核心課程
1.Brain Tumor
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the concepts of deferential diagnoses, clinical signs, radiological study, operation and post-operative care of intra-cranial neoplasms
Skills
Communicating a patient with brain tumor, the student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
Brain tumor usually cause neurological deficits in patients. Surgical intervention is indicated to patients with IICP, seizure, severe focal neurological deficits, and problems of endocrine.
1. Clinical signs and symptoms
History taking
General signs: IICP signs, seizure, conscious disturbance, hormone
Focal signs: Focal neurological deficits, partial seizure
2. Laboratory datas
Tumor markers
Hormone level
SMA, CBC…..
3. Radiology
Brain CT, Brain MRI, Brain MRS, PET, Bone scan……
4. Pathology
World Health Organism ( WHO ) classification
Histo-biochemicho-immunology
5. Operations
Craniotomy
ETA ( Endoscopic transphenoid adenectomy )
Stereotactic biopsy
Gamma-knife radiosurgery
6. Adjuvant therapy
Medication
Steroid
Chemotherapy
Radiotherapy
Immunotherapy
2.Cerebral Vascular Accident
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the concepts of deferential diagnoses, etiology, anatomy, image and clinical presentation, and clinical management of cerebral vascular accident.
Skills
Communicating a patient with acute stage hemorrhagic type cerebral vascular accident, the student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
Cerebral vascular accident always attacks suddenly with rapid worsening prognosis of neurological deficits. The options of indications of medical management and surgical intervention are important.
1. Anatomy
Brain anatomy
Intracranial vessels ( Willis’ circle, territories of intra-cranial vessels…..)
2. Patho-physiology
Infarction: Thrombosis, embolism
Hemorrhage: Hypertensive ICH, vascular deformities, bleeding tendency, intracranial neoplasm, hepatic failure, renal disease, anticoagulants, SLE
3. Clinical presentation
General signs: IICP signs, Cushing’s triads, seizure, conscious disturbance
Focal signs: Focal neurological deficits, partial seizure
4. CVA in ER
A-B-C-D-Es
History taking
Neurological examination
Glasgow Coma Scale
Anatomic diagnosis of stroke ( brain stem or hemisphere lesion )
5. Imaging
Brain CT or CTA
Brain MRI or MRA
Angiography
6. Emergent Treatment of cerebral infarction
Inclusion and excursion criteria of IV r-TPA
Inclusion and excursion criteria IAA
Indication of Craniectomy + ICP monitoring
7. Emergent treatment of Hypertensive ICH
Indication of surgical intervention
External ventricular drainage
Craniotomy
Endoscopic evacuation
Stereotactic aspiration
8. Intensive care
Blood pressure
Sedative administration
IICP, ICP, CPP
Others
3.Head Injury
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the mechanism and definition of head injury, indications of operative intervention and concepts of post-operative care.
Skills
Communicating a patient with head injury, the student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
The mechanisms of head injury, including of primary and secondary insult, are important to predict the prognosis and clinical outcome of patients. We should learn how to make deferential diagnoses of head injury and optimal options of operation or not. To avoid secondary insult is important either in pre-operative or post-operative care.
1. Head injury in wild
A-B-C-D-Es
2. Head injury in Hospital
A-B-C-D-Es
Glasgow Coma Scale
Neurological examinations
3. Definition of brain concussion and brain contusion
History taking
Mechanism of head injury
4. Diagnosis of SAH, EDH, SDH and ICH
Brain CT
Skull film
5. Indication of surgery and ICP monitor
Guidelines of ICP monitor
Consciousness
Herniation and mss effect in Brain CT
Open fracture
6. Post-operative care
Increased intra-cranial pressure ( IICP )
Cerebral perfusion pressure ( CPP )
Lund Therapy
Sedative administration
Hypothermia
Others
4.Spinal Injury
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the mechanism and definition of spinal injury, indications of operative intervention and concepts of post-operative care.
Skills
Communicating a patient with spinal injury, the student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
The mechanisms of spinal injury, including of primary and secondary insult, are important to predict the prognosis and clinical outcome of patients. We should learn how to make deferential diagnoses of spinal injury and optimal options of operation or not. To avoid secondary insult is important either in pre-operative or post-operative care.
