N E U R O S U R G E RY C A S E R E V I E W

NEUROTRAUMA

I WAYA N A R YA N TA P U T R A
OUTLINE

Case 55

Case 56

Case 57

Case 58

Case 59

Case 60

Case 61
CASE 55

• 70 y.o. woman with end-stage Alzheimer’s disease

• 3 day episode of confusion, agitation, inappropriate behavior
• Had history of frequent falls
• Left-sided pronator drift
QUESTIONS
1. Interpret the CT scan. 9. Interpret the studies and provide a differential diagnosis.
2. Other questions or information 10. What is your management plan?
3. Further studies or investigations
4. Education
5. Describe all the steps of surgery
6. Causes of hyponatremia in this case
7. Hyponatremia management
8. She comes back 3 weeks later and has some purulent
discharge from the right posterior incision, somnolent and
has a left hemiparesis slightly. What is your course of
action?
CASE 56

• 42 y.o. woman fell from the third floor of a building

• GCS 7
• Hemodynamically stable
• Pupils are both reactive, but asymmetrical
QUESTIONS
1. Interpret the CT scan.
2. Pathophysiology of intracranial bleed
3. Initial management
4. Criteria for surgical evacuation
5. Prognosis
CASE 57

• 39 y.o. man is involved in an all-terrain vehicle accident.

• GCS was 7 (eyes 1, verbal 1, motor 5).
• Hemodynamically stable
QUESTIONS
1. Interpret the CT scan
2. Pathophysiology of intracranial bleed
3. Management
4. Criteria for surgical evacuation for acute SDH
5. Prognosis
6. Other types of TBI that you see
7. Indications for surgical evacuation in the different types of intracranial hemorrhage
8. Indications for antiepileptic medication
CASE 58

• 20 y.o. man is involved in an accident • The next 3 days, ICP rises

• Hemodynamically stable • Repeat CT scan shows diffuse cerebral edema with
• GCS before intubation is 8 effacement of the subarachnoid spaces.
• Has an intraventricular drain placed to monitor ICP (17 • TCD reveal high velocities in both CA and MCA.
mmHg) with CPP above 70 mmHg
QUESTIONS
1. Other tools can help to optimize ICP management
2. Role of continuous EEG
3. Role of microdialysis
CASE 59

• 26 y.o. male is hit by a car

• GCS is 6
• CT scan shows a small right acute SDH with a 4 mm midline shift
• Intraventricular drain is placed to monitor ICP
QUESTIONS
1. Pathophysiology of raised ICP
2. ICP monitoring
3. Indications for ICP monitoring
4. Managing elevated ICP (describe first-, second-, and third-tier measures)
CASE 60

• 50 y.o. man being involved in an altercation. • Right pupil is 6 mm slow reaction, left pupil is round,
• Unconscious, actively bleeding from a right forehead wound regular, and reactive to light
• Breathing spontaneously hypotensive and tachycardic • Burn marks and black powdered material around the wound
• GCS is 8
QUESTIONS
1. The most likely diagnosis 12. When do you attempt to remove the offending object?
2. Initial management
3. History taking
4. Kind of radiological studies
5. Interpret the CT scan
6. Prophylactic antibiotics
7. Mechanism of damage in gunshot injuries to the brain
8. Indications for surgery
9. Type of intervention
10. Prognosis
11. Factors related to weapons that might affect the severity
CASE 61

• 27 y.o. man with a history of being struck in the head with a blunt object
• GCS is 15
• There are no focal neurologic deficits
CASE 61

• MRI of the brain with coronal T2-weighted and sagittal T1-weighted showing the depressed skull fracture with brain
contusions
• MR venography showing disruption of the posterior portion of the superior sagittal sinus
QUESTIONS
1. Initial work-up and management
2. Other studies would be indicated
3. Outline your plan of care at this point
4. Interpret the MRI
5. Patient develops a right hemiparesis and a speech
disturbance. What is the cause of these findings?
6. Management plan at this time
7. Position for the operative
8. Preoperative special arrangements
9. Plan for skin flap
10. Nontypical neurosurgical devices
11. Anesthesiologist particular instructions (pulse of 120
beats/minute, SBP is 90 mmHg, CVP line is not connected
to a monitor)
12. Next step in the management
13. Would you begin removing depressed fragments or would
you plan a bone flap?
14. Before beginning the bone work would you consider
harvesting any tissue?
15. While performing your bony removal, copious bleeding
begins from a disrupted sagittal sinus. What is your next
step in management?