Neurosurgery Review
for Medical Student
17 Febuary 2552
Stroke
• ผู้ป่วยหญิงอายุ 50 ปี ขณะดูโทรทัศน์ที่โซฟา มีอาการปวดท้ ายทอย
อย่างมาก อาเจียน ซึมลง PE : GCS 13, no motor
weakness, stiff neck +ve จงให้ การวินิจฉัย
a)
b)
c)
d)
e)
Pontine hemorrhage
Cellebellar hemorrhage
Subarchnoid hemorrhage
Basal ganglion hemorrhage
Intraventricular hemorrhage
เฉลย C
Stroke
• Ischemic VS hemorrhagic
• Ischemic syndrome ต่าง ๆ
• Hemorrhagic disease
– Hypertensive hemorrhage
– Amyloid angiopathy
– SAH from ruptured aneurysm
– Ruptured AVM
– (อื่น ๆ – bleeding tumor, coagulopathy, parasite,
vasculitis)
Stroke
• Ischemic VS hemorrhagic
– Hemorrhagic stroke มักมี sign of IICP (ปวดหัว อาเจียน ซึม
ลง)
– Ischemic stroke มักมาด้ วย sudden neurodeficit
• Hemiparesis
• Apasia / apraxia
• Amaurosis fugax
– Onset แยกไม่ได้
– Clinical แยกไม่ได้ 100%  need investigation = CT
Stroke
• Ischemic stroke
– MCA: Hemiparesis, contralateral hemisensory loss,
aphasia
– ACA: Paresis and sensory loss of contralateral lower
extremity
– PCA: Homonymous hemianopia with macular sparing
– Basilar: Cranial nerve signs – diplopia, facial weakness,
vertigo, dysarthria
Stroke
• Hemorrhagic stroke
– Hypertensive ICH
– Ruptured cerebral aneurysm
– Ruptured AVM
– Amyloid angiopathy
– Bleeding tumor
– Coagulopathy
Stroke
• Hypertensive ICH
– Hypertension > 90%
– IICP signs and symptoms (headache, vomiting,
↓consciousness)
– Common site:
• Basal ganglion – Hemiparesis, Aphasia (dominant
hemisphere)
• Thalamus – hemianesthesia
• Cerebellar – ataxia, cerebellar sign +ve
• Pontine – pinpoint pupil
Stroke
• Hypertensive ICH
– Antihypertensive drugs
• SBP > 200  IV antihypertensive
• SBP > 180 or MAP > 130
– IICP suspected  monitor ICP keep CPP 60-80 mmHg
– No IICP suspected  modest ↓ BP to MAP 110 or 160/90
– Surgery VS Medical treatment
• Recommendation: cerebellar hemorrhage > 3 cm (class
I)
AHA guideline 2007
Stroke
• Ruptured cerebral aneurysm
– “Worst headache of my life”
– With or without neurodeficit
– Stiffneck / nuchal rigidity
– CT: Subarachnoid hemorrhage
– Common sequelae:
• Rebleeding
• Hydrocephalus
• Vasospasm
Stroke
• Ruptured cerebral aneurysm
– Key point of management
• Refer to neurosurgeon ASAP (for clipping to prevent
rebleeding)
• If clinical suspected but negative CT
 LP ดู xanthochromia
• Investigation of choice: 4 vessels angiography
(alternative: CT angiography (CTA), MRA)
Stroke
• Ruptured AVM
– Young age**
– Lobar hemorrhage
– Non-hypertension
– Investigation: angiography
– Risk rebleeding 2-3%/y
– Management:
• Surgery – excision
• Embolization
• Radiosurgery
Stroke
• Investigation in intracerebral hemorrhage
• Consider
– Angiography
– CT angiography
In
– Young age (< 45)
– Non hypertension
– Uncommon site (Lobar)
Stroke
• Amyloid angiopathy
– Old age
– Non-hypertension
– Lobar hemorrhage
– No special investigation needed
Trauma
• ผู้ป่วยชายอายุ 50 ปี ขับรถยนต์ชนจักรยานยนต์ สลบไป 10 นาที
ตื่นมารู้เรื่ องดี หน่วยกู้ภยั นาส่งรพ. ตรวจร่างกายแรกรับปกติ อีก 2
ชัว่ โมงซึมลง GCS E1V2M5, pupils right 3 mm, left 5
mm SRTL คิดถึงภาวะใดมากที่สดุ
a)
b)
c)
d)
e)
Epidural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Intracerebral hemorrhage
Diffuse axonal injury
เฉลย a
Trauma
•
•
•
•
•
•
•
Initial management*
Epidural hematoma*
Subdural hematoma*
Traumatic intracerebral hematoma
Traumatic SAH
Skull fracture
Sequalae
Trauma
• Initial management
– ABCDE
– Don’t miss!
• Collar (primary survey = A)
• ET tube in GCS ≤ 8 (primary survey = D)
• Search for other bleeding site in hypotensive patient
– GCS (Must remember!)
