Surviving Neurosurgical Emergencies

8/6/2019 Surviving Neurosurgical Emergencies

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Surviving NeurosurgicalSurviving NeurosurgicalEmer enciesEmer encies

Prof. Sam Eljamel

Consultant Neurosurgeon


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Disclosure

70% of Neurosurgery is70% of Neurosurgery is

emergenciesemergencies

The majority are traumaticThe majority are traumatic

Head injuriesHead injuries

Spinal injuriesSpinal injuries


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Summary Basic principles.Basic principles.

Subarachnoid haemorrhage.Subarachnoid haemorrhage. Spontaneous intracranial hge.Spontaneous intracranial hge.

.. Cauda equina.Cauda equina.

Raised intracranial pressure.Raised intracranial pressure.

Trauma.Trauma. Pituitary apoplexy.Pituitary apoplexy.


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Basic Principles

ABCs.ABCs. Look for and treat lifeLook for and treat life--threatening.threatening.

..

Assess the pupils.Assess the pupils.

Full neurological examination.Full neurological examination.

Full systemic examination.Full systemic examination.


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Look for and treat lifeLook for and treat life--

threatening.threatening.

Pneumothorax.Pneumothorax. Haemothorax.Haemothorax.

Haemopericardium.Haemopericardium. HaemoperitoniumHaemoperitonium

Raised intracranial pressure.Raised intracranial pressure.


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Eye Opening Best Verbal R Best Motor R

Spontaneous Orientated Obeys simple

To Speech Confused Localizing pain

Assess level of consciousness.Assess level of consciousness.

To Pain Words Flexing to pain

None Sounds Abnormal Flex

None Extending

None


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The GCSThe GCS - COMAEye Opening Best Verbal R Best Motor R

Spontaneous Orientated Obeys simple

To Speech Confused Localizing pain

To Pain Words Flexing to pain

None Sounds Abnormal Flex

None Extending

None


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Assess level of consciousness.Assess level of consciousness.

Eye openresponse

Best verbalresponse

Best motorresponse

Spontan. Oriented Obeys Fully

ConsciousTo speech Confused Localise

ain

Coma

To pain Words Flexing topain

None Sounds Abnormalflexion

None Extending

None


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Eye Exam- Pupils

Equal small

Equal large

Unequal


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Eye Exam- Pupils

Equal small

Heroine overdose. Pontine Haemorrhage.


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Eye Exam- Pupils

Unequal

Haematoma/hage.

Tumour. Abscess / infection.

Infarction / other.


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Eye Exam- Pupils Equal large

Everything:

Cranial and epilepsy

Metabolic.

System failure.

Endocrine failure.

Toxic and alcohol.


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Assess the pupils.Assess the pupils.

Equal and reactive.Equal and reactive.

NormalNormal --metabolicmetabolic Unequal.Unequal.

n n p gyn n p gy Equal large unreactive.Equal large unreactive.

Brain stem dysfunctionBrain stem dysfunction Equal and small.Equal and small.

Pontine bleedPontine bleed


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Full neurological examination.Full neurological examination.

Higher mental functions.Higher mental functions. LOC, Speech, Memory, Intelligence & HanddednessLOC, Speech, Memory, Intelligence & Handdedness

Cranial nerves.Cranial nerves. I, II, III, IV,V,VI,VII,VIII,IX,X,XI,XIII, II, III, IV,V,VI,VII,VIII,IX,X,XI,XII

Motor s stem.Motor s stem. Bulk, deformity, abnormal movement, tone, power, reflexesBulk, deformity, abnormal movement, tone, power, reflexes

Sensory.Sensory.

Superficial, deep, corticalSuperficial, deep, cortical Other signs.Other signs.

meningeal, coordination, etcmeningeal, coordination, etc


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50 years old presented with sudden onset headache50 years old presented with sudden onset headachein occipital region with nausea and vomiting,in occipital region with nausea and vomiting,

photophobia otherwise is okay.photophobia otherwise is okay.


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34 years old man presented

with collapse


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60 YEARS OLD WOMAN CAME IN WITH SUDDEN60 YEARS OLD WOMAN CAME IN WITH SUDDENHEADACHE AND RIGHT HOMONYMOUSHEADACHE AND RIGHT HOMONYMOUS

HEMIANAPSIAHEMIANAPSIA


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70 rs lad resented with

dizziness and vertigo


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73 years old woman presented with 2 weeks73 years old woman presented with 2 weeks

history of headaches and Nausea & vomiting,history of headaches and Nausea & vomiting,

was confused, and obeying commands.was confused, and obeying commands.

Deteriorated to localising pain, eye opening toDeteriorated to localising pain, eye opening to

pain.pain.


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71 years old woman was having a meal with a friend in

a Curry house. She went out and within 10 minutes fellto the ground on the pavement. She fell backwards and

hit her occipital region on the pavement. She canremember getting out of the restaurant and being

assessed in A&E about 30-40 minutes later. She wasconfused on examination with no focal neurology and

pupils were equal and reactive.

What will you do?


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y


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ABC

Airways were clear.,

good, expansion Okay etcPulse 76 R, BP 154/76

Now what?


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Life-Threatening conditions:

HaemothoraxHaemopercardium

HaemperitoniumHaematoma intracranially

Pneumothorax tensionThen What?


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Chest X-ray

C-Spine: AP/Lat/Open mouth

Pelvic X-ray: fracture neck offemor!

Then What?


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58 years old business man presented with progressivehoarseness and reduced pp on the left side of the face.


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54 years old presented with 2 collapses (seizures) in 2

weeks and lack of concentration. She seemed to be dis-inhibited and had weak grasp reflex.


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45 years old man presented with bilateral leg pain down


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y p g pto his ankle, sensory impairment to the midthighs and

urinary retention after lifting a heavy suitcase.

Exam reduced PP to L4, weakness of dorsiflexionbilaterally and SLR was 40 degrees with root tension on

both sides


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76 years old woman presented with severe sudden

headache and vomiting.


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75 years old presented with left visual problems, visual


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5 yea s o d p ese ted t e t sua p ob e s, sua

fields demonstrated left temporal visual defect


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Neurosurgical Emergencies

Reduced LOC


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Raised ICP

Seizures

Surviving Neurosurgical Emergencies

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