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
www.radiopaedia.org
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?
www.radiopaedia.org