Introduction to neurosurgery

& traumas

Dr Waleed DabbasNeurosurgery Department

College of Medicine Al Balqa University

Al Salt- Jordan

Neurosurgery

Specialty in brain and spine

Subspecialties:

Neurotrauma

Neurooncology

Cerebrovascular

Functional

Skull base

Neuroendocraniology

and spinal surgery

Neurotraumas

Head injuries

Spinal injuries

Just keep your head away and contemplate

We do not like to see this????

introduction

300/100 000/y

Of these 9/100 000 die

Some are inevitable others are potentially preventable

Causes:

MVA most common in young males. Contributes 60% of deaths from head injuries

Falls

Assaults

Domestic accidents

Sport injury

Gun shot

continued

Primary impact is un preventable

Aim of management is to:

- minimise further brain damage from secondary complications

-Maintain adequate CPP

- Lower ICP

Cerebral perfusion pressure

Normal ICP is less than 10 mm Hg, around 135 mm H2O, High ICP if >15

Best measured by EVD that is connected to ICP monitor

Cerebral perfusion pressure is :MAP-ICP

CPP ranging between 60-100 mm hg

MAP= diastolic+1/3 systolic

Cerebral blood flow CBF= CPP

CVR

CPP= MAP-ICP

Aetiology

Brain injury occurs at the time of impact and as a result development of secondary complications

Primary involves the initial mechanical injury due to local deformation and energy transformation.

Secondary encompass a cascade of biochemical and cellular processes which are initiated by primary process which may cause ongoing cellular damage or even death

Primary damage

1- brain contusion and laceration

Coup and counter coup

Frontal and temporal

continued

2-diffuse axonal injury This type occurs as a result of shearing

injury Causing tearing of axons Mild to severe

Mild :Concussion Severe usually causes corpus callosum, mid

brain, and SCP contusions. CT may be normal but patient in moribund

condition

Secondary brain damage

May be preventableOccurs at any time after

initial impact

1-Intracranial haematomas

Epiduarl haematomas:from MMA, less likely from

venous source or fracture site

Takes biconvex shape. Mortality rate 10%. If deteriorates 40-50%

continued

Sub dural haematomas

Classified to

Acute:

from rupture bridging veins.

concavo-convex shape.

high mortality rate 60%.

Usually associated with

intracerebral contusions and

shearing injury that

increases the morbidity and

mortality rate

continued

subacute :Iso dense on CT scan, Symptoms appear within 4-21

days.

Chronic:More than 3 wUsually in infants and oldsHypo dense on CT scan

.

continued

2- brain oedemaVery common after head injurymay be fatal if left untreatedVasogenic type.increases ICP.

3-CONING OR BRAIN HERNIATION

Central and lateral. Subfalcine transtentorial or diencephalic

,tonsillar.Due to increase in ICP from brain swelling or supratentorial

haematomas as a result of space occupyinglesion.

Brain herniation syndromes

The shift of brain structures goes through weak points which are the orifices inside the skull which is a rigid box that does not expand in a response to this shift

Classified to:

Central or rostro-caudal

Lateral

TYPES

Subfalcine or cingulate herniation:which is the mid line shift: due to space occupying lesion that shifts the ipsilateral structure to opposite underneath the interhemispheric falx.

If continues it ends with transtentorial herniation

Trans tentorial herniation: Lateral or uncal: common The uncus of the temporal lobe herniates

through the tentorial opening. Causing mid brain compression

S&S

Earliest sign is decline in GCS. If proceeds it causes 3rd CN palsy then contralateral hemiplegia. At this stage brain herniation might be reversible but if it continues it end with pontine or medullary syndromes which are irreversible

Central or diencephalon as in mid line structure lesions or bilateral hemispheric lesions.

It causes rapid decline in GCS rather than causing the classic syndrome before it

Takes the same stages

Tonsillar herniation

Posterior fossa lesions that cause herniation of the cerebellar tonsils via the foramen magnum

Causing significant medullary compression and sudden death

Up ward herniation may also occur at the same time through the tentorial herniation

Other types :Transcraniotomy herniation

END RESULT

4-cerebral ischemia

Caused by progressive rise in ICP, hypoxia or hypotension

OTHERS

5- infection

2-5%

as seen in compound depressed #, or basal skull #

6-Epilepsy

immediate after trauma

early within a week in 5%

late after a week in 5%

more common with ICH, depressed #, severe head injury

at 20-25%

Classifications of head injury

1-According to severity

Mild GCS13-15 Moderate 9-12 Severe <9

2-According to morphology.Scalp injuries Cut and lacerated wounds Degloving wounds

.skullVault: Linear: a crack within

the bone without displacement

Depressed: displacement of bone fragment inwards

Either compound or simple

Comminuted: fragmented bone without displacement

Base: Anterior fossa Middle fossa Posterior fossa

.IntracranialExtra-axial EDHSDHSAH

continued

Intra-axialBrain contusions and lacerationsBrain haematomasIntra ventricular haemorrhage

Head injuries may also be closed or openOpen:Basal skull factures and compound depressed fracturesOr as seen in penetrating injuries mainly in war time

