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Emergency Presentation of Neurosurgical Conditions

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Emergency Presentation of Neurosurgical Conditions Emergency presentation of neurosurgical conditions Many neurosurgical conditions present in an acute fashion, and optimal outcome often depends on prompt recognition and referral by general practitioners and emergency room personnel. The approach to neurosurgical emergencies is discussed in this article. P Semple, MB ChB, FCS (Neurosurg) (SA), MMed, PhD Division of Neurosurgery, University of Cape Town Patrick Semple is Associate Professor, Division of Neurosurgery, University of Cape Town, Principal Specialist and Head of Neurocritical Care, Groote Schuur Hospital, Cape Town. His interests are neuroendoscopy, pituitary surgery and neurocritical care. B J Malan, MB ChB Division of Neurosurgery, University of Cape Town Barend Malan is a final-year registrar in the Division of Neurosurgery, University of Cape Town. His interests are neurovascular surgery and neuro- oncology. Correspondence to: B J Malan ([email protected]) Approach to a neurosurgical emergency management is instituted at the same time respirations (Cushing’s reflex) and is a sign begins with an appropriate history of as problems are identified. of impending tonsillar herniation. surrounding events followed by general examination and focused neurological Temperature examination.[1] This should be performed Elevated blood pressure may Fever may indicate underlying CNS while applying general supportive care. After be a reactive phenomenon or infection. outlining a general approach to the patient reflect the underlying cause. presenting with a neurosurgical emergency, General examination the more common clinical scenarios will be Evidence of trauma – scalp bruising or discussed. Vital signs laceration, periorbital (raccoon eyes) or Airway and breathing retro-auricular bruising (Battle sign) and History Ensure adequate airway and oxygen CSF leak from the nose or ear. A detailed history of presenting events and saturation above 95%. Cheyne Stokes general medical history should be obtained respiration is the most common abnormal Neurological examination from the patient if possible, family members breathing pattern, characterised by periods Level of consciousness or emergency service personnel and should of hyperventilation alternating with periods Level of consciousness is assessed using the include the following: of apnoea. Consider intubation if Glasgow GCS (Table 1).[2] The GCS is made up of the Presenting events: coma scale (GCS) <8. sum of the best eye opening, best verbal • rapidity of symptom onset or neurological and best motor responses, with a total score deterioration Circulation ranging from 3 to 15 (normal). • seizures Elevated blood pressure may be a reactive • nausea or vomiting phenomenon or reflect the underlying Fundoscopy and pupillary response • recent or previous trauma cause. With increasing intracranial pressure Fundoscopic examination for papilloedema • recent febrile illness. an acute rise in blood pressure may be is an essential clinical skill. Pupils are accompanied by bradycardia and decreased checked for both size and response to Previous medical history: • hypertension and compliance with Table 1. Glasgow Coma Scale treatment • diabetes mellitus Best motor response 6 Obeys commands 5 Localises painful stimulus • epilepsy 4 Abnormal flexion • known history of previous/underlying 3 Decorticate posturing malignancy/pituitary tumour 2 Decerebrate posturing • HIV and antiretroviral treatment 1 No response • history of anticoagulant use. Best verbal response 5 Orientated 4 Confused speech Surgical history: 3 Words 2 Incomprehensible sounds • previous neurosurgery, e.g. ventriculo- 1 No response peritoneal shunt.[1] Best eye opening response 4 Opens eyes spontaneously 3 Opens eyes to speech Examination 2 Opens eyes to painful stimulus Clinical examination focuses on the 1 No response principles of ABCD, and supportive 75 CME March 2013 Vol. 31 No. 3 Neurosurgical emergencies light. A unilateral dilated pupil suggests Focal motor deficits All patients presenting with unusually the presence of a structural lesion with Focal motor deficits include hemiparesis/ sudden or severe headaches should be uncal herniation. Pontine lesions result in plegia and monoparesis and should be investigated for SAH.