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