taem10:intracranial emergency
TRANSCRIPT
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Approach to Approach to Intracranialemergency Intracranialemergency
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Neurologic symptoms
Weakness, difficulty speaking, concentrating, swallowing, or thinking, imbalance, sensory changes, visual problems, and headache.
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Altered mental status
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Dizziness and vertigo
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HeadacheHeadache
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KEY CONCEPTS
Headache is a common presenting complaint in the emergency department. The emergency physician must distinguish between benign primary headache disorders and the more serious and potentially life-threatening secondary causes of headache.
The majority of patients do not have abnormal neurologic findings; therefore, the key to a successful diagnosis is a thorough and systematic history.
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Patients with the following headache presentations are at risk for serious underlying disease:
• sudden explosive headache; • first or worst headache; • new-onset headache after age 50; • headache associated with papilledema, alteration
in or loss of consciousness, or focal neurologic symptoms;
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• headache after head trauma; • subacute headache with increasing frequency or
severity; • headache associated with fever, cancer, or
immunosuppression; • headache triggered by exertion, sexual activity, or
Valsalva maneuver.
The need for diagnostic studies is dictated by the suspected secondary cause of headache
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Historical danger signs in patients with headache
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SeizuresSeizures
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Stroke
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Stroke means “ rapidly developed clinical signs of focal (global)
disturbance of cerebral function lasting more than 24 hours or
leading to death, with no appearance cause other than a
vascular origin.”
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KEY CONCEPTS
• Patients presenting with the signs and symptoms of an acute ischemic stroke within 3 hours of symptom onset should be evaluated for thrombolytic therapy within the following recommended target time frames: Door to physician: 10 minutes Door to CT completion: 25 minutes Door to CT reading: 45 minutes Door to drug treatment: 60 minutes
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• Carotid Doppler, MRA, or CT angiography studies are recommended before discharging a patient with TIA.
• Avoid overaggressive blood pressure management in patients with acute ischemic stroke.
• Accurate time of symptom onset should be documented for all patients with stroke.
• Assessment of gait is essential to rule out posterior circulation stroke in patients presenting with vertigo.
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KEY CONCEPTS
• Patients presenting with the signs and symptoms of an acute ischemic stroke within 3 hours of symptom onset should be evaluated for thrombolytic therapy within the following recommended target time frames: Door to physician: 10 minutes Door to CT completion: 25 minutes Door to CT reading: 45 minutes Door to drug treatment: 60 minutes
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Figure 99-2 A, CT scan taken 2 hours, 50 minutes after large right middle cerebral artery occlusion. There are subtle, ultra-early ischemic changes, including loss of the gray-white interface (arrows) and subtle evidence of sulcal effacement. B, CT scan of same patient approximately 8 hours after symptom onset shows acute hypodensity (arrows) and more prominent sulcal effacement.
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ผปวย subarachnoid hemorrhage โรคทพบบอยคอ ruptured cerebral aneurysm ,
ruptured ateriovenous malformation
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ผปวย intraventricular hemorrhage ทไมพบกอนเลอดใน
เนอสมอง ควรพจารณาสงตรวจ
Cerebral angiography ,CT angiography . MR angiography
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ผปวย intracerebral hemorrhage อาจแบงเปน lobar hemorrhage , non-
lobar hemorrhage
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Lobar hemorrhage หมายถง intracerebral hemorrhage ทอย
ในตำาแหนง cortical ,subcortical ไดแก
frontal,parietal,occipital,temporal lobes สาเหตของเลอดออกในตำาแหนงนมกไมใชเกดจากความ
ดนโลหตสง
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แตมสาเหตอน เชน cerebral amyloid angiopathy,
aneurysm, AVM จงควรสงตรวจวนจฉยความผดปกตของ
หลอดเลอด ดวย cerebral angiography, CT angiogram, MR angiogram และปรกษา
ประสาทศลยแพทย
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Non-lobar hemorrhage หมายถง intracerebral hemorrhage ท basal
ganglia mostly at putamen, thalamus,cerebellum,brainstem
mostly at pons
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Figure 99-1 The CT slice with the largest area of hemorrhage is identified. The largest diameter of the hemorrhage on this slice is measured in centimeters (A). The largest diameter 90 degrees to A on the same slice is measured (B). C is the approximate number of 10-mm slices on which the intracerebral hemorrhage was seen. The volume of the hemorrhage equals A multiplied by B, multiplied by C, divided by 2 (ABC/2).
