6. Glascow Coma Scale
⢠Scale â used for individual patients and to track
clinical changes
⢠Score â numerical total of each component is for
research purposes
⢠Key issues with usage
⢠For use in acute brain injury
⢠Useful in tracking changes in consciousness for
intracranial pathologies
⢠Desedate and assess
⢠Motor component has highest inter-observer variability
⢠Apply painful stimuli at supraorbital nerve or trapezius pinch
⢠Take the best response for the motor score if unequal
responses
⢠Avoid assigning a score of 1 for an untestable feature â
state why untestable
⢠Describe the patientâs response rather than a
number
8. Assessment of the comatose patient
⢠Core neurological examination
⢠Respiratory rate and pattern
⢠Pupillary changes
⢠Extraocular muscle function
⢠Motor examination
9. Comatose patient core neuro exam
⢠Cheyne-stokes
⢠Diencephalic lesions or bilateral
cerebral hemisphere dysfunction
⢠Due to an increased ventilatory
response to CO2
⢠Hyperventilation
⢠Pontine dysfunction (high)
⢠Usually with other brainstem
signs otherwise consider
psychiatric cause
⢠Apneustic
⢠Pontine lesion
⢠Cluster breathing
⢠High medulla or low pons
⢠Ataxic
⢠Medullary
⢠Pre-terminal
10. Comatose patient core neuro exam
⢠Pupils
⢠Assessment
⢠Check size in ambient light
⢠Reactivity to direct and consensual light
⢠Signs
⢠Small pupils
⢠Narcotics
⢠Pontine lesion which damages bilateral
sympathetic pathways
⢠Unequal
⢠Fixed dilated single
⢠oculomotor nerve palsy
⢠Consider contralateral Hornerâs
syndrome
⢠Bilaterally fixed and dilated
⢠Medullary damage or post-anoxia or
hypothermia
⢠Midposition and fixed
⢠Midbrain lesion damaging sympathetics and
parasympathetics
11. Comatose patient core neuro exam
⢠Extraocular muscle function
⢠Deviation of ocular axes at rest
⢠Bilateral conjugate gaze deviation
⢠Looking towards lesion
⢠Frontal lobe
⢠Look away from lesion
⢠During a seizure
⢠Pontine haemorrhage
⢠Downward deviation
⢠Parinaudâs syndrome â thalamic or
pretectal lesions
⢠down and out
⢠Ipsilateral oculomotor nerve palsy
⢠Unilateral inward deviation
⢠Abducens nerve palsy
⢠Skew deviation (upward and opposite
direction movement)
⢠III or IV lesion at nucleus or nerves
⢠Spontaneous eye movements
⢠Windshield wiper eyes â intact III and MLF
⢠Ping-pong gaze â eyes deviate side to side 3-5
times per sec. Bilat cerebral dysfunction
⢠Ocular bobbing â pontine lesion.
⢠Internuclear ophthalmoplegia
⢠MLF lesion
⢠Lateral gaze and opposite eye doesnât look
medially.
⢠Reflex eye movements
⢠Vestibuloocular reflex â COWS â intact
brainstem
⢠Optokinetic nystagmus â normal sign â if
present then consider psychogenic
12. Comatose patient core neuro exam
⢠Motor
⢠Tone
⢠Reflexes
⢠Response to pain
⢠Babinski
⢠Ciliospinal reflexes
⢠Pupillary dilation to noxious cutaneous stimuli
⢠normal when bilaterally present.