[5] pinpoint pupils, while midbrain lesions are documented during assessment of the motor associated with midposition fixed pupils. component of the Glasgow coma score. Examination Findings include decreased level of Eye movements Common presentations consciousness, neck stiffness and focal Evaluate spontaneous eye movements and • Acute loss of consciousness. Loss of neurological deficits. Focal deficits may the ocular reflexes – oculocephalic (doll’s consciousness is a presentation common be due to mass effect from the aneurysm eye) and oculovestibular. Hemispheric to a variety of medical conditions and is (e.g. third nerve palsy in posterior lesions involving the frontal eye fields result best assessed using the GCS, as described communicating artery aneurysms) or in deviation of the eyes away from the side of above. The causes of coma are divided intracerebral haematomas. the associated hemiplegia. Brainstem lesions into 2 major groups and common causes involving the reticular formation in the pons of each are shown in Table 3. Metabolic Investigation result in conjugate deviation of the eyes causes of acute loss of consciousness Imaging toward the side of the associated hemiplegia. are more likely to produce symmetrical Uncontrasted CT scan of the brain is the Nystagmus may indicate cerebellar lesions.[1] neurological deficits, compared with focal investigation of choice in suspected SAH deficits in structural causes.[3] and may reveal blood in the cisterns at Cranial nerve examination • Sudden-onset severe headache. the base of the brain, intraventricular Third and sixth nerve palsies are common • Subarachnoid haemorrhage (SAH) or intraparenchymal blood (Fig. 1). indicators of raised intracranial pressure. occurs when blood enters the Hydrocephalus may also be present. If Other cranial nerve deficits may also be subarachnoid space, in the majority of uncontrasted CT of the brain is negative, present depending on the location of cases due to rupture of an intracranial a lumbar puncture should be performed to pathology.[1] saccular aneurysm. It occurs most establish the presence of xanthochromia, commonly in the 5th - 6th decades.[4] unless a contraindication to lumbar puncture Meningism is present.[6] Remember that neck stiffness has a number History of causes and does not always mean Sudden-onset severe headache, described Laboratory meningitis – performing a lumbar puncture as ‘the worst headache of my life’, occurs in Full blood count (FBC), clotting profile, in a patient with tonsillar herniation will 80% of patients. Headaches are commonly urea, electrolytes and creatinine (UEC). have disastrous consequences (Table 2). retro-orbital, radiate to the neck and often Initial management occur during periods of intense activity or • Monitor arterial oxygen saturation and straining. Vomiting is also common.[4] Twenty blood pressure Table 2. Causes of neck stiffness per cent of patients have a history of • Supplemental oxygen preceding symptoms, including headache, • Intravenous access and fluid Meningitis nausea, vomiting and dizziness, thought administration, correct hyponatraemia Subarachnoid haemorrhage to arise from small haemorrhages from • Stool softeners to prevent straining Tonsillar herniation (raised intracranial the aneurysm or acute expansion of the • Anticonvulsants, especially if seizures pressure) aneurysm sac. Within seconds or minutes occurred during the initial event.[6] Cervical spine trauma following headache, patients may lose consciousness, develop seizures or die. Table 3. Causes of acute loss of consciousness Toxic/metabolic Structural Electrolyte imbalance Vascular Hypo/hypernatraemia Bilateral cortical/subcortical infarcts Endocrine Bilateral carotid artery stenosis Hypoglycaemia Bilateral di-encephalic infarcts Diabetic ketoacidosis Infectious Addison crisis Abscess Toxins Empyema Ethanol Trauma Drug overdose Neoplastic Organ failure Primary Uraemia Secondary Hypoxaemia Increased intracranial pressure Fig. 1. Uncontrasted CT brain revealing Liver failure Herniation from mass effect Epilepsy Acute lateral shift of the brain extensive subarachnoid blood in the basal cisterns (arrow). 76 CME March 2013 Vol. 31 No. 3 Neurosurgical emergencies Pituitary apoplexy structures (oral cavity, sinuses, middle ear), (Fig. 2) or enhancing subdural collection Pituitary apoplexy results from haemor-rhage either directly or by retrograde venous in the presence of subdural empyema. or infarction of a pituitary adenoma, resulting thrombosis, or haematogenous spread Opacification or air-fluid levels in the sinuses in acute tumour expansion with compression in patients with valvular heart disease may indicate sinusitis. Chest X-ray can reveal of surrounding structures in the sellar region, (infective endocarditis), cyanotic congenital evidence of pneumonia or bronchiectasis.[10] notably the optic nerves and hypothalamus.[7] heart disease and chronic suppurative lung disease (bronchiectasis).[9] Laboratory History FBC, UEC, septic markers (CRP/ESR) The patient may be known to have a pituitary History and blood culture.[10] Lumbar puncture is tumour, but in the majority pituitary apoplexy Patients may have a history of recent febrile contraindicated in the presence of decreased is the first presentation. Symptoms include illness, including
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