 Neurotransmitters, 128–132 Neurulation, 99 “Next-level disease,” 348–349, 349f NF1 See Neurofibromatosis type I (NF1) NF2 See Neurofibromatosis type II (NF2) Nicardipine, 145 Nicotine, 296, 329 Niemann-Pick disease, 232, 408, 409t Night blindness, 77 Night terrors, 87 Nimodipine, 146, 173 Nitrosoureas, 81 460 Index Nitrous oxide, 86, 186 Nocardia brain abscess, 217 Nociceptive pain, 53, 320 Nonsteroidal antiinflammatory drugs (NSAIDs), 136, 136t, 282, 296 Norepinephrine synthesis, 74, 74f Norepinephrine-containing neurons, 22 Normal pressure hydrocephalus (NPH), 156–157, 159, 392 North American Symptomatic Carotid Endarterectomy Trial (NASCET), 224 NPH See Normal pressure hydrocephalus (NPH) NSAIDs See Nonsteroidal antiinflammatory drugs (NSAIDs) Nucleus pulposus, 48 Nystagmus, 157, 286 O “O” sign, 359, 359f Obex, 20f Obstructive hydrocephalus, 229 Obturator nerve, 380 Occipital artery, 2f Occipital bone fracture, 176 Occipital condyle fractures, 438 Occipital cortex, 32 Occipital cortex lesions, 32 Occipital nerve block, 252 Occipital neuralgia, 252 Occipital ventriculostomy, 169 Occipitoatlantal dislocation, 322 Occipitocervical fusion, 296 Occipitomastoid suture, 13 Occult spinal dysraphism, 345 Octreotide, 207 Oculomotor nerve, 208 Oculomotor palsy, 155 Odontoid fractures, 307 Odontoid screw placement, 295 Olanzapine, 131 Olfactory pathway, 35 Oligodendroglioma, 122, 194, 197 Oncogenes, 110 Ondansetron, 141 One-and-a-half syndrome, 155 Open reduction and internal fixation, dens displacement and, 307 Operative anatomy cranial, 170–173 spinal, 282–304 Ophyron, 12f Opioid analgesics, 138, 139t, 320 Opisthion, 12f Optic chiasm, 40, 207 Optic nerve, radiation therapy for tumors near, 213 Optic nerve glioma, 188 Optic strut, 16 Orbit, walls of, 16, 17f Organophosphate toxicology, 149 Os odontoideum, 344 Osteoarthritis, hip, 288 Osteoblastoma, 198, 337 Osteochondroma, 337 Osteoid osteoma, 198, 337, 340 Osteoma, 198 Osteomalacia, 329 Osteomyelitis, 332, 333f, 402 Osteopenia, 329 Osteoporosis, 329–330 Osteosarcoma, 335–336 Otic artery, 248 Otic ganglion, 23f “Owl’s eye,” 400 Oxazepam, 130t Oxycodone, 139t P Pachygyria, 105 Paget disease, 188, 285 Palatal myoclonus, 254 Palmar cutaneous branch of median nerve, 364 Index 461 Panayiotopoulos syndrome, 163 Pancoast tumor, 358 Panencephalitis, subacute sclerosing, 401 Papaverine, 70 Papez circuit, 30, 30f Paracentral lobule, 156 Paraganglioma, 120 Paramedian triangle, 172f Paramyxovirus, 402 Paraneoplastic syndromes, in lung cancer, 194 Parietomastoid suture, 13 Parietooccipital artery, Parinaud syndrome, 35 Parkinson disease malignant melanoma and, 201 treatment of, 129 Parkinson triangle, 172f Parkinsonism, atypical, 412 Parotid glands innervation of, 170 parasympathetics of, 23, 23f Pars nervosa, 14 Pars venosa, 14 Parsonage-Turner syndrome, 376 Patau syndrome, 406, 409t Patrick test, 284–285 PCA See Posterior cerebral artery (PCA) Pedicle screw first vertebra to accommodate, 292, 292f placement of, 292 PEEK cage, 70 Penicillamine, 149 Pentobarbital, 134, 180, 182 Peroneal nerve entrapment, 387 Peroneal nerve injury, 380, 384 Peroneal nerve palsy, 358 Peroneus brevis, 