Neurosurgical Emergencies Craig Goldberg, MD Chief, Division of Neurosurgery Bassett Healthcare I’d like to thank Dr. Borgstrom for including me in this symposium

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 China Las Vegas Utah Chicago Jersey Any definition of rural is highly dependent on your perspective. March 29, 1976 by Saul Steinberg

Defining Rural “I know it when I see it.” Justice Stewart wasn’t exactly talking about rural surgery, but I find his definition functional. Potter Stewart, Associate Justice of the United States Supreme Court Wikipedia.com

Defining Rural With a nod to comedian Jeff Foxworthy, if you pass a tepee on your way to work, you might be a rural surgeon. The author has no financial arrangements with this souvenir stand to report

Guidelines for the Management of Severe Traumatic Brain Injury Guidelines for the Management of Severe Traumatic Brain Injury May 2007 Journal of Neurotrauma www.braintrauma.org With supplementation from additional literature

Why focus on this study?

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

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

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 “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)

Not a first choice 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

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 The most common target 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 Diffuse 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?