Emergency department neurosurgical admissions

1. Emergency Department
Neurosurgical Admissions
Aniruddha Sheth

2. Aims of this talk
• Adult emergency neurosurgical presentations and indications for
surgical intervention

3. Contents
• Assessment of the comatose patient
• Cranial Trauma
• Vascular neurosurgery
• Neuro-oncology
• Hydrocephalus
• Spinal surgery

4. Assessment of the comatose patient
• Glascow Coma Scale vs Score
• Rostro-caudal deterioration
• Assessment of the comatose patient

5. Glascow coma scale

6. Glascow Coma Scale
• Scale – used for individual patients and to track
clinical changes
• Score – numerical total of each component is for
research purposes
• Key issues with usage
• For use in acute brain injury
• Useful in tracking changes in consciousness for
intracranial pathologies
• Desedate and assess
• Motor component has highest inter-observer variability
• Apply painful stimuli at supraorbital nerve or trapezius pinch
• Take the best response for the motor score if unequal
responses
• Avoid assigning a score of 1 for an untestable feature –
state why untestable
• Describe the patient’s response rather than a
number

7. Rostro-caudal deterioration

8. Assessment of the comatose patient
• Core neurological examination
• Respiratory rate and pattern
• Pupillary changes
• Extraocular muscle function
• Motor examination

9. Comatose patient core neuro exam
• Cheyne-stokes
• Diencephalic lesions or bilateral
cerebral hemisphere dysfunction
• Due to an increased ventilatory
response to CO2
• Hyperventilation
• Pontine dysfunction (high)
• Usually with other brainstem
signs otherwise consider
psychiatric cause
• Apneustic
• Pontine lesion
• Cluster breathing
• High medulla or low pons
• Ataxic
• Medullary
• Pre-terminal

10. Comatose patient core neuro exam
• Pupils
• Assessment
• Check size in ambient light
• Reactivity to direct and consensual light
• Signs
• Small pupils
• Narcotics
• Pontine lesion which damages bilateral
sympathetic pathways
• Unequal
• Fixed dilated single
• oculomotor nerve palsy
• Consider contralateral Horner’s
syndrome
• Bilaterally fixed and dilated
• Medullary damage or post-anoxia or
hypothermia
• Midposition and fixed
• Midbrain lesion damaging sympathetics and
parasympathetics

11. Comatose patient core neuro exam
• Extraocular muscle function
• Deviation of ocular axes at rest
• Bilateral conjugate gaze deviation
• Looking towards lesion
• Frontal lobe
• Look away from lesion
• During a seizure
• Pontine haemorrhage
• Downward deviation
• Parinaud’s syndrome – thalamic or
pretectal lesions
• down and out
• Ipsilateral oculomotor nerve palsy
• Unilateral inward deviation
• Abducens nerve palsy
• Skew deviation (upward and opposite
direction movement)
• III or IV lesion at nucleus or nerves
• Spontaneous eye movements
• Windshield wiper eyes – intact III and MLF
• Ping-pong gaze – eyes deviate side to side 3-5
times per sec. Bilat cerebral dysfunction
• Ocular bobbing – pontine lesion.
• Internuclear ophthalmoplegia
• MLF lesion
• Lateral gaze and opposite eye doesn’t look
medially.
• Reflex eye movements
• Vestibuloocular reflex – COWS – intact
brainstem
• Optokinetic nystagmus – normal sign – if
present then consider psychogenic

12. Comatose patient core neuro exam
• Motor
• Tone
• Reflexes
• Response to pain
• Babinski
• Ciliospinal reflexes
• Pupillary dilation to noxious cutaneous stimuli
• normal when bilaterally present.