379 Peroneus longus, 379 Persistent embryologic arterial connections, 248 Pertussis toxin, 86 Petrosectomy, anterior, 168 Phantom limb pain, 368 Phenobarbital, 394 Phenytoin, 133, 161, 182, 394 Pheochromocytoma, 156, 339 Physaliphorous cells, 121 Physical examination, 154–163, 358–362 Pia mater, 24, 24f PICA See Posterior inferior cerebellar artery (PICA) Pick disease, 232 Pillar pain, 364 Pilocarpine, 154 Pilocytic astrocytoma, 118, 250, 255, 255f, 404 Pinch sign, 359, 359f Pineal gland, appearance of, 425 Pineal region tumor, 56–57, 56f, 193–195, 204 Piriformis syndrome, 380, 382 Pituitary adenoma, 208, 211, 426 Pituitary apoplexy, 183, 208, 211 Pituitary gland, adenoma vs., 426 Pituitary pseudotumor, 210 Pituitary stalk thickening, 210 Pituitary stimulation test, 209 Pituitary tumor, 91–92, 92f, 119, 183, 188, 208 Placental alkaline phosphatase, 193 Plasmocytoma, 335 Platelet sequestration, 174 Platelets, 64–65 Platybasia, 345 Platysma, 295 Plavix, 83 Pleomorphic xanthoastrocytoma, 111t PML See Progressive multifocal leukoencephalopathy (PML) Polycystic kidney disease, 233–234 462 Index Polycythemia, 203 Polyradiculopathy, 283 Pontine demyelination, 154 Pontine glioma, 193 Pontine nerve, 20f Pontine tumor, 194 Positional posterior plagiocephaly, 249 Posterior auricular artery, 2f Posterior cerebral artery (PCA), 160, 171 fetal circulation in adults, 225 segments and branches of, 4f terminal branches of, Posterior communicating artery, 4f, 225, 225f Posterior cord syndrome, 312 Posterior fossa, 13f Posterior fossa surgery, 169 Posterior fossa tumor, 195 Posterior inferior cerebellar artery (PICA) in Chiari decompression surgery, 11 infarct in region of, Posterior interosseous nerve palsy, 376 Posterior interosseous neuropathy, 50, 50f Posterior longitudinal ligament, ossification of, 329 Posterior reversible encephalopathy syndrome (PRES), 233 Posterolateral triangle, 172f Posteromedial triangle, 172f Post-fixed brachial plexus, 370, 370f Post-fixed optic chiasm, 207 Postlaminectomy kyphosis, 302f Postoperative antibiotics, 304 Posttraumatic seizure, 181, 394 Posttraumatic syringomyelia, 311 Pott disease, 47, 333 Pott puffy tumor, 249 Powers ratio, 311 Pramipexole, 131 Prazepam, 130t Praziquantel, 397 Prefixed brachial plexus, 370, 370f Prefixed optic chiasm, 207 Pregnancy, cerebral vascular complication in, 184–185 Prehypertension, 218 Preoperative antibiotics, 304 Preoperative assessment, 173–174 PRES See Posterior reversible encephalopathy syndrome (PRES) Pretruncal nonaneurysmal subarachnoid hemorrhage, 220 Primary auditory cortex, 25, 25f Prinzmetal angina, 369 Prion disease, 123, 123f, 403 Proatlantal artery, 248 Prochlorperazine, 185 Progressive multifocal leukoencephalopathy (PML), 194, 402 Progressive supranuclear palsy, 155 Prolactin levels, elevated, 208, 210 Prolactinoma, 208, 260, 260f Prophylaxis antibiotic, 142, 178, 304 cranial irradiation, 190 vasospasm, 145 Propofol, 134 Propofol infusion syndrome, 135 Propoxyphene, 138 Prosopagnosia, 29 Prostaglandins, 237 Prosthion, 12f Psammomatous meningioma, 112, 114f Pseudoarthrosis, 298, 300 Pseudobulbar affect, 393 Pseudorosettes, 112 Pseudoseizure, seizure