1. Spinal injury in wild
A-B-C-D-Es
Immobilization
Brief neurological examination
2. Spinal injury in Hospital
A-B-C-D-Es
Immobilization
Glasgow Coma Scale
Neurological examinations
History taking
Mechanism of spinal injury
NASIS or not
3. Diagnosis of SAH, EDH, SDH and ICH
Lateral plain film
Anterior – posterior plain film
Oblique films, Flexion-extension films
Open-mouth view, swimmer’s view
Spinal MRI
Spinal CT
4. Indication of surgery
Frankle’s scale
Incomplete type or complete type
5. Post-operative care
Intensive care of complete spinal injury
Respiratory system
Cardiovascular system
Gastric-intestinal system
Others
5.Degenerative Spinal Disease
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the mechanism and definition of Degenerative spinal diseases, indications of medication, operative intervention and concepts of post-operative care.
Skills
Communicating a patient with degenerative spinal disorder, the student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
The mechanisms of degenerative spinal diseases, including of primary and secondary insult, are important to predict the prognosis and clinical outcome of patients. We should learn how to make deferential diagnoses of degenerative spinal diseases and optimal options of operation or not. To avoid acute injury, adjacently secondary insult and chronic morbidities is important.
1. Degenerative spinal diseases
History taking
Neurological examinations ( Motor, sensory, DTR )
Mechanisms
2. Radiographic survey
Lateral plain film
Anterior – posterior plain film
Oblique films, Flexion-extension films
Open-mouth view, swimmer’s view
Spinal MRI
Spinal CT
3. Indication of surgery
Clinical presentation: Frankle’s scale, JOAS, Nurick Scale, Odem craiteria
Imaging : Occupying ratio, Cobb’s angle, Modic degeneration…..
4. Options of surgery
Conservative management: medication, radiofrequencey….
Decompression: Laminectomy, foraminotomy, disectomy…
Fixation and fusion: ACD + cage, LMS, TPS, PLF, PLIF, TLIF
5. To know materials
Cage, ACP, TMC, TPS, LMS, PDN, Artificial disc….
6.Functional Neurosurgery
Assumption
The student has a basic skill of history taking.
The student has a basic skill of neurological examination.
Learning Objectives
The objectives are to learn the concepts of anatomy, image and clinical presentation, and clinical management of functional neurological disorder.
Skills
Communicating a patient with specific disease such as Parkinsonism, trigerminal neuralgia, intractable epilepsy,etc. The student demonstrated about history taking and neurological examination at bedside. First impression was made and further imagination studies checked at ward, the student can discuss about more detail information about clinical experiences from the teacher.
Introduction
The options of indications of medical management and surgical intervention of functional neurological disorders, including of parkinsonism, epilepsy, pain, involuntary move disorders are in rapidly progress and necessary to update.
Parkinsonism
1. 病因：degeneration of pigmented neurons in the substantia nigra導致neostriatum之dopamine level降低，非遺傳性，好發於40-70歲。
2. 主要症狀：
Triad of Parkinson’s disease: Tremor (resting), rigidity (cogwheel), brady-kinesia. other signs 有posture instability, micrographia, mask-like facses. gait為: Frozen gait, shuffling steps, festinating gait.
3. 治療：藥物治療有五類：
dopamine (DA) precursor:
如levodopa: 因dopamine不能通過BBB, Levodopa經胃腸吸收，經肝臟運輸至腦部(但有一些被dopa decarboxylase作用成dopamine者無法進腦) 所以，添加decarboxylation阻斷劑(如Carbidopa)的Levodopa (sinemet)較不引起食慾不振、噁心嘔吐之GI症狀。Most effective for brady kinesia, poor for tremor. Overdose可引發chorea
Anticholinergics:
如Trihexyphenidyl (Artane, or Benzhexol, 2mg) improvement : rigidity > tremor > akinesia
DA agonist:
直接刺激post-synaptic DA receptors : (Bromocriptine (parlodel) 及 pergolide
Amphetamines :
(減少DA re-uptake)
Anti-oxidants :
Selegiline. (mono-amine oxidant inhibitor)可抑制DA在Brain的breakdown
4. Surgical treatment:
Stereotactic thalamotomy (ventro-lateral nucleus) or pallidotomy ( Internal segment). Relieving tremor效果比brady kinesia好
Fetal tissue transplantation: implantation of (100 days) fetal dopaminergic brain cells. Further study is needed.