13. Cranial Trauma
• Management of concussion
• Abbreviated westmeade post-traumatic amnesia score
• Severe traumatic brain injury

14. Concussion
• Definition
• Alteration of consciousness without structural damage as a result of non-
penetrating traumatic brain injury
• Neuroimaging indications
• Severe concussion
• any LOC; or,
• LOC ≥ 5 mins or post-traumatic amnesia ≥ 24 hours
• Symptoms persisting > 1 week
• Before returning to competition after a 2nd or 3rd concussion in the same
season

15. Concussion
• Admission criteria
• As per mild head injury advice, can usually monitor at home
• Moderate head injury advice – admit for overnight observation if not fulfilling
the criteria for observation at home

16. Concussion – Abbreviated Westmead PTA
• Use of the abbreviated Westmead PTA
• Only in mild head injury/concussion
• Administer the test at hourly intervals
• Patient is out of PTA when they score 18/18
• Consider discharge for these patients at the discretion of
clinical judgement
• Consider in-hospital admission for patients with a score <18
at 4 hours

17. Severe traumatic brain injury
• Definition :
• GCS ≤ 8
• Clinical signs of high risk of intracranial injury
• Focal neurological findings
• Decreasing level of consciousness
• Penetrating skull injury or depressed fracture
• Initial management recommendations
• Urgent CT head
• Admit
• If focal findings/rapid deterioration – notify neurosurgical team for urgent
assessment and operative management

18. Surgical indications for Severe traumatic brain
injury
• Neurosurgical admission
• Isolated traumatic brain injury requiring
monitoring for deterioration or surgical
intervention.
• If the traumatic brain injury is the main cause
of morbidity with other injuries not requiring
continuous specialist input and monitoring.
• Otherwise for admission under Trauma
• Intracranial Pressure Monitoring
• GCS ≤ 8 and an abnormal CT head showing
mass effect
• Or in a normal CT scan with severe traumatic
brain injury and 2 or more of
• Age > 40 years
• Motor posturing (flexor or extensor)
• Systolic BP < 90mmHg
• Epidural haematoma
• a haematoma of ≥ 30mL regardless of GCS
• GCS ≤ 8 + epidural haematoma and
anisocoria
• Acute Subdural haematoma
• Greater than 10mm of thickness and/or more
than 5mm midline shift regardless of
patient’s GCS
• If thickness < 10mm and MLS <5mm then
evacuate if
• If the GCS decreased by ≥ 2 points from the time
of injury and/or;
• asymmetric or fixed/dilated pupils and/or;
• ICP ≥ 20cmH20 persistently
• Chronic Subdural haematoma
• Symptomatic lesions – focal deficits or mental
status changes
• Subdurals with maximal thickness > 1cm

19. Surgical indications for Severe traumatic brain
injury
• Traumatic Intracerebral haemorrhage (TICH)
• Operative treatment
• Progressive neurological deterioration attributable to the TICH, medically refractory
intracranial hypertension, signs of mass effect on CT
• GCS 6-8 with frontal or temporal contusions > 20cm3 with midline shift >5mm and/or
cisternal compression on CT
• any lesion > 50cm3 in volume
• Non-operative treatment
• No neurological compromise, controlled ICP, no significant signs of mass effect on CT
• Traumatic posterior fossa mass lesions
• Symptomatic posterior fossa lesions or those with mass effect on CT
• Penetrating brain injury

20. Surgical indications for Severe traumatic brain
injury
• Depressed skull fracture
• Open fractures
• Depressed > thickness of calvaria and not meeting non-surgical criteria
• Non-surgical criteria
• No evidence of dural penetration
• And –
• No significant intracranial haematoma
• Depression < 1 cm
• No frontal sinus involvement
• No wound infection/gross contamination
• No gross cosmetic deformity
• Basal skull fractures
• If isolated, no indication for neurosurgical admission
• Have multiple associated conditions that need to be considered
• Traumatic aneurysms, post-traumatic caroticocavernous fistulas, CSF fistula, meningitis/cerebral abscess,
cosmetic deformities, post-traumatic facial palsy, hearing impairment

