Tag Archives: neurosurg

Epidural Hematoma (quick review)

2 Dec

submitted by Christina Brown, M.D.


Definition – Inward bending of cavarum causes bleeding when dura separates from skull:

  • Middle meningeal artery is involved in bleed >50% of time.
  • Meningeal vein is involved in 1/3.



  • Mortality is 12% and is related to preoperative condition.  
  • Skull fracture is associated in 75% of cases, less commonly in children. 


Pediatric Considerations

  • Head injury is the most common cause of death and acquired disability in childhood.  
  • Bleeding is more likely to be venous.
  • Good outcome in 95% of children <5 yr



  • LOC: 85% will have at some point in course:
  • Only 11–30% will have a lucid interval.


MORE Pediatric Considerations

  • Many times the only clinical sign is drop in hematocrit (Hct) of 40% in infants.
  • Bulging fontanel with vomiting, seizures, or lethargy also suggest EDH in infants.
  • Less than 50% of children have LOC at time of injury.
  • Posterior fossa lesions are seen more commonly in children.


Physical Exam

  • Pupillary dilation:  Usually on same side as lesion (90%)
  • Hemiparesis >1/3:  Usually on opposite side from lesion (80%)


Imaging (CT Head)

  • Lenticular, biconvex hematoma with smooth borders may be seen.
  • Mixed density lesion may indicate active bleeding.
  • Most commonly seen in temporal parietal region




Initial Stabilization/Therapy

  • Head-injured patients have 25% improved mortality when triaged to regional trauma centers
  • Prevent hypoxia and hypotension:
    • Rapid-sequence intubation for signs of deterioration or increased intracranial pressure (ICP)
  • Perform rapid neurologic assessment


ED Management

Early surgical intervention (<4 hr) in comatose patients with EDH.  Nonsurgical intervention in asymptomatic patients is associated with high rate of deterioration; >30% require surgical intervention.

Control ICP

  • Prevent pain, posturing, and increased respiratory effort
  • Elevate head of bed 15–20% after adequate fluid resuscitation.
  • Controlled ventilation to PCO2 of 35–40 mm Hg (Avoid hyperventilation unless signs of brain herniation are present).

Continuous end tidal CO2 monitoring

Arterial line placement for close monitoring of MAP, PO2, PCO2

Treat HTN:  Nicardipine, Labetalol

Treat hyperglycemia if present: Associated with increased lactic acidosis and mortality in patients with TBI

Treat and prevent seizures: diazepam, levitiracetam, etc.

and once again, Early (neuro)surgical intervention


  1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Epidural Hematoma, Rosen & Barkin’s 5-Minute Emergency Medicine Consult.
  2. Bullock M R et al.: Surgical management of traumatic brain injury. Neurosurgery.2006; 58(3 Suppl):S16–S24.
  3. Marion D M.: Epidural hematoma.  In: Bradley W G: ed. Neurology in Clinical Practice,5th ed.Elsevier;2008: 54 A,B:1083–1114.
  4. Vincent J L and Berre J.: Primer on medical management of severe brain injury. Crit Care Med.2005; 33(6):1392–1399.
  5. Huh J W and Raghupathi R.: New concepts of treatment in pediatric traumatic brain injury. Anesth Clin.2009: 27(2):213–240.
  6. picture





9 May

submitted by Christina Brown, M.D.

Definition – Air in the cranial vault.  

Mechanically speaking, intracranial air becomes trapped and expands due to a ball valve effect resulting in mass effect, can result in headache and signs and symptoms of increased ICP [5].  

Usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis [1, 2].


  • Headache and altered consciousness are the most common symptoms [3].
  • Tension pneumocephalus = neurosurgical emergency


  • X-rays can diagnose pneumocephalus, but CT scan is the modality of choice.
  • Classical CT sign of tension pneumocephalus = “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the large volcano in Japan.  




  • Neurosurgery C/S. In the vast majority, post-operative pneumocephalus is an expected finding in essentially all post-craniotomy patients.  Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided.  
  • Non-operative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans. 