Management

That includes

Concepts of Initial assessment for traumas

1-Rapid primary survey

2-Resuscitation

3- Adjunct to primary survey /resuscitation

4-Detailed secondary survey

5-Adjuncts to secondary survey

6-Re evaluation

7-Definite care

Primary survey

Get IV access, send bloods

A: airway check for obstruction. ETT

B: breathing

oxygenate, check respiratory movements. ?ventilation

C: circulation

BP, pulse. Control bleeding, restore volume

D: disability

GCS, Pupillary response, focal deficits

E: exposure

Completely undress patient, protect from hypothermia

Resuscitation

GOALS Achieve normovolemia and hemodynamic

stability Compensate for the internal fluid fluxes

from the interstitial and intracellular compartment

Improve the microvascular blood flow Normalise oxygen delivery to cells Parameters: BP,PR,RR,O2 sat, urine output, pulse

pressure, perfusion.

ICP

Skull is a rigid contains:

brain: 1200-1600 ml +150 ml of ECF

CSF: 130- 150 ml

blood: 100-150

They are incompressible and in balance

Monro Kellie doctrine; pressure volume curve

Monro- Kellie Doctrine

Adjuncts Treatment

ECG

Urinary output

Catheters

Pulse oximeter and PCO2

ABGs

Secondary survey

Proceed to secondary survey when

primary completed

ABCDEs are reassessed

Vital function returning to normal

Key components to secondary survey

History: A M P L E Observational at scene, initial clinical observation, progress. Physical examination: head to toe Tubes and fingers in every orifice Complete Neuro exam,: palpate for spine tenderness Musculoskeletal checks Special diagnostic tests

Keep hard neck collar on Re evaluation to minimise missed injuries Pain killers as appropriate

Points to get in head injuries

Mechanism of injury Circumstances of injury LOC PTA Headache and vomiting Seizures Weakness CSF leak Spine pain Other symptoms

Examination

1- level of consciousness GCS (E4 V5 M6).

take the best response. Lowest score 3 highest 15, if intubated (ETT) give 1

2-Pupillary reaction:

unresponsive unilaterally implies pathology of ipsilateral 3ed N. herniation

Anisocoria may be physiological if mild

3-Focality:

asymmetric response implies intracranial event

4-Signs of head trauma

5-Signs of basal skull #: CSF leak, raccoon eyes, sub conjunctival bleed, battle’s sign .

Imaging in trauma

Initial trauma series Lateral c- spine x-ray CXR Pelvis Abdominal U/S if handy CT Scan brain, c-spine as routine In multiple trauma chest, abdomen and

pelvis should be included Angiography in vascular injuries mainly in

pelvis MRI in spinal trauma

Indications for CT and admission

LOC or PTA >5 minutes

Hx of epilepsy

GCS <15 or decline in GCS

Neurological deficits

CSF leak

Positive radiological findings

Social indication?

Treatment

mild and moderate injuries, linear, comminutedObservation:Basal skull #:observation, antibiotics ?CSF leak ceases within 3-10d in 90-95%If continues drainage or dural repair may be needed

Compound depressed #:craniectomy and antibioticsEDH:needs craniotomy if thickness more the 1 cm. or if causing mass effect

CONTINUED

SDH:

usually associated with other injuries that require craniotomy vs craniectomy + ICP monitor

Post traumatic epilepsy:

treatment is controversial

Anticonvulsants usually phenytoin loading and maintenance may be given to patients at risk.

Management of severe head injury

Coma implies:

inadequate airway controlICP is usually elevatedHemodynamics are unstableAim to maintain adequate cerebral perfusionpressure to maintain the integrity of neurons

What brain needs

Rest

Oxygen

Glucose

Treatment

Intubate

Oxygenate

Keep head up at 30

EVD for ICP monitor and CSF drainage

Mannitol is effective bolus or infusion

Lasix may help

Steroids are controversial

Anticonvulsants in high risk patients

SBP must be >100

O2 sat >98%

PCO2 32-35

Temperature <37

Continued

Barbiturates for refractory ICP in salvageable patients. Needs enough experience before getting used due to serious side effects

craniectomy:

Is an effective surgical method for ICP control in certain cases

Consequences

Death

How brain responds

ICP=MAP= ZER0= DEATH

Any increase in intracranial constituents results in subsequent compensatory responses to maintain normal ICP

Failure of compensatory mechanisms results in rise of ICP and reduction in CPP and subsequent herniating syndromes and eventually brain death

CBF is zero when ICP = MAP

ICP Waves

Brain death: no blood flow

So, do not run away or turn your back in this long battle??

Vegetative state

Severe disability

Moderate to mild disability

Back to normal

Other complications

Epilepsy

Infection

Normal pressure hydrocephalus

Post concussional syndrome

Medical complications: electrolyte disturbances, bed sores, DVT, PE…etc

POST CONCUSSIONAL SYNDROME

Common after head injuries

Characterised by headache, poor memory and concentration, lack of interest, dizziness, depression.

Needs reassurance.

Pain relievers

antidepressants

End