21. Vascular Neurosurgery
• Stroke
• Subarachnoid haemorrhage
• Aneurysmal
• Traumatic
• Perimesencephalic
• CT negative

22. Stroke
• Ischemic
• Malignant middle cerebral artery territory infarction
• Patient to be admitted under neurology under the hemicraniectomy protocol
• Neurology will then refer to neurosurgery if surgery is indicated
• Hemicraniectomy indications guidelines
• Age < 70 years
• Non-dominant hemisphere
• Clinical and/or radiographical evidence of acute complete ICA or MCA infarcts
• And direct signs of impending or complete severe hemispheric brain swelling
• Cerebellar infarction
• For a neurology admission
• Surgical indications
• Increased pressure within the posterior fossa with no response to medical therapy
• Acute hydrocephalus

23. Intraparenchymal haemorrhage
• Key neurosurgery admission criteria
• Due to a vascular malformation as per CTa
• Lobar intracerebral haemorrhage in a patient < 65 years
old
• CT + contrast (tumour bleed) or CTa (vascular malformation
bleed) positive
• Cerebellar haemorrhage
• If unclear of management but patient is salvageable and a
good surgical candidate
• Neurology/MAU admission criteria
• Basal ganglia haemorrhage
• Internal capsule haemorrhage
• Brainstem haemorrhage
• Haemorrhage in the setting of a coagulopathy
• Lobar haemorrhage > 65 years of age
• If CTa or CT + contrast negative in a lobar haemorrhage <
65 years of age.
• Unsalvageable patient
• Lobar haemorrhage – relative indications for
neurosurgical intervention
• Lesions associated with mass effect, oedema, or midline
shift causing neurological deterioration from raised ICP.
• Surgery for moderate volume haematomas
• 10-30cm3
• Persistently raised ICP refractory to medical therapy
• Rapid deterioration regardless of location in someone
salvageable
• Favourable location (less than 1cm from cortical surface,
non-dominant lobe)
• Young patient i.e. <65 years of age
• Cerebellar haemorrhage
• GCS ≤ 13 or haematoma ≥ 4cm diameter
• If absent brainstem reflexes and flaccid quadriplegia, not
for surgery
• Intraventricular blood
• For external ventricular drainage if an appropriate
surgical candidate

24. Aneurysmal Subarachnoid haemorrhage
• For neurosurgical admission if CT head, LP or CTa positive
• Unsecured aneurysm management
• Blood pressure targets
• Systolic BP 120 - 150 mmHg
• Diastolic BP < 100 mmHg
• Nimodipine 60mg 4 hourly – if SBP < 120mmHg for 30mg, if SPB < 100mmHg WH
• Levetiracetam 500mg BD if ictus
• Surgical interventions
• Acute hydrocephalus
• External ventricular drainage
• Features favouring clipping of aneurysm
• Appropriate surgical candidate
• Symptoms due to mass effect of intracerebral clot
• Unsuitable for endovascular intervention

25. Unruptured intracranial aneurysm
• Symptoms of concern for pending aneurysmal rupture
• Mass effect from giant aneurysms
• Cranial neuropathies
• Third nerve palsy
• Compressive optic neuropathy
• Trigeminal neuralgia
• Sentinel haemorrhages/headaches
• Discuss with the patient regarding aneurysm rupture risk as per
PHASES score if an incidental aneurysm.
• Can be referred to neurosurgical outpatient clinic for review

26. Non-aneurysmal subarachnoid haemorrhage
• Perimesencephalic subarachnoid haemorrhage
• CT/MRI criteria with imaging done < 2 days of ictus
• Epicentre of the haemorrhage within the interpeduncular/prepontine cistern
• Extension within the anterior part of the ambient cistern or basal part of sylvian fissure
• Absence of complete filling of the anterior interhemispheric fissure
• No more than a minute amount of blood within the lateral part of the sylvian fissure
• No frank intraventricular haemorrhage – can have a small amount of blood within the
occipital horns of the lateral ventricles
• Will need a CTa for assessment of aneurysms
• Neurosurgery admission for investigation via Digital subtraction angiography
• Convexity subarachnoid haemorrhages
• Venous sinus thrombosis, vasculitis
• Refer to neurology
• Vascular malformation
• Neurosurgical admission

27. Intracranial Neuro-oncology
• Solitary intracranial lesion
• Multiple intracranial lesions
• Recurrence of intracranial lesion