Operative – In cases of tension pneumocephalus, a burr hole may need to be performed to relieve pressure. 



  1. Yildiz A, Duce MN, Ozer C, et al. Disseminated pneumocephalus secondary to an unusual facial trauma. Eur J Radiol. 2002;42:65–68. doi: 10.1016/S0720-048X(01)00383-7. 
  2. Jenson MB, Adams HP. Pneumocephalus after air travel. Neurology. 2004;63:400–401.
  3. Kapoor T, Shetty P. J Emerg Med. 2008;35:453–454. doi: 10.1016/j.jemermed.2007.03.046. 
  4. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84:115–117. 
  5. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84 (1): 115-7. Br J Anaesth (abstract)
  6. pictures


Spinal Shock

17 Nov

Definition – Spinal cord injury (SCI) that leads to loss of sympathetic tone below level of the injury.  Hypotension, bradycardia are key clinical signs s/p recent trauma.



  • Fracture of spinal element
  • Dislocation
  • Ligamentous Rupture
  • Disc herniation
  • GSW indirectly (Kinetic energy)


Clinical Signs/Symptoms

  • Paralysis
  • Anesthesia
  • Hypotension
  • Bradycardia (Unopposed Vagal activity).
  • Absent bowel and bladder control


Phases of spinal shock

Phase Time Physical exam finding Underlying physiological event
1 0–1d Areflexia/Hyporeflexia Loss of descending facilitation
2 1–3d Initial reflex return Denervation supersensitivity
3 1–4w Hyperreflexia (initial) Axon-supported synapse growth
4 1–12m Hyperreflexia, Spasticity Soma-supported synapse growth


Emergency Management

  • A/B: patient with a high cervical cord injury may breathe poorly and may require airway suction or intubation.
  • C: Hypotension may occur due to blood loss from other injuries or due to blood pooling in the extremities lacking sympathetic tone because of the disruption of the autonomic nervous system (neurogenic shock).
    • Vasopressors are usually required. Levophed has been used widely amongst patient’s with TSCI with hypotension and bradycardia. Phenylephrine is theoretically taught as 1st line treatment but studies recommend goal of MAP > 85 – 90 (4,5). 
    • Elevation of the legs, the head-dependent position, blood replacement, and/or vasoactive agents may be required (1).
  • Secondary: check for bladder distension by palpation or ultrasound. A urinary catheter should be inserted as soon as possible.


Further Management

  • Cardiovascular complications— Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications.
    • An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury (goal MAP > 85 – 90 mmHg).
  • Respiratory complications – Weakness of the diaphragm and chest wall muscles leads to impaired clearance of secretions, ineffective cough, atelectasis, and hypoventilation.

Glucocorticoids — Methylprednisolone is the only treatment that has been suggested in clinical trials to improve neurologic outcomes — however, the evidence is limited, and its use is debated.  Methylprednisolone is contraindicated in patients with moderate to severe traumatic brain injury.

Surgery — Goals for surgical intervention in TSCI include stabilization of the spine, as well as reduction of dislocations and decompression of neural elements.


Submitted by Christina Brown.



  1. http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=neurogenic+shock&selectedTitle=2%7E17
  2. Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2013; 28:12.
  3. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87:239.
  4. Blood pressure management after acute spinal cord injury. Neurosurgery 2002; 50:S58.
  5. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993; 33:1007.
  6. Stevens RD, Bhardwaj A, Kirsch JR, Mirski MA. Critical care and perioperative management in traumatic spinal cord injury. J Neurosurg Anesthesiol 2003; 15:215.
  7. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  8. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  9. TABLE: http://www.nature.com/sc/journal/v42/n7/full/3101603a.html

strength in numbers: subarachnoid hemorrhage

30 Jul

via a recent EP monthly article on acute SAH vs. traumatic tap:


sensitivity of CT for diagnosing aSAH: 93% (95% CI 89-96%)

sensitivity of CT  within 6 hrs of headache onset: 100% (95% CI 97-100%)

sensitivity of CT beyond 6 hrs: 86% (95% CI 78-91%)


traumatic taps in up to 30% of LPs


one study (caveats: required dx of aneurysmal aSAH on CTA, and 8/15 SAH dx by LP were missed on initial CT read):

  • cutoff of <2000 x 10^6/L  CSF RBCs: 93% sensitivity (CI 66-99.7%)
  • cutoff of <2000… RBCs + no xanthochromia: 100% sensitivity (CI 74.7-100%)
  • only 15 cases of aSAH diagnosed by LP at 12 academic centers in 10 years
  • interesting, but not practice changing just yet


Food for thought.


