Acute Care Neurosurgery by Case Management: Pearls and Pitfalls

Description

This book reviews the common clinical scenarios that might trigger emergent consultation for neurosurgical intervention, with attention to key components of the clinical interview and exam, optimal diagnostic evaluation, indications for and the goals of operative intervention, perioperative considerations, and strategies for complication mitigation. This is not a surgical atlas, but rather, a road map for the journey to the operating room door. The intent is to establish a systematic, evidence-based action plan for the patient presenting in neurologic crisis.   Each chapter opens with a relevant case vignette and then unfolds through uniform sections to tell the story of how one might approach the disease entity in question, from initial request for consultation to definitive management, highlighting steps of the decision-making process:   • What are the highest yield questions to ask during a focused interview? • What are the most pertinent objective exam findings? • What is the proper differential diagnosis? • What is the most appropriate and efficient plan for diagnostic evaluation – with respect to laboratories and imaging? • Does this patient have an indication for emergent or urgent neurosurgical intervention? • If so, what is the goal of that intervention? • What are the most common potential complications of the proposed procedure, and what steps might be taken to mitigate those risks?   Each chapter is punctuated by 3-5 teaching pearls, summarizing these key elements. The overall goal is to create a framework for assessment that might be applied in the emergency department, the trauma bay, or the ICU when a neurologic emergency arises.   The scope of the text encompasses not only cranial and spinal trauma, but also entities such as shunt failure, stroke, aneurysmal subarachnoid hemorrhage, pituitary apoplexy, cauda equina syndrome, and central nervous system infection that might require time-sensitive intervention. An additional section addresses issues requiring emergent neurosurgical response in the ICU setting, including sudden neurologic worsening, status epilepticus, and abnormal clotting/ coagulopathy.   The text will not only serve as a valuable resource for those preparing to take the oral board exam, but will also provide a targeted refresher for clinicians taking general neurosurgical call in the community as well as an educational reference for mid-level practitioners and those in training who are serving as first responders on behalf of a neurosurgical service.   Foreword Preface Contents Contributors Part I: In the Trauma Bay Chapter 1: Acute Extra-Axial Hematoma 1.1 History and Physical Examination 1.2 Differential Diagnosis 1.3 Diagnostic Evaluation 1.4 Clinical Decision-Making and Next Steps 1.5 Clinical Pearls References Chapter 2: Chronic Subdural Hematoma 2.1 History and Neurologic Exam 2.2 Differential Diagnosis 2.3 Diagnostic Evaluation 2.4 Clinical Decision-Making and Next Steps 2.5 Clinical Pearls References Chapter 3: Contusion and Diffuse Injury 3.1 History and Neurologic Exam 3.2 Differential Diagnosis 3.3 Diagnostic Evaluation 3.4 Clinical Decision-Making and Next Steps 3.5 Clinical Pearls References Chapter 4: Penetrating Brain Injury 4.1 History and Neurologic Exam 4.2 Differential Diagnosis 4.3 Diagnostic Evaluation 4.3.1 Imaging Studies 4.3.1.1 CT 4.3.1.2 Cerebrovascular Imaging 4.3.1.3 Spine Imaging 4.3.1.4 MRI 4.3.2 Laboratory Studies 4.4 Clinical Decision-Making and Next Steps 4.4.1 Trauma Bay Management 4.4.1.1 ICP Management 4.4.1.2 Seizure Prophylaxis 4.4.1.3 Antibiotics 4.4.1.4 Foreign Body Management 4.4.2 Operative Indications 4.4.3 Complications 4.4.3.1 CSF Leak 4.4.3.2 Infection 4.5 Clinical Pearls References Chapter 5: Concussion 5.1 History and Neurological Exam 5.1.1 Constitutional Symptoms 5.1.2 