28. Intracranial lesions
• Solitary lesions
• Neurosurgery admission criteria
• Significant mass effect
• Midline shift > 5mm
• Hydrocephalus
• Evidence of raised intracranial pressure secondary to mass effect of the lesion/oedema
• Appropriate surgical candidate
• Karnofsky performance score > 70 (self-caring) or if lower then for consideration if surgical excision can improve quality of life and
survival
• Oncology/MAU admission criteria
• If not appropriate for neurosurgical admission
• Posterior fossa lesion
• Neurosurgery admission criteria
• For urgent CSF diversion to temporise till definitive treatment
• Hydrocephalus
• Effacement of 4th ventricle
• For removal of lesion
• Karnofsky performance score > 70 (able to self care) prior to admission
• Candidates for treatment of extracranial disease with chemotherapy and whole brain radiotherapy

29. Intracranial lesions
• Multiple lesions
• Neurosurgical admission criteria
• Significant mass effect
• Midline shift > 5mm
• Hydrocephalus
• Decreasing GCS from raised intracranial pressure secondary to mass effect of the
lesion/oedema
• Symptomatic lesion and/or if > 3cm diameter
• Appropriate surgical candidate
• Viable for chemo/radio therapy post-resection of lesion.
• Oncology/MAU admission criteria
• If not appropriate for neurosurgical admission
• For work up of lesions with MRI brain + contrast and CT chest/abdo/pelvis

30. Intracranial lesions
• Recurrent/symptomatic known oncological disease
• Neurosurgical admission criteria
• evidence of raised intracranial pressure secondary to mass effect of recurrent lesion
• A candidate for ongoing chemo/radiotherapy if lesion is removed
• Will need to admit to oncological team treating patient first if patient is not
for emergency surgery. Patient to be worked up for consideration of
chemo/radiotherapy prior to discussing surgical interventions.

31. Spinal neuro-oncology
• Assessing spinal stability
• Spinal epidural compression

32. Spinal Instability Neoplastic Score

33. Spinal epidural metastases
• Neurosurgical admission criteria
• Evidence of cord compression
• MRI demonstrating lesion during this admission
• Unknown primary and no tissue diagnosis
• Relative contraindications to surgery
• Total paralysis > 8 hours
• Inability to walk > 24 hours duration
• Expected survival < 3-4 months
• Multiple lesions at multiple levels
• Not able to have surgery due to co-morbidities
• For oncology/MAU admission
• Known disease
• Radiculopathy/plexopathy with no evidence of cord compression
• For review for radiotherapy

34. Infectious diseases
• Post-operative wound infections
• Laminectomy
• Craniotomy infection
• Metalware
• Spinal epidural abscess
• Cerebral abscess
• Shunt infection

35. Post-operative infections
• Laminectomy/instrumentation
• Neurosurgical admission
• Evidence of deep wound infection/collection
• Persistent infective symptoms while on appropriate antibiotic therapy
• Dehiscence of subcutaneous layer and deeper
• Craniotomy
• Neurosurgical admission
• clinical evidence
• Swollen/tender wound
• Wound infection/dehiscence
• Palpable collection
• Evidence of meningitis

36. Vertebral body osteomyelitis
• Admission criteria
• Ongoing disease progression despite adequate antibiotic therapy
• Chronic infection refractory to medical treatment
• Spinal instability
• Severe back pain and/or radiculopathy
• Loss of height of vertebral body affected
• Spinal epidural abscess
• Infections with hardware

37. Spinal epidural abscess
• Neurosurgical admission criteria
• Evidence of cord compression from an epidural abscess correlated to an MRI
+ contrast full spine
• If no evidence of spinal epidural abscess causing symptomatic cord
compression on MRI
• For MAU admission with antibiotic administration
• Initiate antibiotic therapy preferably after specimen taken
• Through surgical drainage or CT guided aspiration of abscess