13. Cranial Trauma
⢠Management of concussion
⢠Abbreviated westmeade post-traumatic amnesia score
⢠Severe traumatic brain injury
14. Concussion
⢠Definition
⢠Alteration of consciousness without structural damage as a result of non-
penetrating traumatic brain injury
⢠Neuroimaging indications
⢠Severe concussion
⢠any LOC; or,
⢠LOC ⼠5 mins or post-traumatic amnesia ⼠24 hours
⢠Symptoms persisting > 1 week
⢠Before returning to competition after a 2nd or 3rd concussion in the same
season
15. Concussion
⢠Admission criteria
⢠As per mild head injury advice, can usually monitor at home
⢠Moderate head injury advice â admit for overnight observation if not fulfilling
the criteria for observation at home
16. Concussion â Abbreviated Westmead PTA
⢠Use of the abbreviated Westmead PTA
⢠Only in mild head injury/concussion
⢠Administer the test at hourly intervals
⢠Patient is out of PTA when they score 18/18
⢠Consider discharge for these patients at the discretion of
clinical judgement
⢠Consider in-hospital admission for patients with a score <18
at 4 hours
17. Severe traumatic brain injury
⢠Definition :
⢠GCS ⤠8
⢠Clinical signs of high risk of intracranial injury
⢠Focal neurological findings
⢠Decreasing level of consciousness
⢠Penetrating skull injury or depressed fracture
⢠Initial management recommendations
⢠Urgent CT head
⢠Admit
⢠If focal findings/rapid deterioration â notify neurosurgical team for urgent
assessment and operative management
18. Surgical indications for Severe traumatic brain
injury
⢠Neurosurgical admission
⢠Isolated traumatic brain injury requiring
monitoring for deterioration or surgical
intervention.
⢠If the traumatic brain injury is the main cause
of morbidity with other injuries not requiring
continuous specialist input and monitoring.
⢠Otherwise for admission under Trauma
⢠Intracranial Pressure Monitoring
⢠GCS ⤠8 and an abnormal CT head showing
mass effect
⢠Or in a normal CT scan with severe traumatic
brain injury and 2 or more of
⢠Age > 40 years
⢠Motor posturing (flexor or extensor)
⢠Systolic BP < 90mmHg
⢠Epidural haematoma
⢠a haematoma of ⼠30mL regardless of GCS
⢠GCS ⤠8 + epidural haematoma and
anisocoria
⢠Acute Subdural haematoma
⢠Greater than 10mm of thickness and/or more
than 5mm midline shift regardless of
patientâs GCS
⢠If thickness < 10mm and MLS <5mm then
evacuate if
⢠If the GCS decreased by ⼠2 points from the time
of injury and/or;
⢠asymmetric or fixed/dilated pupils and/or;
⢠ICP ⼠20cmH20 persistently
⢠Chronic Subdural haematoma
⢠Symptomatic lesions â focal deficits or mental
status changes
⢠Subdurals with maximal thickness > 1cm
19. Surgical indications for Severe traumatic brain
injury
⢠Traumatic Intracerebral haemorrhage (TICH)
⢠Operative treatment
⢠Progressive neurological deterioration attributable to the TICH, medically refractory
intracranial hypertension, signs of mass effect on CT
⢠GCS 6-8 with frontal or temporal contusions > 20cm3 with midline shift >5mm and/or
cisternal compression on CT
⢠any lesion > 50cm3 in volume
⢠Non-operative treatment
⢠No neurological compromise, controlled ICP, no significant signs of mass effect on CT
⢠Traumatic posterior fossa mass lesions
⢠Symptomatic posterior fossa lesions or those with mass effect on CT
⢠Penetrating brain injury
20. Surgical indications for Severe traumatic brain
injury
⢠Depressed skull fracture
⢠Open fractures
⢠Depressed > thickness of calvaria and not meeting non-surgical criteria
⢠Non-surgical criteria
⢠No evidence of dural penetration
⢠And â
⢠No significant intracranial haematoma
⢠Depression < 1 cm
⢠No frontal sinus involvement
⢠No wound infection/gross contamination
⢠No gross cosmetic deformity
⢠Basal skull fractures
⢠If isolated, no indication for neurosurgical admission
⢠Have multiple associated conditions that need to be considered
⢠Traumatic aneurysms, post-traumatic caroticocavernous fistulas, CSF fistula, meningitis/cerebral abscess,
cosmetic deformities, post-traumatic facial palsy, hearing impairment
22. Stroke
⢠Ischemic
⢠Malignant middle cerebral artery territory infarction
⢠Patient to be admitted under neurology under the hemicraniectomy protocol
⢠Neurology will then refer to neurosurgery if surgery is indicated
⢠Hemicraniectomy indications guidelines
⢠Age < 70 years
⢠Non-dominant hemisphere
⢠Clinical and/or radiographical evidence of acute complete ICA or MCA infarcts
⢠And direct signs of impending or complete severe hemispheric brain swelling
⢠Cerebellar infarction
⢠For a neurology admission
⢠Surgical indications
⢠Increased pressure within the posterior fossa with no response to medical therapy
⢠Acute hydrocephalus
23. Intraparenchymal haemorrhage
⢠Key neurosurgery admission criteria
⢠Due to a vascular malformation as per CTa
⢠Lobar intracerebral haemorrhage in a patient < 65 years
old
⢠CT + contrast (tumour bleed) or CTa (vascular malformation
bleed) positive
⢠Cerebellar haemorrhage
⢠If unclear of management but patient is salvageable and a
good surgical candidate
⢠Neurology/MAU admission criteria
⢠Basal ganglia haemorrhage
⢠Internal capsule haemorrhage
⢠Brainstem haemorrhage
⢠Haemorrhage in the setting of a coagulopathy
⢠Lobar haemorrhage > 65 years of age
⢠If CTa or CT + contrast negative in a lobar haemorrhage <
65 years of age.