Trauma
โจทย์ short essay:
moderate HI in rural hospital
Item
GCS
C-spine protection
O2
IV
Refer or CT brain
Suture/dressing
Dilantin
Foley or NG
ตอบถูก
47
14
17
47
50
37
11
20
%
71.21
21.21
25.76
71.21
75.76
56.06
16.67
30.30
Trauma
Glassow Coma scale
Eye
Verbal
Motor
ทาตามสัง่ ได้
Score
6
ปกติ
ปั ดที่บริเวณเจ็บได้
5
ลืมตาเอง
พูดเป็ นประโยค แต่สบั สน
Withdraws
4
ลืมตาเมื่อเจ็บ
ลืมตาเมื่อเรี ยก
พูดเป็ นคามีความหมาย
ส่งเสียงอืออา
3
2
ไม่ลืมตา
ไม่มีเสียง
Decorticate
Decerebrate
ไม่มีการเคลื่อนไหว
1
การดูแลผู้ป่วย
Head
Injury
GCS 13-15
Mild HI
ประเมิน risk Mild HI
1. D/C
2. Admit observe
3. CT
ABCDEs, C spine protection
Resuscitation
ประเมิน GCS
GCS 9-12
Moderate HI
GCS < 9
Severe HI
พิจารณา
O2 mask c bag
IV fluid
พิจารณา
Endotracheal tube
Hyperventilation **
Mannitol/osmolar Rx **
Refer
Trauma
Risk factors for Intracranial lesion for Mild HI
• Clinical findings
–
–
–
–
–
–
GCS < 15 หลัง 1-2 ชั่วโมง*
Amnesia
ปวดศีรษะ
อาเจียน
มีประวัติหมดสติ
มี Sign ของกะโหลกแตก (skull Fx
(Skull Base/Valve)
– ตรวจพบความผิดปกติทางระบบ
ประสาท*
• Risk factors
– อายุ > 60
– Coagulopathy (Warfarin,
Hemophilia,etc)
– ชัก*
– ดื่มสุรา/ใช้ สารเสพติด
– มีกลไกการบาดเจ็บที่รุนแรง เช่น โดนรถ
ชนขณะเดินถนน
Trauma
• Epidural Hematoma (EDH)
– Associated with skull fracture
– Classic: Middle meningeal
artery tear
– Lens shape/biconvex
– Lucid interval*
– Rapidly fatal
– Good prognosis if proper
management
Trauma
• Subdural hematoma (SDH)
– Venous tear/ brain laceration
– High morbidity/mortality due
to underlying brain injury
– Crescent – concaved shape
– Counter coup
Trauma
• Chronic Subdural hematoma
(CSDH)
– Elderly, alcohol abuse,
coagulopathy
– Motor oil fluid, no clot
– Minimal or no Hx of injury
– Insidious onset
• Minor symptoms 
hemiplegia/seizure
Trauma
• Skull Fracture
– Skull Fx  ↑ risk of intracranial bleeding 5 times
– Skull base fracture
• CSF rhinorrhea, otorrhea
• Battle’s sign, Raccoon’s eye (anterior skull base)
• Facial weakness (petrous part of temporal bone)
Trauma
Sequelae of head injury
– Increased intracranial pressure (> 20 mmHg)
• General: sedation, analgesia, elevate head, avoid
hypoxia
• Ventricular drainage
• Mannitol
• Hyperventilation
• 2nd tier
– Phenobarb coma
– Decompressive craniectomy
Trauma
Sequelae of head injury
– Electrolyte imbalance – hyponatremia
– Seizure
• Antiepileptic drug - ↓ early seizure
• Prophylaxis 7 days
• I/C: GCS≤10, intracranial lesion, penetrating injury,
depressed skull fracture
– Carotid-cavernous fistula
•
•
•
•
•
Posttrauma 2-3 mo
Unilateral chemosis, proptosis
Bruit/thrill at the orbit
Ix: angiography
Management: balloon embolizaion
Herniation syndrome
• Central
– Diencephalon  tentorial
– Chronic
– Pupils: SRTL Fixed
• Uncal**
– Uncus and hippocampal gyrus
over tentorium
– CN III compression  unilateral
pupil ↑, hemiparesis
– Consciousness preserved in
early stages
– Classic for EDH
Herniation syndrome
• Cingulate (subfalcine H):
– asymptomatic except ACA
kink, warning of impending
transtentorial H.
• Upward
– posterior fossa mass +
ventriculostomy
• Tonsillar
– Posterior fossa mass + LP
Tumor
Supratentorial
• Gliomas
– Astrocytoma
– Oligodendrogliomas
– Ependymomas
• Meningiomas
• Sellar and suprasellar
– Pituitary adenomas
– craniopharyngiomas
Infratentorial
• Medulloblastoma (Ped)
• Cerebellar astrocytoma
• Brainstem gliomas
• CP angle tumor
– Vestibular schwannoma
(acoustic neuromas)
– Meningiomas
• Meningiomas
Tumor
• Most common brain tumor
– Metastasis
• Most common primary brain tumor
– Astrocytoma
• Most common primary brain tumor in children
– Medulloblastoma
Glioblastoma multiforme
• Grade IV of astrocytoma
• Poor prognosis. 2 yr survival 11 mo for total resection
Tumor
• DDx for patient with progressive hemiparesis
and IICP
– Supratentorial tumor (Metas, gliomas,
meningioma, etc)
– Brain abscess (ped. With rt to lt shunt eg TOF)
• DDx for patient with bitemporal hemianopia
=> sellar and suprasellar tumor
– Pituitary adenoma
– Craniopharyngioma
– Meningioma
Hydrocephalous
• Mechanism
– Obstruction at CSF
pathway:
• Obstructive
hydrocephalous
• CSF pathway: tumor,
blood, etc
– Obstruction at arachnoid
granulation
• Communicating
hydrocephalous
– Overproduction: choroid
plexus papilloma
• Treatment
– Remove etiology
– Drainage
• Ventriculostomy
(temporary)
• Shunting
– VP shunt
– VA shunt
– Ventriculo-pleural shunt