Neurosurgical Emergencies Flashcards
(29 cards)
What are common neurosurgical emergencies?
- Cranial
- head injury: extradural/subdural haematoma, contusions, depressed skull fractures
- hydrocephalus
- infections: intracerebral abscess, subdural empyema - Spinal
- cauda equina
- acute spinal cord compression” bleed, infection, disc, trauma
What is a classic history of extradural haematoma?
- Headache, vomiting, fluctuating consciousness
- GCS 10/15
- Right pupil larger than left
- Sluggish reaction to light
- CT scan: bioconvex, fractured skill (disrupts MMA), brain intact
How is extradural haematoma managed?
- ALTLS
- Admit, bloods, mannitol
- Prevent secondary brain injury: hypotension, hypoxia, infection
- Contact neurosurgeon for urgent craniotomy for evacuation of haematoma
What is a subdural haematoma?
- Concave towards brain
- Ruptures bridging veins
- Worse outcome due to underlying brain injury
- Older patients - brain atrophy = only need minor injury for acute subdural which becomes chronic
How are contusions managed?
- Swell + mature over 72 hours
- Initially conservatively (ICU + ICP)
- Observe for signs of ICP
- Prevent hypoxia + hypotension to prevent secondary brain injury
- Surgery for persistent increased ICP
- Craniotomy or craniectomy (bone fragment not immediately put back in craniectomy)
How is a depressed skull fracture managed?
- Majority conservatively
- Clean + suture overlying lacerations
- +/- antibiotics
- Epilepsy
- Surgery only for significant depression causing neurosurgical deficit, cosmetic purposes or dirty wounds
What are the types of spontaneous intracranial haemorrhage?
- Subarachnoid
- Intracerebral
- Intraventricular
What are the causes of intracranial haemorrhage?
- Cerebral aneurysms
- Arteriovenous malformation
- Hypertension
- Antocoagulants
- Drug abuse
What are common signs of subarachnoid haemorrhage?
- Sudden onset occipital headache
- Neck stiffness
- Nausea, vomiting
How is subarachnoid haemorrhage managed?
- Bed rest
- IV fluids
- Nimodipine
- Analgesics
- Refer to neurosurgeon for angiogram
- Can either treat by
1. Embolisation (coiling)
2. Clipping of aneurysm
How is intracranial haemorrhage managed?
- Stop warfarin/aspirin
- Control hypertension
- Surgery for large superficial haematomas causing mass effect
How is intraventricular haemorrhage managed?
- Symptomatic
- Investigate cause of bleeding
- Treat hydrocephalus - ECD, VP shunt
What is hydrocephalus?
Either imbalance between producing + absorbing CSF or physical obstruction to flow of CSF
What are the causes of hydrocephalus?
- Obstructive (non-comm)
- Tumours
- Abscess
- Cysts
- Congenital aqueduct stenosis
- Chiari malformations - Non-obstructive (communicating)
- IC haemorrhage (SAH, IVH)
- Infection - meningitis
- Post-traumatic
How is hydrocephalus managed?
- Insertion of ventriculo-peritoneal shunt - for communicating all ventricles in communication so only have to drain 1 part & whole system gets drained)
- Enoscopic 3rd ventriculostomy - for non-communicating (hole in 2rd ventricle so CSF drains into subarachnoid space)
What are the types of intracranial infections?
- Intracerebral abscess
- Subdural/extradural empyema
What are the sources of intracranial infections?
- Parasinal sinus infections
- Dental abscess
- Middle ear + mastoid infections
- Haematogenous spread - lung infection, UTI, endocarditis
- Penetrating head trauma
- Post op
What common organisms cause intracranial infections?
- Aerobic/anaerobic streptococci
- Staph
What is the classic history of cranial infection?
Seizure + neurological deficit
How is subdural empyema investigated?
- CT with contrast
- Inflam markers (WCC, CRIP)
- Blood culture
How is subdural empyema managed?
- Urgent craniotomy for evacuation of empyema
- Antibiotics 12 weeks
- Treat source of infection
How is central abscess managed?
- Surgery to aspirate/drain abscess
- Antibiotics 6-12 weeks
- Treat source
What are spinal emergencies?
- Cauda equina syndrome
2. Acute spinal cord compression
What is cauda equina syndrome?
Acute loss of neurologic functions of nerve roots below conus medullaris