⢠Unsalvageable patient
⢠Lobar haemorrhage â relative indications for
neurosurgical intervention
⢠Lesions associated with mass effect, oedema, or midline
shift causing neurological deterioration from raised ICP.
⢠Surgery for moderate volume haematomas
⢠10-30cm3
⢠Persistently raised ICP refractory to medical therapy
⢠Rapid deterioration regardless of location in someone
salvageable
⢠Favourable location (less than 1cm from cortical surface,
non-dominant lobe)
⢠Young patient i.e. <65 years of age
⢠Cerebellar haemorrhage
⢠GCS ⤠13 or haematoma ⼠4cm diameter
⢠If absent brainstem reflexes and flaccid quadriplegia, not
for surgery
⢠Intraventricular blood
⢠For external ventricular drainage if an appropriate
surgical candidate
24. Aneurysmal Subarachnoid haemorrhage
⢠For neurosurgical admission if CT head, LP or CTa positive
⢠Unsecured aneurysm management
⢠Blood pressure targets
⢠Systolic BP 120 - 150 mmHg
⢠Diastolic BP < 100 mmHg
⢠Nimodipine 60mg 4 hourly â if SBP < 120mmHg for 30mg, if SPB < 100mmHg WH
⢠Levetiracetam 500mg BD if ictus
⢠Surgical interventions
⢠Acute hydrocephalus
⢠External ventricular drainage
⢠Features favouring clipping of aneurysm
⢠Appropriate surgical candidate
⢠Symptoms due to mass effect of intracerebral clot
⢠Unsuitable for endovascular intervention
25. Unruptured intracranial aneurysm
⢠Symptoms of concern for pending aneurysmal rupture
⢠Mass effect from giant aneurysms
⢠Cranial neuropathies
⢠Third nerve palsy
⢠Compressive optic neuropathy
⢠Trigeminal neuralgia
⢠Sentinel haemorrhages/headaches
⢠Discuss with the patient regarding aneurysm rupture risk as per
PHASES score if an incidental aneurysm.
