Neurosurgical Emergencies

Preventing Poor Outcomes for Neurosurgical Patients

“…Importantly, all patients with depressed skull fractures (wherein one segment of skull is driven below the level of the adjacent segment) should be admitted to the ICU. 2 13 If the skull fracture is managed nonoperatively, in addition to frequent neurologic examinations, serial imaging should be done since these can help identify complications such as underlying brain contusions that can blossom with time and warrant surgical intervention. 2 Postoperatively, patients should be managed in the ICU and undergo follow-up imaging, since patients may develop delayed or progressive intracerebral hemorrhage in addition to elevated ICP.…”

“…1 2 On initial imaging, traumatic subarachnoid hemorrhage (SAH), epidural hematoma, subdural hematoma (SDH), hemorrhagic parenchymal contusions (intraparenchymal hemorrhage), intraventricular hemorrhage (IVH), and skull fractures may be seen. 2 The cervical spine should also be imaged, and in the interim the patient should wear a cervical collar until injury is ruled out. 1 Additionally, the airway should be assessed, and endotracheal intubation performed particularly if the GCS is <8.…”

“…1 2 Decompressive craniectomy is performed early in the clinical course, and studies have shown better outcomes with this surgical technique as opposed to craniotomy and evacuation. 2 4 5 6 Frontotemporoparietal hemicraniectomy to achieve middle cranial fossa decompression may be considered for unilateral hemispheric swelling to allow for temporal lobe swelling and avoidance of uncal herniation. Bifrontal craniectomy with division of the falx cerebri is performed for bifrontal swelling.…”

“…Mechanical ventilation should aim toward preventing hypercarbia (which can lead to increased vasodilation and ICP), and goal PaCO 2 should be between 35 and 45 mm Hg. 2 8…”

“…In aSAH, acute hydrocephalus is a common complication that results from obstructive hydrocephalus via intraventricular or parenchymal hematoma blocking CSF flow in the ventricular system and/or (more commonly) communicating hydrocephalus from impaired CSF resorption at the arachnoid granulations. 2 20 22 Management requires placement of either an EVD or lumbar drain. 20 21 EVDs are commonly placed in patients who present with ventriculomegaly and casting or near-casting of the third or fourth ventricle, patients who have progressive ventriculomegaly with neurological decline, or if there is concern for impending hydrocephalus while undergoing endovascular aneurysm treatment.…”