Neurosurgical Emergencies

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Neurosurgical Emergencies

• Frank Culicchia MD
• Department of Neurosurgery
• LSUHSC New Orleans

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Symptoms and Signs of Elevated ICP

• Triad
• Headache, nausea, vomiting
• Cranial nerve palsies
• Papilledema
• Vital sign changes
• Cushings
• Arterial hypertension and bradycardia
• Respiratory changes

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Papilledema

• Swelling of the optic nerve head with engorgement
  of the retinal veins
• May be accompanied by hemorrhages into the nerve
  and adjacent retina
• Presence almost always indicates raised
  intracranial pressure.

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Pathophysiology Secondary Injury

• Increased intracranial pressure
• Severity of injury tends to increase due to
  heightened ICP, especially if pressure exceeds 40
  mm Hg (remember CPP)
• Increased pressure also can lead to cerebral
  hypoxia, cerebral ischemia, cerebral edema,
  hydrocephalus, and brain herniation
• Monro-Kellie doctorine
• In 1783 Alexander Monro deduced that the cranium
  was a "rigid box" filled with a "nearly
  incompressible brain" and that its total volume
  tends to remain constant. The doctrine states
  that any increase in the volume of the cranial
  contents (e.g. brain, blood or cerebrospinal
  fluid), will elevate intracranial pressure.
  Further, if one of these three elements increase
  in volume, it must occur at the expense of volume
  of the other two elements. In 1824 George Kellie
  confirmed many of Monro's early observations.

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Cerebral Perfusion Pressure

• CPP MABP-ICP
• Normal approximately 55
• Children tolerate lower CPP than elderly

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Pathophysiology Secondary Injury

• Monro-Kellie Doctrine (modified)
• v.intracranial (constant) v.brain v.CSF
  v.blood v.mass lesion
• Normally brain 80, CSF 10, Blood 10
• Temperature, MABP, CPP, positioning, resistance,
  etc.

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Pathophysiology Secondary Injury

• Cerebral Edema
• caused by effects of neurochemical transmitters
  and by increased ICP
• Disruption of the blood brain barrier, with
  impairment of vasomotor autoregulation leading to
  dilatation of cerebral blood vessels
• Types of cerebral edema
• Vasogenic
• Cytotoxic
• Transependymal

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Cerebral Autoregulation
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Assessment of Autoregulatory Reserve
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Pathophysiology Secondary Injury

• Brain Herniation
• Supratentorial herniation is due to direct
  mechanical compression by an accumulating mass or
  to increased intracranial pressure
• 3 types of supratentorial herniation are
  recognized
• Subfalcine herniation The cingulate gyrus of the
  frontal lobe is pushed beneath the falx cerebri
  when an expanding mass lesion causes a medial
  shift of the ipsilateral hemisphere. This is the
  most common type of herniation
• Central transtentorial herniation characterized
  by displacement of the basal nuclei and cerebral
  hemispheres downward while the diencephalon and
  adjacent midbrain are pushed through the
  tentorial notch
• Uncal herniation displacement of the medial edge
  of the uncus and the hippocampal gyrus medially
  and over the ipsilateral edge of the tentorium
  cerebelli foramen, causing compression of the
  midbrain, while the ipsilateral or contralateral
  third nerve may be stretched or compressed

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Pathophysiology Secondary Injury

• Cerebellar Herniation
• infratentorial herniation in which the tonsil of
  the cerebellum is pushed through the foramen
  magnum and compresses the medulla, leading to
  bradycardia and respiratory arrest

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Pathophysiology Secondary Injury

• Hydrocephalus
• communicating type is more common which
  frequently is due to the presence of blood
  products causing obstruction to flow of the
  cerebral spinal fluid (CSF) in the subarachnoid
  space and absorption of CSF through the arachnoid
  villi
• noncommunicating type of hydrocephalus often
  caused by blood clot obstruction of CSF flow at
  the interventricular foramen, third ventricle,
  cerebral aqueduct, or fourth ventricle

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Management of Elevated ICP Interventions

• Airway/ventilator support
• Maintain adequate CPP
• Osmotic diuresis
• Hypertonic saline
• Sedation/analgesia

• Hypothermia
• Neuromuscular blockade
• Barbiturate coma
• Glycemic control
• CSF drainage
• Craniectomy

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Therapeutic Modalities for Reduction of ICP
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CNS Infections

• Meningitis
• Abcess
• Brain
• Spinal cord
• Subdural
• Epidural
• Encephalitis

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CNS Infections Signs and Symptoms

• Meningismus
• Nuchal rigidity
• Headache
• Photophobia
• Fever
• Lethargy

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CNS Infections Cause

• Bacterial
• Viral
• Fungal
• Parasites
• Prions

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CNS Infections Pathophysiology

• Hematogenous
• Originate from infection elsewhere in the body
• Respiratory
• Endocarditis
• Direct extension
• Sinus infections
• Osteomyelitis
• Trauma or surgery

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Meningitis

• Viral meningitis causes milder symptoms, requires
  no specific treatment, and resolves without
  complications
• Bacterial meningitis is a very serious disease
  and may result in a learning disability, hearing
  loss, permanent brain damage, and even death
• Viral infections are 2-3 times more common.

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Meningitis

• Overall incidence of bacterial meningitis in US
  is estimated to be more than 400 per 100,000
  newborn babies, and 1-10 cases per 100,000 adults
  per year, or 25,000 cases yearly
• Approximately two-thirds of all cases are in
  children
• Usually occurs in isolated cases without
  epidemics
• More common in males than females
• More likely in late winter and early spring

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Meningitis

• Three types of bacteria are the most common
  causes of meningitis in all age groups except
  newborns
• Streptococcus pneumonia (causing pneumococcal
  meningitis)
• Neisseria meningitidis (causing meningococcal
  meningitis)
• Haemophilus influenza type b (Hib)
• Hib vaccine as part of routine pediatric
  immunization has significantly reduced the
  occurrence of serious Hib disease
• Newborns are usually infected with coliform
  (bacteria in the gut, contracted at birth) such
  as Escherichia coli or Listeria and Group B Strep

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Brain Abcess
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Types of Primary TBI

• Skull fracture
• vault or basilar
• hematoma, cranial nerve damage, and increased
  brain injury
• compound vs. simple open vs. depressed

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Depressed Skull Fracture
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Depressed Skull Fracture
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Depressed Skull Fracture
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Depressed Skull Fracture
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Types of Primary TBI

• Intracranial Hemorrhages
• Epidural hematoma
• impact loading to the skull with associated
  laceration of the dural arteries or veins, often
  by fractured bones and sometimes by diploic veins
  in the skull's marrow
• most common, a tear in the middle meningeal
  artery causes this type of hematoma. When
  hematoma occurs from laceration of an artery,
  blood collection can cause rapid neurologic
  deterioration
• Subdural hematoma
• tends to occur in patients with injuries to the
  cortical veins or pial artery in severe TBI, with
  associated mortality rate approximately 60-80

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Acute Subdural Hematoma
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Acute Subdural Hematoma
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Acute Subdural Hematoma
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Acute Subdural Hematoma
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Epidural Hematoma
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Epidural Hematoma
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Epidural Hematoma