vs., 155 Pseudotumor cerebri, 425 Psoas muscle dissection, 290 Pterion, 12, 12f, 16 Index 463 Pterygopalatine fossa, 16 Pterygopalatine ganglion, 23f Ptosis, in cranial nerve palsy vs Horner syndrome, 158 Pulmonary edema, neurogenic, 185 Pulse-synchronous tinnitus, 229 Pupil, Adie, 154 Pupillary light reflex, 30, 154, 157 Purkinje cells, 32 Putamen, 27 Pyramid, 20f Pyramidal decussation, 42, 42f Pyridoxine, 144 Q Quadrangular space, 377 Quadrangular space syndrome, 377 Quadrigeminal cistern, 171 R Rabies, 399 Radial nerve, 373, 375 Radial nerve injury, 372, 386 Radial nerve lesions, 373 Radiation necrosis, 192, 213 Radiation therapy, 213–214 Radiculopathy, 282–283, 285, 290, 331, 358, 412 Ramsay-Hunt syndrome, 162 Range of motion, of cervical spine, 289 Ranitidine, 141 Rasmussen syndrome, 107 Rathke cleft cyst, 426 Rebleeding, in untreated aneurysm, 222 Recombinant activated factor VII, 69 Recurrent artery of Heubner, 223–224 Recurrent laryngeal nerve, 295 Red flags, in spinal evaluation, 283–284 Red man’s syndrome, 84 Red nucleus, 35f, 36, 37f Reducible fracture, 321 Reed-Sternberg binucleated cells, 122 Reflex(es) Achilles, 284 in brain death evaluation, 177 bulbocavernous, 319 F, 366 H, 254, 329, 366 Hering-Breuer inflation, 82 internal hamstring, 379 L4, 284 light, 154 pupillary light, 30, 154, 157 superficial abdominal, 291 Renal cancer, metastatic tumor from, 115t Renal destructive spondyloarthropathy, 327 Rendu-Osler-Weber disease, 244 Restiform body, 34 Reticulin stain, 119–120 Retina, cherry red spot in, 161 Retinitis pigmentosa, 161 Retinoblastoma, 122, 246 Revision surgery, 294, 325 Rheumatoid arthritis, 326–328, 334, 368, 433 Rhinion, 12f Rolandic points, 164 Ropinirole, 131 Rosenthal fibers, 110, 110f Rosettes, 112, 113t, 122 Rubella, 402 S S-100 staining, 120, 201 Sacral plexus, 383f Sacral sparing, 318 Sacrectomy, 337 Sacrum, masses in, 336 Sagittal synostosis, 242 SAH See Subarachnoid hemorrhage (SAH) Salivatory nucleus, 23f Sarcoid, 197–198 Sarcomere, 86, 87f 464 Index Satiety center, 28 S100B, 65–66 Scalp injury, at birth, 240 Scaphocephaly, 242 Scheduling, surgery, 215–216 Schirmer test, 176 Schistosomiasis, 401 Schizencephaly, 407 Schober test, 284 Schwann cells, 121 Schwannoma, 117–118, 118f, 120, 160, 188, 191, 204t, 261, 261f Sciatic nerve, 382, 382f, 384 SCIWORA See Spinal cord injury without radiographic abnormality (SCIWORA) SCM See Split cord malformation (SCM) Scoliosis, 337 Scotoma, 79 Secretory meningioma, 120 SEGA See Subependymal giant cell astrocytoma (SEGA) Seizures See also Epilepsy absence, 396 complex partial, 396, 411, 425 electrical activity in, 155 posttraumatic, 181, 394 pseudoseizures vs., 155 Seizure-threshold-lowering drugs, 133 Selective serotonin reuptake inhibitors (SSRIs), 132 Selegiline, 131 Senile plaques, 124 Serotonin syndrome, 132 Seventh cranial nerve palsy, 162 Shaken-baby syndrome, 243 Shock, spinal, 319 Shunt failure, 404 Shunt infection, 142–143, 215–216 Shunt occlusion, 183 Shunt surgery scheduling, 215–216 SIADH See Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Sincipital encephalocele, 246 Sixth nerve palsy, Skull, 11–17 Skull fracture basal, 181 