References: epmonthly article, picture


ocular ultrasound for elevated ICP

22 Jan

(re-post of an old review, but came up again recently, worth a refresher)


from sonoguide.com:

Evaluation of the optic nerve sheath diameter (ONSD) can detect EICP.

On ultrasound a normal optic nerve sheath measures up to 5.0 mm in diameter.

The ONSD is measured 3 mm posterior to the globe for both eyesA position of 3 mm behind the globe is recommended because the ultrasound contrast is greatest, the results are more reproducible

Two measurements are averaged.

An average ONSD greater than 5 mm is considered abnormal and elevated intracranial pressure should be suspected.



35 patients, 14 with elevated ICP on CT

all 14 with elevated ICP were detected with ONSD >5.0mm (mean ONSD was 6.27mm)



50 patients with brain injury + 26 controls

ultrasounded ONSD, then intraparenchymal catheter to measure ICP

severe brain injured patients (ONSD 6.1 +/- 0.7 mm; ICP 26.2 +/- 8.7 mmHg)

moderate brain injury (ONSD 4.2 +/- 1.2 mm; ICP 12.0 +/- 3.6 mmHg)

controls (ONSD 3.6 +/- 0.6 mm; ICP 10.3 +/- 3.1 mmHg).

best cut-off value of ONSD for predicting elevated ICP was 5.7 mm (sensitivity = 74.1% and specificity = 100%)




References: sonoguide; study 1; study 2; picture


Arnold-Chiari malformation

26 Jun


Developmental anomalies affecting the cerebellum and brainstem may present with vestibular or cerebellar symptoms in adulthood.

occurs most commonly with type I Arnold-Chiari malformation-> downward displacement of the cerebellar tonsils through the foramen magnum.

clinical manifestations of this malformation are related to cerebellar involvement, obstructive hydrocephalus, brainstem compression, and syringomyelia.

  • Cerebellar ataxia in the type I malformation usually affects the gait and is bilateral; sometimes asymmetric.
  • Hydrocephalus from blockage of CSF flow leads to headache and vomiting.
  • Compression of the brainstem by herniated cerebellar tissue may be associated with vertigo, nystagmus, and lower cranial nerve palsies. 

diagnosed by CT or MRI studies that demonstrate cerebellar tonsillar herniation.

Patients with symptoms related to compression of the cerebellum or brainstem may benefit from surgical decompression of the foramen magnum.

The treatment for this is suboccipital craniectomy, sometimes with the removal of the posterior ring of C1 vertebrae.


Submitted by J. Stone.


Sources: Pathology the Big Picture., textbook; Clinical Neurology, textbook, Posterior Fossa Malformations. Chapter 8 – disorders of equilibrium.; Schwartz’s Principles of Surgery, chapter 42 Neurosurgery, congenital and developmental anomalies.; picture 1, picture 2


headache, elevated INR, CT negative. what now?

3 Jun


Your next patient is a 60 yo female with a severe, acute onset headache.

She recently had an elevated INR on routine check and was stopped on her Coumadin.

CT is negative (no bleed).  



Yet, you’re still worried about a SAH…



According to uptodate, there are no studies that have quantified bleeding risk in patients with thrombocytopenia or coagulopathy after LP.



No LP until correction in patients with

  • plts < 50-80K,
  • active bleeding,
  • INR > 1.4


You can always treat empirically (FFP/vitamin K, etc).


Submitted by J. Rothstein.


References: uptodate article; picture