Neurological Symptoms 5.1.3 Previous Concussion 5.2 Differential Diagnosis 5.2.1 Post-Concussion Syndrome 5.2.2 Second Impact Syndrome 5.2.3 Chronic Traumatic Encephalopathy 5.3 Diagnostic Evaluation 5.3.1 Sports Concussion Assessment Tool (SCAT) 5.3.2 Computed Tomography 5.3.3 Magnetic Resonance Imaging (MRI) and Advanced Neuroimaging Techniques 5.3.4 Cerebrospinal Fluid (CSF) and Serum-Based Biomarkers of Injury 5.4 Clinical Decision-Making and Next Steps 5.5 Clinical Pearls References Chapter 6: Traumatic Arterial and Venous Injuries 6.1 History and Neurologic Exam 6.2 Differential Diagnosis 6.3 Diagnostic Evaluation 6.4 Clinical Decision-Making and Next Steps 6.5 Clinical Pearls References Chapter 7: Cerebrospinal Fluid Fistulae 7.1 History and Neurologic Exam 7.1.1 Cranial CSF Leaks 7.1.1.1 Traumatic and Iatrogenic 7.1.1.2 Non-traumatic 7.1.2 Spinal CSF Leaks 7.1.3 Postoperative CSF Leaks 7.1.4 Delayed and Occult CSF Leaks 7.2 Differential Diagnosis 7.2.1 Cranial 7.2.2 Spinal 7.2.3 Postoperative 7.3 Diagnostic Evaluation 7.3.1 Cranial 7.3.2 Spinal 7.3.3 Unclear Cases 7.4 Clinical Decision-Making and Next Steps 7.4.1 Cranial 7.4.2 Spinal Leaks 7.4.3 Spontaneous Leaks 7.5 Clinical Pearls References Chapter 8: Decompressive Craniectomy 8.1 History and Neurologic Exam 8.1.1 History 8.1.2 Examination and Early Management 8.2 Differential Diagnosis 8.3 Diagnostic Evaluation 8.4 Clinical Decision-Making and Next Steps 8.5 Clinical Pearls References Chapter 9: Cervical Spine Fractures/Acute Cervical Spinal Cord Injury 9.1 History and Neurologic Exam 9.2 Differential Diagnosis 9.3 Diagnostic Evaluation 9.4 Clinical Decision-Making and Next Steps 9.5 Clinical Pearls References Chapter 10: Thoracolumbar Spine Fractures 10.1 History and Neurologic Exam 10.2 Differential Diagnosis 10.2.1 Compression Fracture 10.2.2 Burst Fracture 10.2.3 Chance Fracture 10.2.4 Fracture-Dislocation 10.2.5 Minor Fractures 10.3 Diagnostic Evaluation 10.4 Clinical Decision-Making and Next Steps 10.5 Clinical Pearls References Chapter 11: Central Cord Syndrome 11.1 History and Neurologic Exam 11.2 Differential Diagnosis 11.2.1 Acute Cervical Spinal Cord Injury 11.2.2 Spinal Epidural Abscess 11.2.3 Metastatic Epidural Spinal Cord Compression 11.2.4 Peripheral Nerve Injury 11.3 Diagnostic Evaluation 11.4 Clinical Decision-Making and Next Steps 11.5 Clinical Pearls References Chapter 12: Peripheral Nerve Injury 12.1 History and Neurologic Exam 12.2 Differential Diagnosis 12.2.1 Missile Injury 12.2.2 Compression Injury 12.2.3 Iatrogenic Injury 12.2.4 Non-traumatic Mimics of Injury 12.3 Diagnostic Evaluation 12.4 Clinical Decision-Making and Next Steps 12.5 Clinical Pearls References Part II: In the Emergency Department Chapter 13: Ischemic Stroke 13.1 History and Neurologic Examination 13.2 Differential Diagnosis 13.3 Diagnostic Evaluation 13.4 Clinical Decision-Making and Next Steps 13.5 Clinical Pearls References Chapter 14: Spontaneous Intracerebral Hemorrhage (Including Posterior Fossa) 14.1 History and Neurologic Exam 14.2 Differential Diagnosis 14.3 Diagnostic Evaluation 14.3.1 Imaging 14.3.2 Laboratory Tests 14.4 Clinical Decision-Making and Next Steps 14.4.1 Critical Care 14.4.2 Acute Management 14.4.3 Blood Pressure Control 14.4.4 Reversal of Coagulopathy 14.4.5 Intracranial Pressure Monitoring 14.4.6 Antiepileptic Drug (AED) Prophylaxis 14.4.7 Surgical Management 14.5 Clinical Pearls References Chapter 15: Aneurysmal Subarachnoid Hemorrhage 15.1 History and Neurologic Exam 15.2 Differential Diagnosis 15.2.1 Common Causes of Sudden Onset, Severe Headache 15.2.2 Others Causes of Sudden Onset, Severe Headache 15.3 Diagnostic Evaluation 15.4 Clinical Decision-Making and Next Steps 15.5 Clinical Pearls References Chapter 16: Pituitary Apoplexy 16.1 History and Neurologic Exam 16.2 Differential Diagnosis 16.3 Diagnostic Evaluation 16.4 Clinical