2. “To the age of the hearer, in which men had heard and heard only, had
succeeded the age of the eye in which men had seen and been content
only to see. But at last came the age of the hand – the thinking,
devising, planning hand, the hand as an instrument of the mind, now
reintroduced into the world in a modest little monograph from which
we may date the beginning of experimental medicine” – Sir William
Osler
12. MCQs
9. Most common primary metastasis to the Brain come from…
A. Melanoma
B. Kidney
C. GI
D. Lung
13. MCQs
10. Temporal lesions most commonly cause which of the following
forms of brain herniation?
A. Subfalcine herniation
B. Uncal herniation
C. Central transtentorial herniation
D. Tonsillar herniation
16. Neurologic Examination
• Glasgow Coma Scale
• Mental Status – awake, lethargic, stuporous, comatose.
• Cranial Nerves – pupil reactivity, eye movement, facial symmetry and
gag.
• Motor testing – maximal effort of major muscle groups
• Sensory testing – Light touch, proprioception, temperature and pain
17. Table 42-2. Schwartz, S.I, & Brunicardi, F.C. (2015). Schwartz’s principles of surgery (10th
ed.). Pg 1712
18. Diagnostic Studies
• Xrays – fractures, osteoblastic or osteolytic lesions, pneumocephaly.
Not used as much
• CT Scan
• Non contrast CT useful in new onset neuro deficits, trauma or decreased
mental status. High sensitivity of acute hemorrhage.
• Contrast CT – neoplastic or infectious processes
• Thin slice CT angiography – vascular lesions
• MRI
• T1 – useful for detecting neoplastic and infectious processes
• T2 – facilitate assessment of lesion associated edema and neural compression
in the spine by presence or absence of bright T2 CSF signals
19. Diagnostic Studies
• Invasive Monitoring
• External ventricular drain – perforated plastic catheter passed into frontal
horn of lateral ventricle, fluid column allows transduction of ICP.
• Intraparenchymal fiber-optic pressure transducer (bolt)– less invasive
compared to EVD
• Brain tissue oxygen sensors – similar to bolt, but can assess pressure, oxygen
and temperature.
• Electromyography/Nerve Conduction Studies
21. Raised ICP
• Normal ICP 4-14mmHg
• Monro-Kellie doctrine – cranial vault is a rigid structure and thus total
volume of contents determines ICP. (Brain tissue, CSF and Blood).
• The pressure-volume curve demonstrates a compensated region with
a small ΔP/ΔV, and an uncompensated region with large ΔP/ΔV.
• In the compensated region, increased volume is offset by decreased
volume of CSF and blood.
• Increased ICP can lead to shifts and herniation.
22. Table 42-3. Schwartz, S.I, & Brunicardi, F.C. (2015). Schwartz’s principles of surgery (10th
ed.). Pg 1714
23. Raised ICP
• Uncal Herniation – temporal lesions push uncus medially and
compress the midbrain, PCA passes between uncus and midbrain, can
be occluded leading to occipital infarcts.
• Subfalcine herniation – Cingulate gyrus pushed under the falx cerebri.
ACA branches pass along the medial surface of the cingulate gyrus,
occlusion leads to medial frontal and parietal infarcts.
• Diffuse increases in cerebral hemisphere pressure can cause central,
transtentorial herniation.
• Pressure in posterior fossa –upward central herniation or downward
tonsillar herniation.
24. Table 42-4. Schwartz, S.I, & Brunicardi, F.C.
(2015). Schwartz’s principles of surgery
(10th ed.). Pg 1714
25. ICP
• Presentation
• headache, nausea, vomiting, progressive mental status decline, hemiparesis
may be present if there is a focal mass lesion. Cushing’s triad – hypertension,
bradycardia and irregular respirations.
• Management
• Airway protection
• bolus of mannitol 1g/kg
• Ventriculostomy or craniectomy
• Obtunded patients have a decreased respiratory drive, causing PaCO2 to
increase and vasodilation of cerebral vessels worsening ICP.
26. Brain Stem Compression
• Posterior fossa lesions like tumors, hemorrhage or stroke can cause
mass effect rapidly killing the patient in two ways;
• Occlusion of the 4th ventricle can lead to acute obstructive hydrocephalus,
raised ICP, herniation and death.
• Direct brainstem compression – hypertension, agitation, progressive
obtundation leading to death.
• Management – immediate ventriculostomy, suboccipital craniectomy
27. Stroke
• Ischaemic or Hemorrhagic
• Hemorrhagic – can be seen early in stroke via CT scan.
