Neurosurgical Emergencies

Craig Goldberg, MD

Chief, Division of Neurosurgery

Bassett Healthcare

Overview

• Defining “rural”

• Evidence-based guidelines for TBI treatment

• Brain surgery for the general surgeon

• Head CT basics

• A few words on spine (if there is time)

Defining Rural

March 29, 1976 by Saul Steinberg

ChicagoChicagoUtahUtah

ChinaChina

JerseyJersey

Las VegasLas Vegas

Defining Rural

Potter Stewart, Associate Justice of the United States Supreme Court

“I know it when I see it.”

Wikipedia.com

Defining Rural

The author has no financial arrangements with this souvenir stand to report

Guidelines for the Management of Severe Traumatic Brain Injury

May 2007 Journal of Neurotraumawww.braintrauma.org

• With supplementation from additional literature

Why focus on this study?Latest installment in this series (1995 and 2000)

significant strides in improving outcomes by minimizing secondaryinjury

mortality (50% down to 25% in 30 years)functional outcomelength of hospital staycost

Evidence-basedadvantageslimitations

available data – some options are really standards of caresometimes impossible to study a treatment or device

Almost all of these can be followed in a “rural” setting

Airway, Breathing, and Circulation

Hyperventilation

• Level II - prophylactic hyperventilation NOT recommended

• IS recommended as a temporizing measure for the reduction of high ICP, but should be avoided in the first 24 hours after injury and should have SjO2 or PbrO2 monitors

BP and O2

Level II: avoid SBP <90mmHg

Level III: avoid O2 < 90%, PaO2 < 60mmHgunlikely ever to be a randomized controlled study

CPP Thresholds

• Level II: > 70mmHg can lead to CHF, ARDS

• Level III: 50-70mmHg is target

Infection Prophylaxis

• Level II:– Antibiotics for intubation

– Early tracheostomy and extubation

• Level III:– Early extubation

– Abx and ventriculostomy rotation NOT recommended

Hyperosmolar therapy

Level II: mannitol 0.25 to 1gm/kg is effective in highICP(avoid SBP < 90mmHG)

Level III: before ICP monitoring, use only for transtentorialherniation (blown pupil) or progressive neuro deteriorationwithout extracranial cause

RCT needed for 3% saline

DVT Prophylaxis

• Level III:– use SCDs

– use SQ heparin but• no data on dose or timing• does increase hematoma

Additional Treatments

Steroids

• Level I: In patients with moderate or severe traumatic brain injury (TBI), high-dose methylprednisolone is associated with increased mortality and is CONTRAINDICATED

• This is the ONLY standard in these recommendations.

Seizure Prophylaxis

• Level II:– For EARLY (first week) seizure prevention

– Not good for late

Hypothermia

Level III: prophylactic hypothermia doesn't decreasemortality (may work if used > 24hrs)May lead to higher GOS

“only given to patients in a randomised (sic) controlled trial”Cochrane Library Vol(1) 2009

Nutrition

• Level II: – Full caloric intake by day 7

“Patients who were not fed within 5 and 7 days after TBI

had a 2- and 4-fold increased likelihood of death, respectively.”Journal of Neurosurgery Jul 2008, Vol. 109, No. 1, Pages 50-56: 50-56.

Chemical Coma

• Level II - prophylactic barbiturates NOT recommended

• but barbiturates ARE recommended to control refractory ICP

• Propofol can control ICP but has not shown improvement in mortatlity or 6 month outcome

Indications for ICP monitoring

• Level II: Salvageable with GCS 3-8 and abnormal CT (start to treat @ ICP 20)

• Level III: normal CT with GCS 3-8 and 2 of the following– age >40– SBP < 90

– posturing– (start to treat clinically)

• The issue of non-neurosurgeons doing emergency craniotomies and burr holes was brought up. The consensus of the Committee is that neurosurgeons themselves should be the ones doing these operations. We do all acknowledge, however, that there are extreme circumstances in rural America where general surgeons that are properly trained might be able to perform a lifesaving cranial procedure when other alternatives are not available. The Committee, therefore, is not totally opposed to such a concept.

