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Electives - Neurosurgery

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ACE - A. I. in Neurosurgery

Elective Number: (Oasis E50a) 1801

Rotation Supervisor: Dr. Ashok Asthagiri

Coordinator: Karen Saulle, 982-3244, 3rd Floor Outpatient Clinic, Room 3518

Duration: Maximum 4 weeks, Minimum 2 weeks

Available: All rotations

Report to: Chief Resident(s)

Time to Report: 5:45 am

Typical Day: 6:00 am - 6:00 pm

Place to Report: 6th floor Hospital East, Dayroom 6806

Attendance: A student may not take time off during an ACE.

Attendance at elective activities is mandatory.

  • Anyone who is ill or has a personal or family emergency must contact Student Affairs and the Attending on Service.
  • Students are allowed to take off up to 1 day per week to interview between November 1 and February 1.
    • Specific days missed must be approved by the Attending on Service.

Number of students per rotation: 2 - 4

Course Description: An elective is offered on Neurosurgery for two - four students at a time for any period up to one month. Each student is assigned to the prime care of several patients and assumes major responsibility for their care. In addition to participation in daily clinical rounds, the student assists in the operating room and in the outpatient clinic. Informal teaching sessions focusing on the most common neurosurgical diseases are conducted three times a week. At the end of this rotation, the student will be able to discuss clinical presentation, radiological findings, surgical indications and basic surgical approaches to the most common neurosurgical diseases such as degenerative brain and pituitary tumors, intracranial aneurysms, carotid stenosis, spinal disease and hydrocephalus. There is night call once a week, weekend call and weekend rounds.

Learning objectives:

General Skills Topics:

  • The Neurological Examination:
    • perform a complete neurological examination including evaluation of mental status, speech, cranial nerve function, sensory and motor function, reflexes, cerebellar function and gait.
  • Fundamentals of Neuroimaging
    • distinguish between blood, air, CSF and bone on computed tomographic (CT) scans
    • recognize characteristics of basic magnetic resonance imaging sequences including T1- adnd T2-weighted sequences
    • recognize spine fractures and dislocations
    • recognize specific disease entities listed below such as epidural, subdural and intracerebral hematomas, subarachnoid hemorrhage, brain tumors and hydrocephalus
  • Intracranial hypertension
    • understand the pathophysiology of raised intracranial pressure, cerebral perfusion pressure and the influence of blood pressure, blood gases, and fluid and electrolyte balance
    • recognize the clinical manifestations of acute brain herniation including the Cushing reflex, midbrain effects and vital signs.
    • appreciate the impact of focal mass lesions, structural shifts and their consequences.

Intracranial Disease Topics

  • Diagnosis and Managment of Head Trauma
    • understand and demonstrate application of the Glasgow Coma Scale
    • recognize the presentation of brain herniation syndromes in the setting of trauma
    • demonstrate the ability to initiate management of raised intracranial pressure in head trauma
    • recognize and initiate management of concussion, brain contusion and diffuse axonal injury
    • recognize and initiate management of acute epidural, subdural hematoma including surgical indications
    • recognize and initiate management of penetrating head trauma including gunshot wounds
    • understand the principles of managment of open, closed and basilar skull fractures, including cerebrospinal fluid leak, and chronic subdural hematoma (in children and adults).
  • Diagnosis and Managment of Brain Tumor and Abscess
    • understand the relative incidence and location of the major types of primary and secondary brain tumors
    • recognize the general clinical manifestations of brain tumors (focal deficit, mass effect, supratentorial versus infratentorial)
    • appreciate specific syndromes of presentation: extra-axial (cerebellopontine angle, pituitary, frontal...) and intra-axial
    • understand the diagnostic tools that are currently used for evaluation (laboratory tests, radiology, biopsy)
    • understand broad treatment strategies in the treatment of tumors (surgery, radiosurgery, radiation and chemotherapy)
    • recognize the clinical manifestations of abscess and focal infections due to local spread, hemotogenous disease associated with immune deficiency, and how they differ and mimic brain tumors
    • understand the general principles in the treatment of abscess and focal intracranial infections
  • Diagnosis and Managment of Headaches
    • understand the major causes of intracranial hemorrhage including vasculopathy in the elderly (hypertension and amyloidosis), aneurysm, vascular malformation, tumor, drugs and coagulapathy
    • recognize the signs and symptoms of subarachnoid, cerebral and cerebellar hemorrhage
    • demonstrate the appropriate application of diagnostic tools in the evaluation of acute headache (CT and MRI, role of lumbar puncture and angiography)
    • understand the natural history of and broad treatment strategies for intracranial aneurysms and vascular malformations (microsurgery, radiosurgery, endovascular therapy as well as treatment of vasospasm)
  • Diagnosis and Management of Ischemic Cerebrovascular Disease
    • discuss the symptoms and signs of anterior and posterior circulation ischemia emphasizing carotid artery disease, and contrast this with hemorrhagic stroke
    • classify the types of ischemic stroke including embolic, hemodynamic and lacunar
    • discuss factors involved in the developement of cerebral ischemic disease including atherosclerosis, cardiac disease, arterial dissection, fibromuscular dysplasia, vasculitis, venus thrombosis and hematologic disease
    • discuss the management of cerebral ischemia and their indications including medical management, risk factor modification and surgical/endovascular therapy
    • diagnose and monitor carotid occlusive disease using noninvasive methods and understand indications for angiography and carotid endoarterectomy and angioplasty/stenting.

