Surviving Neurosurgical Emergencies

Prof. Sam Eljamel Consultant Neurosurgeon

Disclosure
70% of Neurosurgery is emergencies The majority are traumatic
Head injuries Spinal injuries

Summary
Basic principles. Subarachnoid haemorrhage. Spontaneous intracranial hge. Infarction. Cauda equina. Raised intracranial pressure. Trauma. Pituitary apoplexy.

Basic Principles
ABCs. Look for and treat life-threatening. lifeAssess level of consciousness. Assess the pupils. Full neurological examination. Full systemic examination.

Look for and treat lifelifethreatening.

Pneumothorax. Haemothorax. Haemopericardium. Haemoperitonium Raised intracranial pressure.

Assess level of consciousness.

Eye Opening Spontaneous To Speech To Pain None Best Verbal R Orientated Confused Words Sounds None Best Motor R Obeys simple Localizing pain Flexing to pain Abnormal Flex Extending None

The GCS - COMA

Eye Opening Spontaneous To Speech To Pain None Best Verbal R Orientated Confused Words Sounds None Best Motor R Obeys simple Localizing pain Flexing to pain Abnormal Flex Extending None

Assess level of consciousness.

Eye open response Spontan. To speech To pain None Best verbal Best motor response response Oriented Obeys Confused Words Sounds None Localise pain Flexing to pain Abnormal flexion Extending None Fully Conscious

Coma

Eye Exam- Pupils

Equal small Equal large Unequal

Eye Exam- Pupils

Equal small Heroine overdose. Pontine Haemorrhage.

Eye Exam- Pupils

Unequal Cranial pathology:
Haematoma/hage. Tumour. Abscess / infection. Infarction / other.

Eye Exam- Pupils

Equal large Everything:
Cranial and epilepsy Metabolic.
System failure. Endocrine failure.

Toxic and alcohol.

Assess the pupils.

Equal and reactive.
Normal -metabolic

Unequal.
Intracranial pathology

Equal large unreactive.

Brain stem dysfunction

Equal and small.

Pontine bleed

Full neurological examination.

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

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

Motor system.
Bulk, deformity, abnormal movement, tone, power, reflexes

Sensory.

Superficial, deep, cortical

Other signs.
meningeal, coordination, etc

50 years old presented with sudden onset headache in occipital region with nausea and vomiting, photophobia otherwise is okay.

34 years old man presented with collapse

60 YEARS OLD WOMAN CAME IN WITH SUDDEN HEADACHE AND RIGHT HOMONYMOUS HEMIANAPSIA

70yrs lady presented with dizziness and vertigo

73 years old woman presented with 2 weeks history of headaches and Nausea & vomiting, was confused, and obeying commands. Deteriorated to localising pain, eye opening to pain.

71 years old woman was having a meal with a friend in a Curry house. She went out and within 10 minutes fell to the ground on the pavement. She fell backwards and hit her occipital region on the pavement. She can remember getting out of the restaurant and being assessed in A&E about 30-40 minutes later. She was confused on examination with no focal neurology and pupils were equal and reactive.

What will you do?

ABC Airways were clear. Breathing: RR 20, Air entry good, expansion Okay etc Pulse 76 R, BP 154/76 Now what?

Life-Threatening conditions: Haemothorax Haemopercardium Haemperitonium Haematoma intracranially Pneumothorax tension Then What?

Chest X-ray C-Spine: AP/Lat/Open mouth C2 odontoid fracture! Pelvic X-ray: fracture neck of femor! Then What?

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

54 years old presented with 2 collapses (seizures) in 2 weeks and lack of concentration. She seemed to be disinhibited and had weak grasp reflex.

45 years old man presented with bilateral leg pain down to his ankle, sensory impairment to the midthighs and urinary retention after lifting a heavy suitcase. Exam reduced PP to L4, weakness of dorsiflexion bilaterally and SLR was 40 degrees with root tension on both sides

76 years old woman presented with severe sudden headache and vomiting.

75 years old presented with left visual problems, visual fields demonstrated left temporal visual defect

Neurosurgical Emergencies
Reduced LOC Raised ICP Focal Neurological Deficit Seizures