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ผปวย nonlobar hemorrhage ขอบงชในการปรกษาประสาทศลยแพทย
คอ coma score less than 13 , volume more than 30 cc. ,
midlineshift more than 0.5 cm. ยกเวน ผปวย cerebellar hemorrhage ควรปรกษาประสาทศลยแพทยทก
ราย
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การคำานวณปรมาตรกอนเลอด = 0.524 . x .y. z มลลลตร
(X,Y,Z = ความยาวของเสนผาศนยกลางของกอนเลอดในแนว
แกน X,Y,Z หนวยเปน เซนตเมตร)
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การรกษาภาวะความดนในกะโหลกศรษะสง
• Clear airway ใสทอชวยหายใจ และ Floey’s Catheter
• ใหนอนยกศรษะและสวนบนของรางกายสง 20 – 30 องศา
• จดทำาผปวยโดยใหหลกเลยงการกดทบหลอดเลอดดำาทคอ (jugular vein)
• Hyperventilation เพอให PaCO2 = 30 – 35 mmHg แตวธนมประโยชนในชวงสน ๆ กอนผาตด
• พจารณาใหยา
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การรกษาภาวะความดนในกะโหลกศรษะสง (ตอ)
• 20% mannitol : loading dose 1 gm/kg ทางหลอดเลอดดำาภายใน 20 นาท ตามดวย 0.25 – 0.5 gm/kg ทก 6 ชวโมง ควรตรวจ serum osmolarity ทกวน ควบคม serum osmolarity ≤ 320 mOsm/l (grade C) หรอ10% glycerol 250 ml ทางหลอดเลอดดำา ภายใน 30 นาท ทก 6 ชวโมง หรอ50% glycerol 50 ml ทางปาก วนละ 4 ครง หรอFurosemide 1 mg/kg ทางหลอดเลอดดำา (grade C)
• หลกเลยงการให hypotonic solution• การใช steroid ยงไมมหลกฐานทางคลนกสนบสนน
วาไดประโยชน (grade A)
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Pre test
DDx of isolated CN III palsy
1.Uncal brain herniation
2.Pcom aneurysm rupture
3.CN III neuritis
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ICP
VOLUMECOMPENSATE
DECOMPENSATE
INCREASED INTRACRANIAL PRESSURE
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BRAIN HERNIATION
1.Subfalcine
2. Uncal
3. Central
4.Tonsilar
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Uncal herniation sings
1.CN III palsy
2.Hemiparesis
Impaired light reflex
Ipsilateral
Contralateralmidbrain
uncus
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PHYSICAL EXAMINATION
VITAL SIGNS
GCS
PUPILS
MOTOR
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MANAGEMENT
Of
HEAD INJURY
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MINOR HEAD INJURY
GCS 15 NO LOSS OF
CONSCIOUSNESS
NO AMNESIA
NO SKULL FRACTURE
DISCHARGE
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TRANSIENT LOSS OF CONSCIOUSNESS
Or AMNESIA
SKULL FRACTURE
OBSERVE NS.
Or GCS 14
WITH HEADACHE
CT BRAIN
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MODERATE HEAD INJURY
( GCS 9-13)
CT BRAIN
6Hr. Not improved Repeat CT
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(GCS < 8)
CT BRAIN NOT DELAYED
CONSIDER INTUBATION
AND MINITOL
SEVERE HEAD INJURY
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IMMEDIATE CONSULTATION
GCS DECREASE < 2
ANISOCORIA
HEMIPARESIS
LUCID INTERVAL
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Clinical risk of head- injured patients
1.Secondary expanding lesions ICP
Transtentorial brain herniation
2.Operation after transtentorial herniation with
Severe brain stem compression make poor results
3.EDH and SDH common occur within 6 hr.
4.ICH may delayed after 24 hr
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Common pitfalls
Inaccurate GCS Score
Drunken patients
Not worse but not full GCS
Neglect open wounds
Operation within 6 hr hematomasat other sites may develop
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Common pitfalls (cont.)