• Ischaemic – may take up to 24 hours for changes to appear on CT
scan.
• Thrombolysis can be done if within 3 hours of onset of symptoms.
28. Seizure
• Uncontrolled electrical activity
• New onset seizure often signifies an irritative mass lesion in the brain
especially in adults.
• Patients with traumatic intracranial hemorrhage are at risk of
seizures.
• New onset seizures warrant imaging.
30. Skull fractures
• Open fractures require debridement and repair of the scalp.
• Indications for craniotomy – depression greater than cranial
thickness, intracranial hematoma and frontal sinus involvement.
However fractures overlying the dural sinuses require restraint,
exploration can lead to life threatening hemorrhage.
• Base of skull fractures if asymptomatic require no treatment.
However if associated with cranial nerve deficit or persistent CSF leak,
may warrant intervention.
31. Closed Head Injury
• Primary vs. Secondary Injury – hypoxia, hypotension, hydrocephalus,
ICP, thrombosis and hemorrhage.
• Assessment involves the ATLS protocol. Assess ABCDE with C-collar,
Secondary Survey.
• Why C-collar? C spine injuries among head injured patients range
between 4-8%
32. • In the setting of an isolated mandible,
nasal, orbital floor, malar/maxilla, or
frontal/parietal bone fracture, cervical
spine injury ranged from 4.9 to 8.0 %,
head injury ranged from 28.7 to 79.9
%, and concomitant cervical spine and
head injury was present in 2.8 to 5.8
%.
• In the setting of two or more facial
fractures, the prevalence of cervical
spine injury ranged from 7.0 to 10.8
%. The prevalence of head injury
ranged from 65.5 to 88.7 %, and the
prevalence of concomitant cervical
spine and head injury ranged from 5.8
to 10.1 %.
33. Glasgow Coma Scale
• Scored out of 15.
• Special circumstances:
• Swollen or damaged eyelids – 1C
• Dysphasic patient – 1D
• Intubated patient – 1T
• Pain
• Nail bed pressure – peripheral stimulus
• Sternal rub – central stimulus
• Supraclavicular (trapezius) pinch– central stimulus
• Superior orbital ridge – central stimulus
34. Types of Closed Head Injuries
Concussion
Observed or documented disorientation or confusion immediately after
an event.
• Impaired balance within 1 day after injury
• Slower reaction time within 2 days from injury
• Impaired verbal learning memory within 2 days from injury
Colorado grading – grade 1 – confusion, grade 2 – amnesia, grade 3 –
LOC
Normal Imaging.
35. Types of Closed Head Injuries
Contusion
• Bruise on the brain, with breakdown of small vessels and
extravasation of blood into brain. Contused areas appear bright on CT
scan.
• By themselves contusions may not cause mass effect but perilesional
edema may. Contusions may enlarge and progress to frank hematoma
esp in first 24 hrs.
• Contre-coup injury?
36. Types of Closed Head Injuries
Diffuse Axonal Injury
• Damage to axons throughout the brain due to acceleration,
deceleration.
• On CT scan – characteristic hemorrhages at grey-white matter
junction.
• On MRI – increased signal intensity at grey-white matter junction,
particularly at the corpus callosum and dorsolateral midbrain.
37. Intracranial Hematomas
Epidural Hematoma
• Blood between skull and dura
• Vessels
• Temporoparietal locus – middle meningeal artery
• Frontal locus – anterior ethmoidal artery
• Occipital locus – transverse or sigmoid sinus
• Vertex locus – superior sagittal sinus
• Symptoms – lucid interval “talks and dies”, uncal herniation from EDH
causes contralateral hemiparesis and ipsilateral CN3 palsy (eyeball
position is down and outward- SO,LR, pupil dilation and ptosis)
38. Intracranial Hematomas
Epidural Hematoma
• Imaging – biconvex bright clot never crossing suture lines.
• Open craniectomy
• Non-operative:
• Clot volume <30cc
• Max thickness <1.5cm
• GCS>8
• Prognosis after evacuation better for EDH vs. SDH as lower energy
involved in EDH.
39. Intracranial Hematomas
Acute Subdural Hematoma
• Blood between Dura and arachnoid
• Vessels – bridging veins
• Symptoms – intractable headache, confusion, may present with
localizing signs
• CT Scan - bright crescent shaped clot
• Craniotomy if thickness>1cm, MDS>5mm, GCS drop>2pts
40. Intracranial Hematomas
Chronic Subdural Hematoma
• Chronic? Collection atleast 2-3 weeks old.