growing, 181, 250 Sleep cycles, 88 Sleep deprivation, 82 Slit-like ventricles, 425 SLR See Straight leg raise (SLR) Smile, transverse, 157 Smoking, 296, 329 “Snuff box,” 375 Soleus, 366 Solitary plasmocytoma, 335 Solu-Medrol, 317 Somatomedin C, 211 Somatosensory evoked potential (SSEP), 297 Somatostatin analogue, 187 Sommer’s sector, 25, 26f Spasticity, 254 Spence rule, 437 Spinal anatomy, 282–304 Spinal cord, 46f Spinal cord injury without radiographic abnormality (SCIWORA), 315 Spinal cord tethering, 343, 404 Spinal dysraphism, 345 Spinal epidural abscess, 332 Spinal evaluation, 283–284 Spinal immobilization, 306 Spinal infection, 293 Spinal nerves, 282 Spinal shock, 319 Spinal stabilization, 297 Spinal stenosis, 307 indications for surgery, 294 lumbar, 324–325, 324f–325f nonsurgical treatment of, 282 Spinal trigeminal nucleus, 38, 39f Spinal trigeminal tract, 20f Index 465 Spinocerebellar pathways, 286 Spinothalamic tract, 20f Split cord malformation (SCM), 345 Spondylitis, infectious, 433 Spondylolisthesis, 288, 328, 328f, 435 Spontaneous diplopia, 154–155 Spurling test, 283 Spurling’s sign, 49 Square shift, 425 SSEP See Somatosensory evoked potential (SSEP) SSRIs See Selective serotonin reuptake inhibitors (SSRIs) Stability genes, 110 Stabilization, spinal, 297 “Stalk effect,” 210 Status epilepticus, 182, 394 Steele rule of thirds, 437 Steele-Richardson-Olszewski syndrome, 155 Stellate ganglion, 22 Stephanion, 12f Steroids antiinflammatory, 137 in bacterial meningitis, 143 bony fusion and, 296 gastrointestinal hemorrhage and, 174 normal physiologic replacement of, 137 side effects of, 137–138 Straight leg raise (SLR), 284–285 Stress, ulcers, 141 Stria terminalis, 27 Striae medullaris, 20f Stroke atrial fibrillation and, 222 bow hunter’s, 219 carotid bruit and, 222 carotid endarterectomy and, 224 carotid occlusion and, 231 carotid stenosis and, 222 definition of, 218 hemorrhagic, 219 internal carotid artery occlusion and, 224 myocardial infarction and, 222 rate of mortality in, 218 risk factors for, 218 transient ischemic attack and, 219 in young adults, causes of, 233 Sturge-Weber syndrome, 244–245, 395, 427 Subacute sclerosing panencephalitis, 401 Subarachnoid hemorrhage (SAH), 64–65, 175, 184–185, 220–223, 226, 232–234 Subdural empyema, 217 Subdural hematoma, 179 Subdural tap, in infant, 248 Subependymal germinal matrix hemorrhage, 100–101, 101f Subependymal giant cell astrocytoma (SEGA), 111t Subfrontal operative route, 165, 165f Subluxation atlantoaxial rotatory, 313 in locked facets, 311 Submandibular ganglion, 23f Suboccipital nerve, 45, 295 Suboccipital triangle, 13 Subscapular nerves, 289 Subsidence, 69 Sulcus limitans, 20f Sulcus limitans incisure, 20f Sunderland classification, 361–362 Superficial abdominal reflex, 291 Superficial middle cerebral vein, 5, 5f, Superficial temporal artery, 2f Superficial temporal artery biopsy, 166 Superficial triangle, 20f Superior anastomotic vein, 5, 5f, Superior cerebellar artery, Superior cerebellar peduncle, 34–35 466 Index Superior gluteal nerve, 383, 383f Superior orbital fissure, 170 Superior petrosal sinus, Supinator, 376 Supramarginal gyrus, 19 Suprascapular