emergency department neurosurgical admissions
TRANSCRIPT
Emergency Department Neurosurgical Admissions
Aniruddha Sheth
Aims of this talk
• Adult emergency neurosurgical presentations and indications for surgical intervention
Contents
• Assessment of the comatose patient
• Cranial Trauma
• Vascular neurosurgery
• Neuro-oncology
• Hydrocephalus
• Spinal surgery
Assessment of the comatose patient
• Glascow Coma Scale vs Score
• Rostro-caudal deterioration
• Assessment of the comatose patient
Glascow coma scale
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
Rostro-caudal deterioration
Assessment of the comatose patient
• Core neurological examination• Respiratory rate and pattern
• Pupillary changes
• Extraocular muscle function
• Motor examination
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
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
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
Comatose patient core neuro exam
• Motor• Tone
• Reflexes
• Response to pain
• Babinski
• Ciliospinal reflexes• Pupillary dilation to noxious cutaneous stimuli
• normal when bilaterally present.
Cranial Trauma
• Management of concussion• Abbreviated westmeade post-traumatic amnesia score
• Severe traumatic brain injury
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
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
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
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
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
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
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
Vascular Neurosurgery
• Stroke
• Subarachnoid haemorrhage• Aneurysmal
• Traumatic
• Perimesencephalic
• CT negative
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
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
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
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
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
Intracranial Neuro-oncology
• Solitary intracranial lesion
• Multiple intracranial lesions
• Recurrence of intracranial lesion
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
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
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.
Spinal neuro-oncology
• Assessing spinal stability
• Spinal epidural compression
Spinal Instability Neoplastic Score
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
Infectious diseases
• Post-operative wound infections• Laminectomy
• Craniotomy infection
• Metalware
• Spinal epidural abscess
• Cerebral abscess
• Shunt infection
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
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
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
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
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
Shunt complications
• Key information• Reason for shunt initially
• Type of shunt • Brand
• Ventriculoperitoneal/ventriculoatrial/ventriculopleural
• 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
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
Overshunting
• For neurosurgical admission• Slit ventricles
• Associated with intracranial hypotension symptoms
• Subdural haematoma• If symptomatic
• Symptoms similar to shunt malfunction
• > 1-2 cm thickness
Spinal neurosurgery
• Acute cauda equina
• Radiculopathy
• Complications post-spinal surgery• Simple spinal surgery
• Instrumented spinal surgery
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
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
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
Questions