⢠Can be referred to neurosurgical outpatient clinic for review
26. Non-aneurysmal subarachnoid haemorrhage
⢠Perimesencephalic subarachnoid haemorrhage
⢠CT/MRI criteria with imaging done < 2 days of ictus
⢠Epicentre of the haemorrhage within the interpeduncular/prepontine cistern
⢠Extension within the anterior part of the ambient cistern or basal part of sylvian fissure
⢠Absence of complete filling of the anterior interhemispheric fissure
⢠No more than a minute amount of blood within the lateral part of the sylvian fissure
⢠No frank intraventricular haemorrhage â can have a small amount of blood within the
occipital horns of the lateral ventricles
⢠Will need a CTa for assessment of aneurysms
⢠Neurosurgery admission for investigation via Digital subtraction angiography
⢠Convexity subarachnoid haemorrhages
⢠Venous sinus thrombosis, vasculitis
⢠Refer to neurology
⢠Vascular malformation
⢠Neurosurgical admission
28. Intracranial lesions
⢠Solitary lesions
⢠Neurosurgery admission criteria
⢠Significant mass effect
⢠Midline shift > 5mm
⢠Hydrocephalus
⢠Evidence of raised intracranial pressure secondary to mass effect of the lesion/oedema
⢠Appropriate surgical candidate
⢠Karnofsky performance score > 70 (self-caring) or if lower then for consideration if surgical excision can improve quality of life and
survival
⢠Oncology/MAU admission criteria
⢠If not appropriate for neurosurgical admission
⢠Posterior fossa lesion
⢠Neurosurgery admission criteria
⢠For urgent CSF diversion to temporise till definitive treatment
⢠Hydrocephalus
⢠Effacement of 4th ventricle
⢠For removal of lesion
⢠Karnofsky performance score > 70 (able to self care) prior to admission
⢠Candidates for treatment of extracranial disease with chemotherapy and whole brain radiotherapy
29. Intracranial lesions
⢠Multiple lesions
⢠Neurosurgical admission criteria
⢠Significant mass effect
⢠Midline shift > 5mm
⢠Hydrocephalus
⢠Decreasing GCS from raised intracranial pressure secondary to mass effect of the
lesion/oedema
⢠Symptomatic lesion and/or if > 3cm diameter
⢠Appropriate surgical candidate
⢠Viable for chemo/radio therapy post-resection of lesion.
⢠Oncology/MAU admission criteria
⢠If not appropriate for neurosurgical admission
⢠For work up of lesions with MRI brain + contrast and CT chest/abdo/pelvis
30. Intracranial lesions
⢠Recurrent/symptomatic known oncological disease
⢠Neurosurgical admission criteria
⢠evidence of raised intracranial pressure secondary to mass effect of recurrent lesion
⢠A candidate for ongoing chemo/radiotherapy if lesion is removed
⢠Will need to admit to oncological team treating patient first if patient is not
for emergency surgery. Patient to be worked up for consideration of
chemo/radiotherapy prior to discussing surgical interventions.
33. Spinal epidural metastases
⢠Neurosurgical admission criteria
⢠Evidence of cord compression
⢠MRI demonstrating lesion during this admission
⢠Unknown primary and no tissue diagnosis
⢠Relative contraindications to surgery
⢠Total paralysis > 8 hours
⢠Inability to walk > 24 hours duration
⢠Expected survival < 3-4 months
⢠Multiple lesions at multiple levels
⢠Not able to have surgery due to co-morbidities
⢠For oncology/MAU admission
⢠Known disease
⢠Radiculopathy/plexopathy with no evidence of cord compression
⢠For review for radiotherapy
35. Post-operative infections
⢠Laminectomy/instrumentation
⢠Neurosurgical admission
⢠Evidence of deep wound infection/collection
⢠Persistent infective symptoms while on appropriate antibiotic therapy
⢠Dehiscence of subcutaneous layer and deeper
⢠Craniotomy
⢠Neurosurgical admission
⢠clinical evidence
⢠Swollen/tender wound
⢠Wound infection/dehiscence
⢠Palpable collection
⢠Evidence of meningitis
36. Vertebral body osteomyelitis
⢠Admission criteria
⢠Ongoing disease progression despite adequate antibiotic therapy
⢠Chronic infection refractory to medical treatment
⢠Spinal instability
⢠Severe back pain and/or radiculopathy
⢠Loss of height of vertebral body affected
⢠Spinal epidural abscess
⢠Infections with hardware
