NEUROSURGICAL EMERGENCY GUIDELINE DEVELOPMENT GROUP P3 NEURO CENTER OF NEUROSCIENCE RESEARCH AND SERVICE USM Chairperson Professor Dr Zamzuri Idris Head of Department Members Associate Professor Dato Dr Abdul Rahman Izaini Ghaini Consultant Neurosurgeon and Neurosciences Lecturer Dr Badrisyah Idris Consultant Neurosurgeon and Neurosciences Lecturer Dr Regunath Kandasamy Consultant Neurosurgeon and Neurosciences Lecturer Dr Tan Yew Chin Neurosurgeon and Neurosciences Lecturer Advisor and Reviewer Professor Dato Dr Jafri Malin Abdullah Director of P3 Neuro Institute, USM, Consultant Neurosurgeon and Neuroscientist Center of Neuroscience Research and Service USM
Clinical Guidelines for Spontaneous Aneurysmal Subarachnoid Hemorrhage Clinical Feature suggesting Aneurysmal: Sentinel headaches/thunderclap headaches Seizure Abrupt onset of neurological deficit ( hemiparesis, aphasia,ataxia, vertigo...) loss of consciousness Obtundation/coma meningismus focal neurological deficit Ocular hemorrhage SAH Plain CT brain CTA/DSA Negative MRA brain Cerebral aneurysm MRA <----------- negative <----------- NBM Analgesias NS referral Seizure prophylaxis Nimodipine BP control ( SBP<160mmHg) Preop Ix & workup Repeat MRA in 2 weeks LP Positive Surgical clipping Or Coiling No SAH LP after exclude other diagnosis LP negative: to rule out other causes
Clinical Guidelines for Brain Abscess Intracranial HTN Neurological deterioration Abscess >3cm Mass effect Periventricular location Diagnostic uncertainty IV Rocephine /Metronidazole Consider antiepileptics Antiedema therapy Burr hole & aspiration Or Craniotomy and excision of abscess Abscess recurrence in follow up CECT brain Consider Craniotomy and excision of abscess Clinical features suggesting brain abscess Intracranial HPT Seizure Neurological deficit Fever Meningism CECT brain/ Or MRI DWI MRS IGS If in doubt Ix: FBC BUSE INRAPTT GXM CRP/ESR Blood C+S Consider TB workup Clinical improvement Minimal neurological symptoms Duration < 2 wk ( cerebritis stage) Poor surgical candidate Small abscess < 3cm, surgically inaccessible location, multiplicity, lack of mass effect IV Rocephine /Metronidazole Consider antiepileptics Antiedema therapy Clinical deterioration Abscess increase in size No decrease in size after 4 weeks
Clinical Guidelines for Pedatric Hydrocephalus Clinical features suggesting hydrocephalus Irritability/Failure to thrive Oral intolerance/seizure Full & tense anterior fonranelle Sun setting eyes Upward deviation of head circumference crossing curves Continued head growth >1.25cm/wk Obstructive Hydrocephalus CT Brain Communicating Hydrocephalus Rapid neurological deterioration Clinical stable LP if no contraindications Consider MRI Brain Infection urgent CSF diversion Tumour Congenital structure abnormality Antibiotics/ Consider EVD or Shunt for TB/Cryptoccal meningitis Surgical excision + CSF diverion Shunt or ETV
Clinical Guidelines for Brain Tumour Clinical features suggesting brain tumour Intracranial hypertension Neurological deficit Cognitive/higher mental dysfunction Seizure Progressive course of disease CECT/IGS brain Imaging diagnosis of brain tumour IV Dexamethasone if no suspicion of lymphoma PPI/H2 Antagonist Consider seizure prophylaxis Analgesia MRI /DTI/DWI/IGS/MRA/MRV Primary brain tumour Definitive/palliative multidisciplinary management include neurosurgery and oncology teaam Rapid clinical deterioration Ix: FBC BUSE INRAPTT GXM CXR TB workup Emergency Surgery Secondary/metastatic Brain tumour CT TAP Biopsy suspicious lesion
Clinical Guideline for Traumatic Brain Injury Management at the Casualty Department Check Airway, Breathing,Vital Signs and GCS Unable to support airway Breathing difficulty SBP< 90mmHg GCS less than 13 Secondary Survey Penetrating injury Depressed skull Fractures Flail Chest Pelvic fracture 2 proximal long bone fractures Amputation/pulseless extremities No Mechanism of Injury: High risk mechanism: Fall >6m Motor crash>30km/hr Pedestrian/bicyclist hit by car/lorry Ejection out of vehicle Passenger death in same compartment Yes Red Yes Red Yes Red/Yellow No Age> 65 Anticoagulant/antiplatelet Pregnancy Yes Yellow No Green
Selection Criteria for CT brain and cervical spine Risk Factors for Immediate CT brain ( warrant CT brain within 1-2 hr) 1. GCS <13 at initial management 2. GCS <15 at 2 hours after injury 3. Vomiting 2 times or more after injury 4. Focal neurological deficit 5. Post traumatic seizure 6. Signs of basal skull fracture ( Raccoon eyes/battle sign) Risk Factors for Urgent CT brain ( warrant CT brain within 6 hr) 1. Age > 65 2. Patient on antiplatelet/anticoagulant therapy 3. Post traumatic amnesia > 30min 4. Dangerous mechanism of injury 5. Previous cranial surgery Risk Factors for Cervical CT 1. GCS<13 2. Intubated patient 3. Requirement to exclude cervical spine injury before surgery 4. Age > 45 5. Neurological deficit 6. Dangerous mechanism: Fall> 3 feet, ejection from vehicle, high speed MVA>100km/h References: American College of Surgeon Committee xoinii Trauma Advanced Trauma Life Support Student Course Manual (9th Edition). Chicago: 2012. Connolly ES, Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711 1737. doi10.1161/str.0b013e3182587839. Ftaziet JL, Ahn ES, Gl Jallo. Management of brain abscesses in children. Neurosurg Focus. 2008;24:1 10. National Institute for Health and Care Excellence. Triage, assessment, investigation and early management of head injury in children, young people and adults. UK: NICE; 2014.