• Imaging – iso/hypodense, a true chronic SDH is as dark as CSF.
• Vascularised membranes may form within the clot as it matures and
become focus for further bleeding (acute on chronic).
• Elderly, Alcoholics and Pts on anticoag at highest risk from minor
head trauma.
• SDH >1cm or with symptoms should be drained. Usually Burrhole.
41. Spinal Trauma
• Need to actively search for signs of spinal injury in all trauma patients.
• Starts with on-site care, transportation and ATLS protocol: C-collar, in-
line stabilization and log rolling.
• ASIA chart allows an accurate and reproducible record or neurological
deficits – sensory deficits in all dermatomes, power in major
myotomes, reflexes and perianal sensation and anal sphincter tone.
• C spine xrays are part of Trauma series. 3 views – lateral, AP and
odontoid.
• Xrays of thoracic and lumbar spine can provided a rapid initial
assessment of bony injuries
42. Spinal Trauma
Clearance of C Spine
• Conscious patient
• Fully alert and oriented
• No associated head injury
• Free of sedatives or alcohol
• No distracting injury
• Complete Normal Neuro-exam
• No post neck tenderness
• Able to turn 45 degrees side to
side
Canadian C spine Rule vs. Nexus C spine Rule
• CCR more sensitive than Nexus (99.4 % vs 90.7%)
and more specific (45.1% vs 36.8%) p<0.001
43. Spinal Trauma
Clearance of C Spine
• Unconscious patient
• Imaging is key
• Adequacy – Occiput to T1
• Five lines of alignment
• Ant soft tissue shadow – C1-C4 shadow ≤50% of body width, C5-C7 ≤100%
• Ant vertebral line – steps or breaks – unstable injury
• Post vertebral line – represents the anterior border of spinal canal)
• Base of spinous process line (spinolaminar line) – posterior border of spinal canal
• Tips of spinous process line – check for avulsion #
• Atlanto-dens interval - <3mm adults, <5mm in child. – larger interval means subluxation
• Space available for the cord >14mm
• Odontoid view – No overhang of lateral mass of C1 over C2. interval between odontoid peg
and C1 lateral masses should be equal.
• AP view – alignment of spinous processes and lateral edges
45. Initial Management of Neurotrauma – Brain
Injury -
1. Decompressive Craniectomy – reduces ICP and ICU days however does not
improve neuro outcomes as measured by GOS score at 6 months post injury in
severe TBI. Primary decompression when high ICP is anticipated or ICP
uncontrolled after maximal medical management in salvageable patient.
2. Prophylactic hypothermia – Not recommended. Not recommended
3. Hyperosmolar therapy – Mannitol 0.25-1g/kg, avoid SBP <90mmHg. Restrict
Mannitol use to patients with signs of herniation or progressive neurological
deterioration. HTS – shown to be more effective at lowering ICP but no
mortality benefit. Risk of rebound ICP with mannitol (HTS preferred)
4. CSF drainage (EVD) – Use of CSF drainage to lower ICP in patients with GCS<6
during the first 12 hours should be considered. EVD used in reducing ICP in
trauma patients
46. Initial Management of Neurotrauma – Brain
Injury -
5. Ventilation therapies – hyperventilation can be used as a temporizing
measure to lower ICP, should be avoided in the first 24 hours after injury
when cerebral blood flow is often reduced. (Rarely used as means of
lowering ICP)
6. Analgesics and Sedatives – barbiturates not recommended for
prophylaxis against raised ICP, but are recommended for treatment of ICP
refractory to standard surgical and medical therapies. Hemodynamic
stability is essential before and after administration. (Sedation with
sedation off intervals to assess neuro-function ideal)
7. Steroids – contraindicated – associated with increased mortality
(Contraindicated)
8. Nutrition – Early enteral feeding recommended – no mortality benefit
shown. (if no contraindication to feeding, then as early as possible)
47. Initial Management of Neuro-trauma – Brain
Injury -
9. Infection Prophylaxis – Open skull fractures (No Abx for BOS#)
10. DVT prophylaxis – LMWH or low dose unfractionated heparin can be used –
associated with increased risk of expansion of intracranial hemorrhage.
