Neurosurgical Case Scenarios

SNS Intern Boot Camp Course - 2014

Case #1 – FC, 38yoF• 38 year old female

• Sudden headache 7 days ago

• Brought in comatose, 8 hours after ictus:

• GCS 8• Moves extremities

symmetrically• PERRLA, no cranial deficits

What would you do next?

Case #1 – FC, 38yoF• Right MCA aneurysm

• Clipped on post-hemorrhage day #2

• Awake and following commands• Extubated on day #3• Oriented x2, no deficits

Case #1 – FC, 38yoF• Right MCA aneurysm

• Post-clipping day #6• Hemorrhage day #7

• Paged by ICU RN• “Acting funny”

• On exam:• Localizes with right arm• Withdraws on left, less active• Opens eyes to pain• Mumbles, non-

comprehensible• GCS 9• EVD working, ICP = 23mmHg

Case #1 – FC, 38yoF• CT

• What next?

Case #2 – CCB, 18yoM• 18 year old Male

• Dove into Lake Michigan, intoxicated

• 3 hours ago• Hit head, neck pain• Tingling in hands

• Transferred from another hospital

• On exam:• GCS 15• Collar and board• Intact• Normal head CT• Neck pain to palpation

Case #2 – CCB, 18yoM• 18 year old Male

• What next?

Case #2 – CCB, 18yoM• Transferred from another hospital

• CT (unavailable), MRI

• What next? R L

Case #2 – CCB, 18yoM• Gardner-Wells tongs applied

• Started with 15 lbs

Case #2 – CCB, 18yoM• Gardner-Wells tongs applied

• Started with 15 lbs

• Increased 5 lbs / 10min, XR• At 45 lbs: tingling in all 4

extremities, hand grip weakness?

• What next?

Case #3 – RD, 6yoM• 6 year old male

• Myelomeningocele• Correction + shunt at birth• 3 revisions, most recent 3

months ago

• “Fussy” all day, fever 104 F, vomiting

• Called by peds ER• Sleepy• Became apneic and

unarousable in the CT scanner

Case #3 – RD, 6yoM• 6 year old male

• Myelomeningocele• Correction + shunt at birth• 3 revisions, most recent 3

months ago

• “Fussy” all day, fever 104 F, vomiting

• Called by peds ER• Sleepy• Became apneic and

unarousable in the CT scanner

www.neuroradiologycases.com

CT – 1 month ago

Case #3 – RD, 6yoM• 6 year old male

• Myelomeningocele• Correction + shunt at birth• 3 revisions, most recent 3

months ago

• “Fussy” all day, fever 104 F, vomiting

• Called by peds ER• Sleepy• Became apneic and

unarousable in the CT scanner

• What next? Alfayate et al., 2011

CT today

Case #4 – 55yoM• 55 year old male

• Hypertension

• Did not wake up at usual hour, family called EMS

• On exam• Unarousable• Localizes bilaterally• PERRL

• What next?

Case #4 – 55yoM• 55 year old male

• EVD inserted, no noticeable change

• What next?

Case #5 – 65yoF• 65 year old female

• Obese, coronary artery disease (ASA 81mg + Plavix daily)

• Admitted to Internal Medicine because of low back pain

• Neuro exam: normal

• Imaging: diffuse disc degeneration

• Medical management of LBP• Narcotics• Lumbar epidural steroid

injection

Case #5 – 65yoF• 65 year old female

• You are called to Internal Medicine floor 2 hours post-LESI

• Patient drowsy since arrival (sedation received during injection) but following commands

• Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities

• What next?

Case #5 – 65yoF• 65 year old female

• You are called to Internal Medicine floor 2 hours post-LESI

• Patient drowsy since arrival (sedation received during injection) but following commands

• Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities

• What next?

Ahn et al., 2009

Case #6 – 43yoM• 43 year old male

• Smoker, hypertensive, obese

• Right hemiparesis, aphasia

• Acute onset, 2 hours ago• Received IV tPA at outside

hospital, 1 hour ago• No improvement

• Initial CT is provided

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Case #6 – 43yoM• 43 year old male

• Options?

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Case #6 – 43yoM• 43 year old male

• Options?

• Neurology team orders MRI, now 2:30 since onset

• What next?

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