Spinal Disease Topics

  • Diagnosis and Management of Spine Trauma and Spinal Cord Injury
    • assess patients with suspected spinal cord injury in the emergency room including the interpretation of radiologic studies of spinal trauma
    • initiate acute management of spinal cord injury including immobilization, steroids and systemic measures
    • understand the definition and subsequent management principles of the unstable spine
    • demonstrate understanding of the management principles in spinal cord injury including indications for decompressive and stabilizing surgery and treatement of medical complications associated with spinal cord injury (skin, bladder, bowel movement, respiratory)
    • diagnose and understand the natural history and managment principles of whiplash and soft tissue injury (minor but common traumatic spine injuries)
  • Diagnosis and Management of Nontraumatic Neck and Back Problems
    • discuss spinal pain and radiculopathy:
      • signs and symptoms (including cauda equine syndrome)
      • common causes, diagnosis, and management (cervical and lumbar disc herniation, osteoarthritic disease, spondylolisthesis)
      • differential diagnosis including metastic disease, primary spinal tumors, peripheral nerve pathology and their management
    • discuss myelopathy:
      • signs and symptoms (including comparision of acute and chronic injury)
      • common causes, diagnosis, and management (cervical/thoracic disc herniation, osteoarthritis)
      • differential diagnosis (including transverse myelitis, metastatic disease, primary spinal tumors, amyothrophic lateral sclerosis)

Peripheral Nerve Disease Topics

  • Diagnosis and Management of Peripheral Nerve Injury and Entrapment
    • diagnose traumatic nerve injury (laceration, stretch and compression) and understand indications and general strategies for treatment
    • recognize the signs and symptoms of common nerve entrapment (carpal tunnel syndrome, ulnar nerve entrapment) and their etiology, conservative management strategies and indications for surgical intervention.

Other Common Neurosurgical Problems

  • Diagnosis and Management of Hydorcephalus and Spinal Dysraphism
    • recognize the symptoms and signs of hydrocephalus in children
    • recognize the symptoms and signs of hydrocephalus in adults
    • discuss common etiologies of hydrocephalus in children and adults, and differentiate between communicating and obstructive hydrocephalus
    • understand the treatment strategies for hydrocephalus
    • recognize common syndromes of spinal dysraphism, their neurologic manifestations and broad principles of management
  • Diagnosis and Management of Surgically Treatable Pain Problems, Movement Disorders and Epilepsy
    • recognize the features of trigeminal and glossopharyngeal neuralgia, causalgia/complex regional pain syndrome and cancer pain, indications for surgical referral, and the spectrum of surgical therapeutic options
    • recognize movement disorders amenable to surgical intervention, including Parkinson's disease, dystonia, spasticity, and hemifacial spasm, indications for surgical referral and the spectrum of therapeutic options
    • understand the general classification of seizure disorders, definition of intractable epilepsy and the broad categories of surgical intervention for epilepsy including invasive electrodes for monitoring resective and disconnective surgery.
Visiting students must submit a letter of recommendation from their Department of Neurosurgery and a CV with their application (apply through VSAS).