37. Spinal epidural abscess
⢠Neurosurgical admission criteria
⢠Evidence of cord compression from an epidural abscess correlated to an MRI
+ contrast full spine
⢠If no evidence of spinal epidural abscess causing symptomatic cord
compression on MRI
⢠For MAU admission with antibiotic administration
⢠Initiate antibiotic therapy preferably after specimen taken
⢠Through surgical drainage or CT guided aspiration of abscess
38. Cerebral abscess
⢠CT brain with contrast in setting of high clinical suspicion of abscess
⢠Neurosurgical admission criteria
⢠If no microbiological diagnosis
⢠Significant mass effect exerted by lesion with evidence of raised intracranial pressure
⢠Neurological symptoms attributable to the cerebral abscess
⢠Known abscess
⢠Interval neurological deterioration
⢠Progression of abscess towards ventricles
⢠Abscess enlarging after 2 weeks of antibiotic therapy
⢠No decrease in size of the abscess after 4 weeks of antibiotic therapy
⢠Initiate antibiotic therapy preferably after specimen taken
39. Shunt infection
⢠Neurosurgical admission
⢠High clinical suspicion of shunt infection
⢠Recent infection
⢠Fevers
⢠Seizure
⢠High blood CRP
⢠Discuss with neurosurgery for consideration of sampling of CSF via shunt valve
⢠CSF MCS, glucose and protein
⢠Can have concurrent shunt malfunction with blockage
40. Shunt complications
⢠Key information
⢠Reason for shunt initially
⢠Type of shunt
⢠Brand
⢠Ventriculoperitoneal/ventriculoatrial/v
entriculopleural
⢠Pressure setting of the shunt
⢠Fixed vs programmable and what level
known
⢠Reasons and dates of revisions
⢠Ability of the shunt to pump and
refill
⢠Difficult to depress â suggests distal
occlusion
⢠Slow refilling (normal refilling takes 15-
30sec) â suggests proximal obstruction
⢠Radiographic evaluation
⢠CT head non-contrast
⢠Assess ventricular calibre
⢠Have previous imaging available to
compare ventricular calibre in
different clinical states
⢠X-ray shunt series
⢠Lateral skull, AP C-spine, AP chest and
AP + lateral abdo
⢠Assess for kinks/disconnections
42. Overshunting
⢠For neurosurgical admission
⢠Slit ventricles
⢠Associated with intracranial hypotension symptoms
⢠Subdural haematoma
⢠If symptomatic
⢠Symptoms similar to shunt malfunction
⢠> 1-2 cm thickness
43. Spinal neurosurgery
⢠Acute cauda equina
⢠Radiculopathy
⢠Complications post-spinal surgery
⢠Simple spinal surgery
⢠Instrumented spinal surgery
44. Acute cauda equina
⢠Presenting features
⢠70% acute presentations
⢠Back pain and radicular leg pain
⢠Can have a subacute syndrome evolving
over days to weeks
⢠Consider in patients with chronic back
pain rapidly escalating regardless of
trauma or injury
⢠30% can present without pain
⢠Sudden onset numbness, leg weakness
or difficulty walking
⢠Urinary symptoms
⢠Altered urethral sensation
⢠Loss of desire to void
⢠Poor stream
⢠Feeling of retention or straining to void
⢠Perineal symptoms
⢠Can include paraesthesia, numbness
and/or pain
⢠Faecal symptoms
⢠Incontinence
⢠Time course
⢠Sudden onset with no previous low
back pain symptoms
⢠History of recurrent backache and
sciatica with the latest episode
combined with cauda equina
symptoms
⢠Backache and bilateral sciatica
progressively developing into cauda
equina
45. Degenerative spine disease
⢠Radiculopathy admission criteria
⢠Progressive motor deficit
⢠E.g. foot drop
⢠Not indicated with paresis of unknown
duration
⢠Myelopathy admission criteria
⢠Evidence of acute cord compression
⢠Deteriorating gait
⢠Incontinence
⢠Neurological signs corresponding to a
cord compression syndrome
⢠Transverse lesion
⢠Motor system
⢠Central cord
⢠Brown-Sequard
⢠Brachalgia and cord
⢠MRI features correlating to cord
compression.
⢠Spinal claudication
⢠Admit if demonstrating cauda
equina
46. Post-spinal surgery
⢠post-simple spine surgery
⢠Admission criteria
⢠Treat as per new herniated disc
⢠Evidence of cord compression or cauda equina
⢠Post-complex spine surgery
⢠Admission criteria
⢠Radiographic evidence of peri-prosthetic fracture
⢠As per radiculopathy or cord-compression