Huntinton’s Chorea:
autosomal dominant neuro-degenerative disorder with dementia, choreoathetosis and personality changes; preferential loss of striato-Gpe ( external segment of globus pallidus) projection neurons, 發病年齡40-45歲，預後不良，藥物以phenytoin或tegretol治療，手術以stereotactic internal pallidotomy為主。
Hemiballism:
典型者為infarction或hemorrhage in subthalamic semilunar nucleus (STN) of Luys (STN破壞)導至decreased inhibitory basal ganglia output to thalamus. 外科治療stereotactic pallidotomy (internal segmnet)
Spasticity
1. 常發生在CVA, spinal cord injury, cerebral palsy 及 Multiple sclerosis
2. 藥物治療：Muscle relaxants (如Baclofen, Tizanidine)
3. 手術方式：
Selective posterior rhizotomy
Selective neurectomy ( obturator neurectomy, pudendal neurectomy)
myelotomy : Bischof’s myelotomy ( via lateral), midline “T” myelotomy ( T11~L1 laminectomy and T12-S1 myelotomy,保留S2-4之bladder reflex)
Stereotactic thalamotomy or dentatotomy ( useful in cerebral palsy or unilateral dystonia)
Pain: ( Intractable pain, cancer pain)
1. electric stimulation
deep brain stimulation
spinal cord stimulation ( dorsal column stimulation)
2. Intracranial ablasive procedures
Cingulotomy, (bilateral)
3. Spinal ablasive procedures
Cordotomy ( Interuption of the lateral spinothalamic tract fibers.適單側nipple以下之痛
b.Commissural myelotomy ( mediolongitudinal myelotomy)適雙側、中間胸部以下之痛
c.Dorsal root entry Zone (DREZotomy): deafferentation pain resulting from nerve root avulsion.
4. Sympathectomy (T2):
for causalgia major ( involve nor-epinephrine released at sympathetic terminals together with hypersensitivity secondary to denervation or sprouting)
癲癇手術治療
1. 發生率與罹病率：年發生率約30-45/10萬人，罹病率約0.5-1.0%，約20-30%可藥物完全控制，70%獲改善，但有10%的癲癇以藥物控制不佳或產生抗藥性、毒性者需接受手術
2. Criteria:
藥物治療失敗(毒性、抗藥性、耐受性)或因藥物治療導致干擾精神、智能或社會行為者臨床和EEG顯示有大腦皮質的origin而且切除後不會產生新的神經學缺損者Seizure之patterns和frequency穩定，epileptogenic area成熟，病人必須有強烈的意願和合作有家庭和環境的支持做術後的復健
3. Basic procedures:
resection of epileptic focus:包括cortical resections, temporal lobectomy, amygdalo- hippocampectomy
b .section of copus callosum, and/or hemispherectomy
4. Pre-operation evaluation:
所有病人必須接受Imaging study to rule out neoplasm 。如MRI, CT scan, PET scan ( positron emission tomography) EEG, or Wada test (intracarotid amytal test,在做angiogram之開始注射100-125mg的amobarbital進入ICA，評估病人的運動、語言和記憶功能，求定位dominant hemisphere)
5. 手術前主要orders
a .taper 抗癲藥物，術前一天要完全DC
b.術前一天晚上給10mg Decadron,手術當天早上再給一次
c.若因停藥發生seizure:給予phenobarbital (luminal) 130mg IV. (<100mg/min)
6. 手術中考量
麻醉方式:Local:可用narcotics (如Fentanyl)或droperidol
全麻:避免使用banzodiazepines及barbiturates
術中cortical stimulation: For定位motor strip, sensory cortex或speech centers
7. 術中EEG: (cortical EEG):尤其是superior temporal gyrus,和inferior frontal gyrus. Depth electrodes in amygdala(距temporal tip 3 cm)和hippocampus(距temporal tip 5cm)