38. Cerebral abscess
• CT brain with contrast in setting of high clinical suspicion of abscess
• Neurosurgical admission criteria
• If no microbiological diagnosis
• Significant mass effect exerted by lesion with evidence of raised intracranial pressure
• Neurological symptoms attributable to the cerebral abscess
• Known abscess
• Interval neurological deterioration
• Progression of abscess towards ventricles
• Abscess enlarging after 2 weeks of antibiotic therapy
• No decrease in size of the abscess after 4 weeks of antibiotic therapy
• Initiate antibiotic therapy preferably after specimen taken

39. Shunt infection
• Neurosurgical admission
• High clinical suspicion of shunt infection
• Recent infection
• Fevers
• Seizure
• High blood CRP
• Discuss with neurosurgery for consideration of sampling of CSF via shunt valve
• CSF MCS, glucose and protein
• Can have concurrent shunt malfunction with blockage

40. Shunt complications
• Key information
• Reason for shunt initially
• Type of shunt
• Brand
• Ventriculoperitoneal/ventriculoatrial/v
entriculopleural
• Pressure setting of the shunt
• Fixed vs programmable and what level
known
• Reasons and dates of revisions
• Ability of the shunt to pump and
refill
• Difficult to depress – suggests distal
occlusion
• Slow refilling (normal refilling takes 15-
30sec) – suggests proximal obstruction
• Radiographic evaluation
• CT head non-contrast
• Assess ventricular calibre
• Have previous imaging available to
compare ventricular calibre in
different clinical states
• X-ray shunt series
• Lateral skull, AP C-spine, AP chest and
AP + lateral abdo
• Assess for kinks/disconnections

41. Undershunting
• Neurosurgical admission criteria
• Acutely raised intracranial pressure
• Symptoms
• High pressure headaches
• Nausea/vomiting
• Diplopia
• Lethargy
• Ataxia
• seizures
• Signs
• Parinaud’s syndrome
• Upwards gaze palsy
• Lid retraction
• Convergence palsy
• Accommodation palsy
• Abducens palsy
• Blindness/visual field impairment
• Papilledema
• Swelling around shunt tubing
subcutaneously
• Radiological changes
• CT head demonstrates
ventriculomegaly

42. Overshunting
• For neurosurgical admission
• Slit ventricles
• Associated with intracranial hypotension symptoms
• Subdural haematoma
• If symptomatic
• Symptoms similar to shunt malfunction
• > 1-2 cm thickness

43. Spinal neurosurgery
• Acute cauda equina
• Radiculopathy
• Complications post-spinal surgery
• Simple spinal surgery
• Instrumented spinal surgery

44. Acute cauda equina
• Presenting features
• 70% acute presentations
• Back pain and radicular leg pain
• Can have a subacute syndrome evolving
over days to weeks
• Consider in patients with chronic back
pain rapidly escalating regardless of
trauma or injury
• 30% can present without pain
• Sudden onset numbness, leg weakness
or difficulty walking
• Urinary symptoms
• Altered urethral sensation
• Loss of desire to void
• Poor stream
• Feeling of retention or straining to void
• Perineal symptoms
• Can include paraesthesia, numbness
and/or pain
• Faecal symptoms
• Incontinence
• Time course
• Sudden onset with no previous low
back pain symptoms
• History of recurrent backache and
sciatica with the latest episode
combined with cauda equina
symptoms
• Backache and bilateral sciatica
progressively developing into cauda
equina

45. Degenerative spine disease
• Radiculopathy admission criteria
• Progressive motor deficit
• E.g. foot drop
• Not indicated with paresis of unknown
duration
• Myelopathy admission criteria
• Evidence of acute cord compression
• Deteriorating gait
• Incontinence
• Neurological signs corresponding to a
cord compression syndrome
• Transverse lesion
• Motor system
• Central cord
• Brown-Sequard
• Brachalgia and cord
• MRI features correlating to cord
compression.
• Spinal claudication
• Admit if demonstrating cauda
equina

46. Post-spinal surgery
• post-simple spine surgery
• Admission criteria
• Treat as per new herniated disc
• Evidence of cord compression or cauda equina
• Post-complex spine surgery
• Admission criteria
• Radiographic evidence of peri-prosthetic fracture
• As per radiculopathy or cord-compression

47. Questions