This document provides an overview of common emergency neurosurgical presentations and indications for surgical intervention. It discusses the assessment of comatose patients, including the Glasgow Coma Scale. It then covers various neurosurgical topics like cranial trauma, vascular neurosurgery including stroke and subarachnoid hemorrhage, neuro-oncology, hydrocephalus, and spinal surgery. For each topic, it outlines clinical criteria for determining if surgical intervention is required.

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