Decision-Making and Next Steps 16.5 Clinical Pearls References Chapter 17: Hydrocephalus and Shunt Failure 17.1 History and Neurologic Exam 17.2 Differential Diagnosis 17.3 Diagnostic Evaluation 17.4 Clinical Decision-Making and Next Steps 17.5 Clinical Pearls References Chapter 18: Acute Intracranial Infection 18.1 History and Neurologic Exam 18.2 Differential Diagnosis 18.2.1 Epidural Abscess 18.2.2 Subdural Empyema 18.2.3 Intracerebral Abscess 18.3 Diagnostic Evaluation 18.4 Clinical Decision-Making and Next Steps 18.4.1 Epidural Abscess 18.4.2 Subdural Empyema 18.4.3 Intracerebral Abscess 18.4.4 Suppurative Intracranial Thrombophlebitis 18.5 Clinical Pearls References Chapter 19: Nontraumatic Spinal Cord Compression 19.1 History and Neurologic Exam 19.2 Differential Diagnosis 19.2.1 Spinal Cord Compression Secondary to Infection 19.2.1.1 Discitis/Osteomyelitis 19.2.1.2 Epidural Abscess/Subdural Empyema 19.2.1.3 Intramedullary Spinal Cord Abscess 19.2.2 Spinal Cord Compression Secondary to Hemorrhage 19.2.2.1 Spinal Epidural Hematoma 19.2.2.2 Spinal Subarachnoid Hemorrhage (SAH) or Subdural Hematoma (SDH) 19.2.2.3 Intramedullary Spinal Hemorrhage 19.2.3 Spinal Cord Compression Secondary to Neoplasm 19.2.3.1 Extradural Tumors 19.2.3.2 Intradural, Extramedullary Tumors 19.2.3.3 Intramedullary Tumors 19.3 Diagnostic Evaluation 19.4 Clinical Decision-Making and Next Steps 19.4.1 Infectious Pathology 19.4.1.1 Discitis/Osteomyelitis 19.4.1.2 Spinal Epidural Abscess/Subdural Empyema 19.4.1.3 Intramedullary Abscess 19.4.2 Hemorrhagic Pathology 19.4.2.1 Spinal Epidural Hematoma 19.4.2.2 Spinal Subarachnoid Hemorrhage/Subdural Hematoma 19.4.2.3 Intramedullary Spinal Hemorrhage 19.4.3 Neoplastic Pathology 19.4.3.1 Extradural Neoplasms 19.4.3.2 Intradural, Extramedullary Neoplasms 19.4.3.3 Intramedullary Neoplasms 19.5 Clinical Pearls References Chapter 20: Cauda Equina Syndrome 20.1 History and Neurologic Exam 20.2 Differential Diagnosis 20.2.1 Cauda Equina Syndrome 20.2.2 Conus Medullaris Syndrome 20.2.3 Sacral Disease/Compression 20.2.4 Peripheral Nerve Lesion 20.2.5 Non-compressive Lesions 20.3 Diagnostic Evaluation 20.4 Clinical Decision-Making and Next Steps 20.5 Clinical Pearls References Part III: In the ICU Chapter 21: Sudden Neurologic Worsening in the Postoperative Patient 21.1 History and Neurologic Exam 21.2 Differential Diagnosis 21.3 Diagnostic Evaluation 21.4 Clinical Decision-Making and Next Steps 21.4.1 Seizure 21.4.2 Intracranial Hematoma 21.4.3 Tension Pneumocephalus 21.4.4 Infarction 21.4.5 Vasospasm/Delayed Cerebral Ischemia 21.4.6 Obstructive Hydrocephalus 21.4.7 Spinal Epidural or Subdural Hematoma 21.4.8 Spinal Cord Ischemia or Spinal Cord Reperfusion Syndrome 21.5 Clinical Pearls References Chapter 22: Fever in the Neurocritically Ill Patient 22.1 History and Neurologic Exam 22.2 Differential Diagnosis 22.3 Diagnostic Evaluation 22.4 Clinical Decision-Making and Next Steps 22.5 Clinical Pearls References Chapter 23: Seizure and Status Epilepticus 23.1 History and Neurologic Exam 23.2 Differential Diagnosis 23.3 Diagnostic Evaluation 23.4 Clinical Decision-Making and Next Steps 23.5 Clinical Pearls References Chapter 24: Encephalopathy and Delirium 24.1 History and Physical Exam 24.2 Differential Diagnosis 24.2.1 Common Neurological Conditions 24.2.2 Systemic Conditions 24.3 Diagnostic Evaluation 24.4 Clinical Decision-Making 24.5 Clinical Pearls References Chapter 25: Thrombosis and Coagulopathy 25.1 History and Neurologic Exam 25.2 Differential Diagnosis 25.2.1 Toxic-Metabolic or Infectious Insult 25.2.2 Subarachnoid Hemorrhage 25.2.3 Extra-Axial Hemorrhage 25.2.4 Intraparenchymal hemorrhage 25.2.5 Hemorrhage into an Existing Lesion 25.3 Diagnostic Evaluation 25.3.1 Coagulopathy 25.3.2 Thrombosis 25.4 Clinical Decision-Making and Next Steps 25.4.1 Coagulopathy 25.4.2 Thrombosis 25.5 Clinical Pearls References Index