nerve, 373 Suprascapular nerve block, 364 Suprascapular nerve entrapment, 51, 51f Suprasellar tumors, 204, 207, 212 Supraspinatus weakness, 374 Supratentorial arachnoid cysts, 247–248 Sural nerve, 362 Sural nerve biopsy, 362, 367 Sural nerve block, 362–363 Surgery indications for adult spine stenosis, 294 cervical spine, 293 lumbar spine, 293 for primary spine tumor, 294 for revision surgery, 294 Surgical anatomy, 170–173 Surgical techniques cranial, 163–169 peripheral, 362–365 spinal, 282–304 Sydenham, chorea, 399 Sympathetic outflow, 293 Sympathetic plexus, 293 Synaptic cleft, 73, 73f Synaptophysin, 201 Syndrome of inappropriate antidiuretic hormone secretion (SIADH), 146, 209 Synostosis, primary, 242 Syphilis, 334, 399, 413 Syringobulbia, 43 Syringomyelia, 308, 311, 343, 404 T T7 area, 289 T1 radiculopathy, 358 T3 vertebra, 289 Tabes dorsalis, 399 Tarsal tunnel surgery, 363 Tay-Sachs disease, 408, 409t TCAs See Tricyclic antidepressants (TCAs) TcMEPs See Transcranial motor evoked potentials (TcMEPs) Tectorial membrane, 309, 309f Tegmentum tumor, 165 Telangiectasia, 244 Temazepam, 130t Temozolomide, 81, 82f, 202 Temperature regulation, 29, 29f Temporal arteritis, 220 Temporal association cortex, 29 Temporal bone, 14 Temporal bone fracture, 104, 176–177 Temporal lobectomy, 205 Temporal tip, safe removal lengths, 166 Temporalis, 12 Tensilon test, 363 Tension pneumocephalus, 186 Tentorial artery, Tetanus, 90 Tetany, 73 Tethered cord, 343, 404 Thalamic pain syndrome, 77 Thalamocortical afferents, 31 Thalamoperforators, 227 Thalamostriate vein, 170 Thalamus arterial supply of, 8, 8f nuclear organization, 31f Thermoregulation, 29, 29f Thiamine, 134 Thiamine deficiency, 159 Thiopental, 224 Third ventriculostomy, 174 Thoracic corpectomy, 302 Thoracic myelopathy, 288 Thoracic outlet, 377, 378f Thoracic outlet syndrome, 378, 386–387, 386f Thoracic spine, approaches to, 296–297 Thoracic stenosis, 296–297 Thoracodorsal nerve, 290, 375 Index 467 Thumb movement, 373 Thyroid cartilage, 43 Thyroid-stimulating hormone, 208 TIA See Transient ischemic attack (TIA) Tibial nerve block, 363 Tinel sign, 361 Tinnitus pitch of, 157 pulse-synchronous, 229 Tobacco, 296, 329 Tolcapone, 131 Torcula, 170 Towne view, 176 Toxicology, 149 Toxoplasmosis, 194, 215 Tracheoesophageal groove, 295 Traction, upper limit of, in cervical spine injury, 295 Tramadol, 138 Tranexamic acid, 232 Transarticular screw, C1-C2, 294, 434, 435f Transcallosal approach, 167f Transcranial motor evoked potentials (TcMEPs), 297 Transforming growth factor beta, 68 Transient cortical blindness, 178 Transient ischemic attack (TIA), 219, 231 Transoral operative route, 186 Transplacental infections, 397 Transverse foramina, 297 Transverse ligament, 44, 44f, 295, 308, 433 Transverse myelitis, intrathecal methotrexate and, 316 “Transverse smile,” 157 Trapezoid body, 20f Trauma, 102–104 cranial, 175–181 spinal, 305–323 Traumatic extracranial arterial dissection, 427 Trautman triangle, 166 Trendelenburg gait, 383 Trichrome stain, 192 Tricyclic antidepressants (TCAs), 132, 320–321 Trigeminal artery, 248 Trigeminal neuralgia, 8, 213, 252–253, 368, 411, 414 Trigeminal schwannoma, 