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Emergency department neurosurgical admissions

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Emergency department neurosurgical admissions

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Emergency department neurosurgical admissions

  1. 1. Emergency Department Neurosurgical Admissions Aniruddha Sheth
  2. 2. Aims of this talk • Adult emergency neurosurgical presentations and indications for surgical intervention
  3. 3. Contents • Assessment of the comatose patient • Cranial Trauma • Vascular neurosurgery • Neuro-oncology • Hydrocephalus • Spinal surgery
  4. 4. Assessment of the comatose patient • Glascow Coma Scale vs Score • Rostro-caudal deterioration • Assessment of the comatose patient
  5. 5. Glascow coma scale
  6. 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. 7. Rostro-caudal deterioration
  8. 8. Assessment of the comatose patient • Core neurological examination • Respiratory rate and pattern • Pupillary changes • Extraocular muscle function • Motor examination
  9. 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. 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. 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. 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. 13. Cranial Trauma • Management of concussion • Abbreviated westmeade post-traumatic amnesia score • Severe traumatic brain injury
  14. 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. 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. 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. 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. 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. 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. 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. 21. Vascular Neurosurgery • Stroke • Subarachnoid haemorrhage • Aneurysmal • Traumatic • Perimesencephalic • CT negative
  22. 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. 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. 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. 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. 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. 27. Intracranial Neuro-oncology • Solitary intracranial lesion • Multiple intracranial lesions • Recurrence of intracranial lesion
  28. 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. 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. 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. 31. Spinal neuro-oncology • Assessing spinal stability • Spinal epidural compression
  32. 32. Spinal Instability Neoplastic Score
  33. 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. 34. Infectious diseases • Post-operative wound infections • Laminectomy • Craniotomy infection • Metalware • Spinal epidural abscess • Cerebral abscess • Shunt infection
  35. 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. 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. 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. 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. 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. 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. 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. 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. 43. Spinal neurosurgery • Acute cauda equina • Radiculopathy • Complications post-spinal surgery • Simple spinal surgery • Instrumented spinal surgery
  44. 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. 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. 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. 47. Questions

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