Neurosurgery Pearls

  1. Xanthochromia is a yellow discoloration of the CSF supernatant that results from the breakdown of RBCs into oxyhemoglobin, methemoglobin, and bilirubin. Why is its presence in CSF more specific for SAH than the presence of RBCs?
    Because xanthochromia is the result of a process that only occurs in vivo, its presence is more specific for SAH than the presence of RBCs (JEM, 7/10, p. 13). (JEM, 7/10, p. 13).
  2. Why MRI the entire spine if you're looking for a spinal cord syndrome?
    MRI The Entire Spine!

    When obtaining an MRI of the spine for evaluation of a spinal cord syndrome, the well known phenomenon of false localizing sensory levels should be kept in mind. The entire spinal cord should be imaged so that false negative results that may be caused by misleading localizing signs, such as a thoracic sensory level caused by a cervical lesion, can be avoided (1,2).

    A study of 324 episodes of malignant spinal cord compression found that clinical signs were very unreliable indicators of the level of compression. Only 53 patients (16%) had a sensory level that was within 3 vertebral levels of the level of compression demonstrated on MRI. Pain (both midline back pain and radicular pain) was a similarly poor predictor of the level of compression (3).
  3. What systolic blood pressure mandates aggressive reduction with parenteral antihypertensive medication in a patient presenting to the ED with an acute spontaneous intracranial hemorrhage?
    An SBP of 200 mm Hg or greater warrants aggressive reduction (Stroke, 2010; 41).
  4. A 45 year old male is brought in by ambulance after falling from tree. He is able to talk but unable to move his extremities. He has recieved 2 liters of fluid enroute for hypotension. His most recent vital signs show: pulse 80, BP 75/50, RR 20, 36.5°C, O2 sat 97% on 2 liters via NC. While doing your FAST exam, you see an IVC which does not change with respiration. What is the most appropriate next step?
    This patient has neurogenic shock from a cervical spinal injury, resulting in hypotension from lack of sympathetics.

    He doesn't need fluids at the time because the "tank is full," indicated by a non-collapsing IVC upon respiration.

    He will need a surgical intervention, so neurosurgery will be recommended.

    IV steroids are controversial in spinal injuries.

    Thus, the most appropirate next step is to start pressors for his hypotension from spinal shock

    Clinical Bottom Line: Use the ultrasound to evaluate fluid status in patients with shock. Spinal shock may show hypotension and normal heart rate. Start pressors for spinal shock if patient is adequately fluid resuscitated.
  5. A patient arrives in the ED obtunded and is found to have a significant spontaneous intracerebral hemorrhage. Are propylactic anticonvulsants indicated?
    Prophylactic anticonvulsant medicationshould not be used (Stroke. 2010;41). The incidence of clinical seizures within the first 2 weeks after ICH has been reported to range from 2.7% to 17%.
  6. What is the incidence of clinical seizures within the first 2 weeks after ICH?
    2.7% to 17%
  7. Regarding hemostatic therapy for acute spontaneous ICH, the new/revised recommendations from the 2007 AHA/ASA guidelines include:
    • -Patients with severe thrombocytopenia or factor deficiency should receive platelets or factor replacement.
    • -Patients with ICH due to oral anticoagulants (warfarin) should receive intravenous vitamin-K and vitamin-K dependent factor replacement.
    • -Prothrombin complex concentrates (PCCs) are being increasingly used and are considered a reasonable alternative to FFP. To date, studies have not shown improved outcome with PCCs.-Recombinant factor VIIa (rFVIIa) is not recommended as a sole agent for warfarin-related ICH
    • -rFVIIa is not recommended in unselected patients
    • -Usefulness of platelet transfusions for patients using antiplatelet medications is unclear and currently investigational.
  8. Most commonly encountered entrapment neuropathy?
    -Carpal Tunnel Syndrome
  9. For most patients with supratenotrial spontaneous intraparenchymal intracranial hemorrhage, the usefulness of surgery is uncertain. What CT scan characteristics of the ICH might prompt consideration of craniotomy for evacuation?
    For patients presenting with lobar clots >30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered (Stroke 2010;41:2108).
  10. The clinical value of post-void residual when evaluating for cauda equina or epidural compression syndrome:
    Measurement of a post-void bladder residual volume tests for the presence of urinary retention with overflow incontinence (a common, though late finding) (sensitivity of 90%, specificity of 95%). Large post-void residual volumes (>100 mL) indicate a denervated bladder with resultant overflow incontinence and suggest significant neurologic compromise. The probability of cauda equina syndrome in patients without urinary retention is approximately 1 in 10,000.

    The administration of glucocorticoids can minimize ongoing neurologic damage from compression & edema until definitive therapy can be initiated (Dexamethasone, 10mg-100mg IV)
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Neurosurgery Pearls
Neurosurgery Pearls