188, 191 Trihexyphenidyl, 131 Triple-H therapy, 226, 258 Trochlear nerve, 20f, 40 Tuberculosis, 398t Tuberous sclerosis, 244–246, 405 Tumors astrocytic, 110, 111t genetics of, 110 markers, 120, 201 metastatic, 112, 114f, 115t, 199, 318, 438 radiation necrosis vs., 192 spinal compression from, 318 Tumor-suppressor genes, 110 Tympanic plexus, 23f U Ulcers, stress, 141 Ulnar nerve entrapment, 385, 385f Ulnar nerve injury, 359, 372 Ulnar palsy, 375 “Uncoupling” agents, 173 Upgaze palsy, 160 Upper extremity, 370–378 Upper subscapular nerve, 289 Uveitis, acute anterior, 287 V Vacuolar myelopathy, AIDSassociated, 401 Vagal injury, unilateral, 41 Vagal nerve, 20f Vagal triangle, 20f Vagal trigone, 19 Valproate, 134 Valproic acid, 133 Vancomycin, 143 Varicella, 402 Vascular claudication (VC), 340–341 468 Index Vasculature, 2–11 Vasogenic edema, 83 Vasopressin, synthesis of, 28, 29f Vasospasm, 146, 226 Vasospasm prophylaxis, 145 VC See Vascular claudication (VC) Vein of Galen aneurysm, 229 Vein of Galen malformation, 249 Vein of Labbé, 5, 5f, Vein of Trolard, 5, 5f, Venous angioma, 229 Venous angle, Ventricles, 17–21 Ventricular dilatation, 256, 256f Ventriculitis, multidrug resistant, 144 Ventriculoatrial shunt, 168–169 Ventriculoperitoneal shunt, 215, 246–247 Ventriculoperitoneal shunt overdrainage, 425 Ventriculopleural shunt, 169 Ventriculostomy, 174 Ventroposterolateral (VPL) nucleus, 30, 31f Ventroposteromedial (VPM) nucleus, 30, 31f Vermian agenesis, 256, 256f Vernet syndrome, 230 Verocay body, 117–118, 118f Vertebra plana, 344 Vertebral artery aneurysm, 220 Vertebral artery ligation, unilateral, 298 Vertebrobasilar insufficiency, 231 Vertex, 12f Vertical gaze center, 38 Vestibular nerve, 20f Vestibular schwannoma, 205, 261, 261f VHL See Von Hippel-Lindau (VHL) syndrome Vidian nerve, 22 Vimentin staining, 120 Viral meningitis, 397, 398t Virchow-Robin spaces, Vitamin B6, 144 Vitamin B12 deficiency, 159 Vomer, 13, 14f Von Hippel-Lindau (VHL) syndrome, 203, 205, 259, 259f, 339, 339f Von Willebrand disease, 148 Von Willebrand factor staining, 120 VPL See Ventroposterolateral (VPL) nucleus VPM See Ventroposteromedial (VPM) nucleus W Wallenberg syndrome, Warfarin, 147 Wartenberg sign, 378 Wartenberg syndrome, 378 Watershed zone, 341 Weber syndrome, 35, 35f Wedge compression fracture, 313, 314f Wernicke-Korsakoff syndrome, 159 Wernicke’s area, 25, 25f West syndrome, 395–396, 413–414 Wilson disease, 429 Windkessel phenomenon, 67 Wrist drop, 52 Z Zolpidem, 129 Zygapophyseal joint, 42 Zygoma, 163 Zygomatic arch, 170 ... bulbar muscle involvement in myasthenia gravis .22 28 What diseases may manifest as facial myokymia? Intrinsic brainstem glioma or multiple sclerosis (MS )2 29 What maneuver can elicit nystagmus characteristic... poisoning20 26 What is significant about the pitch of tinnitus? Low-pitch tinnitus is seen in conductive deafness and Ménière disease; high-pitch tinnitus is seen with sensorineural deafness .21 27 ... predictive).17 21 What is the name of the area involved with cortical inhibition of bladder and bowel voiding that is damaged in NPH? The paracentral lobule17 5 Cranial Neurosurgery: General 157 22 What