Progression of extra cerebral hematoma within 6 hr and intracerebral hematomamay delayed to 24 hr
Misdiagnosis of brain death in GCS=3with operable hematoma
Waiting for consent
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20 year old male
MC rider collision with Taxi
Unconscious ,try intubation by EMS
but failed
½ Hr. to ER GCS E2 M6 V3
1 Hr to CT brain 1 Hr to OR
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Pre op condition
BP 180/100 P 100 GCS E2 M5 V3
Pupils RT 5mm sluggish RTL
Lt 3mm. Sluggish RTL
Lt Hemiparesis Grade II
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Male 38 year old ขบสามลอเครองชนแทกซ
BP 140/80 P 80 R 20
GCS E3 M6 V4 Pupils 3mm RTL both
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Male 41y ขบสามลอเครองชนแทกซ
แรกรบรตวด ไมสลบ ใหคำาแนะนำา กลบบานได
12 ชวโมงตอมาปวดศรษะมาก พดสบสน
BP 150/90 P 80 R20
GCS E4 M 6 V4
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Post op persistent headache
and hyponatremia
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Right frontal craniotomy
post op good recovery
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Male 21 year old ถกตทศรษะไมรสกตว
½ Hr to ER BP 130/70 P60 R20
GCS E1 M3 V1 Pupils R2mm L 3mm RTL
½ Hr to CT
GCS E1 M3 V1 Pupils R2mm L 5mm Fixed
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Post op good recovery
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51yr Male MCA
GCS E4 V4 M6
30 min change to
GCS E2 V2 M5
Pupils Rt 5mm
Lt 3mm sluggish RTL
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30 min. to OR Good recovery
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57y.old male Passenger on a car collision with a truck
Initial GCS =E3,M6,V3
Pupil 3mm. RTL both
Periorbital swelling & ecchymosis
Bloody rhinorrhea
No other sinificant injury
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CT scan at 2hr after injury
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2hr.later GCS change to E1,M5,V2
BP 160/90 P 50 RR 20
Pupil R 2 mm. L3 mm. well RTL both
Motor : equally move both sides
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Repeated CT scan 2hr after the first
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Before After
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Post op good recovery
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32 y old male GCS =15
Suture scalp wound and discharge
½ Hr readmission with GCS E1 M5 V1
Pupil 5mm fixed Rt Lt hemiparesis
Suddenly change to GCS E1 M2 Vt
1 Hr CT scan at center outside hospital
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Consult neurosurgeon
Bolus dose of mannitol
GCS E1 M2 Vt
Waiting for consent
GCS 3 BP 80/40
Death
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Male 22y.MCA,GCS E1M2V1
Pupils Rt 5mm Lt 3mm sluggish RTL
CT brain
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Sudden change to GCS 3 and pupils fixed dilated both
Diagnosis of brain death
6 hr later improved to GCS E1 M3 Vtafter mannitol infusion
Pupils Rt 3mm sluggish react to light Lt 5mm fixed
Operated but not recovered
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2CASE
ผปวยชายไทย อาย 15 ป ข MC ชนรถเกง 10 . MIN PTA
: 110/70 , 70 , 20PE BP P R = GCS E3 M5 V1 3 . Pupils mm Sluggish RTL both
Rt Hemiparesis grade II
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Immediately change to GCS=3
Go on to OR within 30 min
Post op good recovery
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45 y old man MC rider collision with MC
First seen at a private hospital BP 150/100 P 100
GCS E2 M5 V3 Pupils 3mm RTL both
1 hr refer to Lerdsin hospitalGCS E2 M4 Vt pupils 3mm RTL both
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BP 155/60 P 50
BP130/70 P60
Conservative treatment GCS E4 M5 Vt Rt hemiparesis
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BP 130/70 P57BP 135/70 P54
17 น. 22 น.
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Sudden change to GCS E1 M1 Vt dilated fixed pupils on the 5thday
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Operated but not recovered death
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Multiple Intracranial Hemorrhage
Male 30 y GCS = 3 BP 80/50
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Severe Primary Brain Injury
Male 30 y Decerebrate GCS=3
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47y.old Male
Acute confusional state
Headache with vomitting for 3wkDiagnosis to migrain at ER two times
History of minor head injury admitted for 3days at2 months ago
Misdiagnosis as brain tumor by CT
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27y old maleSevere headache for 1wk
Diplopia for 3days
History of minor head injury 1mo ago
CT brain showing bilateral SDH
The first physician advice conservative treatment
then the patient came to Lerdsin hospital
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17y.old female
Sudden headache then unconsciousPE at ER : BP 130/90 P80 R20
GCS=E1M3V1 Pupils Rt 5mm Lt 2mm sluggish RTL
CT not available in hospital Then exploratory craniotomy was performed immediately
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SDH about 50 ml
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ICH about 50ml
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Cortical AVM at temporoparietalabout 3cm in diameter
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AVM was totally excised
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The patient recovered well with mild left hemiparesis
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Female 37 y old presented with severe headache and vomiting without localizing sign
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History of headache for 10 months
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2day after CT evaluated by neurosurgeon
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ลกษณะอาการปวดศรษะทควรระวง
อาการปวดทไมเคยปวดรนแรงเชนนมากอน
อาการปวดททเลาบางครงแตไมหายเปนปกต
อาการปวดททำาใหไมสามารถไปทำางานหรอมกจวตรไดปกต
อาการปวดทมความรนแรงมากขน
อาการปวดรวมกบมอาเจยนรวมดวย
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อาการปวดทมลกษณะปวดทวไปทงศรษะเหมอนจะระเบด
อาการปวดบรเวณหนาผาก หรอทายทอย
อาการปวดรวมกบอาการตงบรเวณตนคอ
เคยมประวตบาดเจบทศรษะมากอน
สญเสยการไดยน การดมกลน เดนเซ กระตกของกลามเนอ