• From Council of State Neurosurgical Societies Neurotrauma Committee Meeting, April 25, 2003

Not a first choice

Intracranial Pressure Monitoring

• Devices– Ventriculostomy

• Still “gold standard”• Ventricles sometimes hard to cannulate• Can get obstructed with debris• Costs less • Can be recalibrated

– Fiber optic monitors• Diagnostic, not therapeutic• Readings can drift• Doesn’t go through the brain• Easier to insert

Anatomy

• The skull is approx 1cm thick

• The ventricles are approx 6cm deep to the outer surface of the skull

Anatomy

• The most common entry point is – 10-12cm back from the glabella

– Then lateral approx 2-3cm to the mid-pupillary line

• The most common target point is– The foramen of Monro (connects the lateral

ventricle to the third ventricle which is past the choroid plexus)

Procedure

• Often done at bedside in ER or ICU– (rarely on floor, in emergency, then immediate

transfer to ICU likely)

• Patient supine, head elevated to 30 degrees or more

• Analgesia, sedation, paralysis (if intubated)

• Right side of head shaved

Procedure

• Cranial access kit, ventriculostomy tube and drainage bag opened

• Local anesthetic instilled

• Small linear (A-P) incision made

• Self-retaining retractor inserted

• Burr hole drilled

• Bone dust cleared

Procedure

• Dura punctured

• Tube inserted to approx 6cm depth

• CSF pressure measured, specimen collected

• Tube tunneled postero-laterally

• Tube secured, wound closed

• Tube attached to drainage bag and set to desired level (usually 10cm above pts ear)

CSF Dynamics

• When tube attached to transducer– Triphasic waveform, with second wave

corresponding to dicrotic notch on a-line– Please do NOT use heparin

• Normal ICP 5-15mmHg = 7-20cm H2O• Autoregulatory range (Monro-Kelly

doctrine) • Small changes in volume lead to little or no

changes in pressure

CSF Dynamics

• Normal CSF volume: – 50cc in ventricles, 150cc total

• CSF volume is replenished 3 times per day (approx 400-500cc per day)

• Typical drainage volumes are 5-20cc/hr• There will usually be an initial high-

pressure gush. ICP can be measured

Transport

• Clamp off (no drainage) for transport– Bed to stretcher to ambulance to other hospital

if patient can tolerate– Trying to avoid overdrainage– Do NOT leave open and below head– May need to be opened, either intermittently or

continuously for lengthy transport– Pressure changes with air travel further

complicate the issue

Head CT Basics

Classification

• Morphology– Intracranial lesions

• Focal– Epidural hematomas

– Subdural hematomas

– Intracerebral hematomas

• Diffuse– Concussion - usually non-structural

– Diffuse axonal injury (DAI)

Epidural Hematoma on CT

• Lentiform

• Arterial

• Associated with– Skull fx

• “Lucid interval”

• Usually younger

• Outcome good– If treated in time

Subdural Hematoma on CT

• Crescentic – (moon-shaped)

• Usually venous• 3-4 times more • common than EDH• High morbidity &

– mortality (50%)

• Usually assoc with– brain injury

Intracerebral Hematoma on CT

• More diffuse

• Capillaries and small– Vessel source

• Actual injury to the– Brain itself

• Can be remote from– Impact site– Coup vs contrecoup

Craniotomy 101

• Verify the correct side on imaging– if no imaging, go with the side of the blown

pupil– if both pupils are blown, go with the side that

blew first– if you don’t know, go in on the left first

Spine

Spine

• Steroids• Treatment with methylprednisolone for either 24

or 48 hours is recommended as an option in the treatment of patients with acute spinal cord injuries that should be undertaken only with the knowledge that the evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit.

• Neurosurgery supplement to March 2002, Vol 50#3, pS63

Spine

• Solumedrol protocol– bolus 30mg/kg IV over 15 min

– 45 min pause– 5.4mg/kg/hr X 23 hrs if < 3hrs from injury– X 47 hrs if < 8hrs from injury

Spine

• Hypothermia– unproven and experimental

Conclusions

• Rural is rural

• Don’t treat TBI with steroids

• Do keep the patient oxygenating and perfusing

• Many treatments to try with suspected or documented high ICP

Conclusions

• Steroids in spine are an option, hypothermia has no proven benefit (yet?)

• If there is a possibility that you might find yourself doing brain surgery, this lecture is not enough

Questions?