Pneumatic compression stockings been shown to be comparable to LMWH
however compression stocking inferior to LMWH. (Wait 12 days to begin
Enoxaparin)
11. Seizure Prophylaxis – In pts with ICH or depressed skull #, phenytoin 17mg/kg
loading dose and 300-400mg/d maintenance shown to reduce early
posttraumatic seizures. (Can use phenytoin prophylactically upto 7 days)
12. GI prophylaxis – H2RA vs. PPI. H2RA- undergo tachyphylaxis, thus unpredictable
acid suppression, also do not block vagal stimulated gastric secretion. PPI
superior to H2RA in regard to acid suppression. Omeprazole interacts with
CYP450, can interact with phenytoin. Pantoprazole less CYP interaction.
48. Initial Management of Neuro-trauma – Spinal
Injury -
1. Steroids – Contentious, Schwartz recommends decision to be based
on local practice patterns for legal liability issues.
2. Orthotic devices – C-Collar, Thoracolumbar Orthosis
3. Surgical Decompression and Stabilisation
49. CNS Tumors
• Intracranial Tumors
• Cause brain injury from mass effect, dysfunction or destruction of adjacent
neural structures, swelling or abnormal electrical activity.
• Supratentorial tumors commonly present with focal neurological deficits such
as contralateral limb weakness, visual deficits or seizures.
• Infratentorial tumors often cause increased ICP due to hydrocephalus from
compression of the 4th ventricle, causing headache, nausea and diplopia
• Cerebellar hemisphere or brain stem dysfunction can result in ataxia,
nystagmus, cranial nerve palsies. Infratentorial tumors rarely cause seizures.
• MRI ± gadolinium contrast is recommended
• Initial Mx – Dexamethasone for reduction of vasogenic edema and phenytoin
for patients who have seized.
50. CNS Tumors
• Metastatic tumors
• Lung, breast, kidney, GI tract and melanoma. (Lung and breast >50%)
• Mets tend to seed at the grey-white matter junction and also cerebellum and
meninges (leptomeningeal carcinomatosis).
• Well circumscribed, round and multiple lesions should prompt metastatic work up
(CT chest, abdomen, pelvis and bone scan).
• Management depends on the primary, overall tumor burden, patient’s medical
condition, location and number of metastasis.
• Single lesion – Craniotomy + Whole brain Radiotherapy or stereotactic radiosurgery
beneficial than WBRT alone.
• Post-op radio – reduces original lesion recurrence but no survival benefit.
• Craniotomy for multiple lesions not recommended unless all lesions can be resected.
52. Spinal Tumors
• Majority of spinal tumors are benign.
• Effects usually involve either destruction of the bones and ligaments
causes spinal instability leading to deformities, subluxation.
• Tumor growth within the canal can cause direct compression of the
cord or roots leading to pain and loss of function.
54. Cerebrovascular Disease
• Ischemic Stroke -85%
• Thrombotic disease – carotid most affected, diagnosis via angiography.
Treatment – carotid endarterectomy
• Embolic disease – occlusion tends to favor the anterior circulation
• ACA stroke – medial, frontal and parietal lobes incl motor cortex – contralat leg
weakness
• MCA stroke – lateral frontal and parietal lobes. Contralat face and arm weakness.
Language deficits if dominant hemisphere. Prox MCA stroke with wide area of ischemia
can lead to mass effect
• PCA stroke – supplies occipital lobe – contralateral homonymous hemianopsia
• PICA stroke – supplies lateral medulla and inferior half of the cerebellar hemispheres –
nausea, vomiting, nystagmus, dysphagia, ipsilateral Horner’s syndrome, ipsilateral limb
ataxia (lateral medullary or Wallenberg’s syndrome)
• Mx – revascularization with tPA within 3 hrs
61. MCQs
5. Standard treatment for Asymptomatic SDH >2cm is
A. Craniectomy
B. Burrhole drainage
C. Observation and Serial CT
D. Bedside ventriculostomy
62. MCQs
6. Is not part of Cushings triad
A. Hypertension
B. Pinpoint pupils
C. Bradycardia
D. Irregular respirations
63. MCQs
7. Best Treatment Option is
A. Burrhole surgery
B. In hospital Non-op care
C. Craniectomy
D. Discharge home to come to
Neuroclinic
64. MCQs
8. Name the Cervical Collar (each ½ mark)
B – Miami J Collar
A – Philadelphia Collar
65. MCQs
9. Most common primary metastasis to the Brain come from…
A. Melanoma
B. Kidney
C. GI
D. Lung
66. MCQs
10. Temporal lesions most commonly cause which of the following
forms of brain herniation?
A. Subfalcine herniation
B. Uncal herniation
C. Central transtentorial herniation
D. Tonsillar herniation
