Mismanagement of the Neurosurgical Patient: Case Studies

Atif Haque, M.D., F.A.A.N.S., F.A.C.S.Neurological Surgeon

Adjunct Clinical Assistant Professor

UNT 4th Annual Neuroscience Summit9 September 2017

Disclosures

Consultant for Medtronic

Mismanagement of Neurosurgical Patients

Objectives Case Studies

Objectives

Identify missteps in the treatment of selected neurosurgical conditions.

Understand the recommended best treatment strategies of these selected conditions.

Learn how to avoid the pitfalls presented in the case studies.

Case 1

Presentation 54 yo female 1 month h/o left upper extremity

generalized weakness Minimal neck pain No arm pain

Case 1

Exam 4/5 strength throughout LUE Hyperreflexic in LUE + Hoffman’s reflex LUE Otherwise normal exam

Case 1

Disc bulges with central canal stenosis at C5-6 and C6-7, eccentric to the L

Case 1

First opinion—orthopedic spine surgeon Offered C5-7 ACDF

Came to me for a second opinion

Upper vs. Lower Motor Neuron

UMN paralysis Flaccid then

spastic Hyperreflexic ± clonus Pathologic

reflexes Examples-

Stroke, SCI, TBI, myelopathy

LMN paralysis Flaccid Hyporeflexic Atrophy ± fasciculations Examples-

radiculopathy, nerve entrapment, polio

Case 1

Mild stenosis No pain UMN findings in

light of no real cord compromise

? Mild headaches

Case 1

MRI brain Craniotomymeningioma

Case 2

Presentation 52 yo male Many month h/o left lower extremity

generalized weakness Moderate back pain Minimal leg pain No sensory issues Neck and arm pain

Case 2

Exam 4/5 strength left lower extremity diffusely Normal reflex exam in lowers,

hyporeflexic in uppers Normal strength elsewhere

Case 2

First opinion—orthopedic spine surgeon L4-5 fusion No improvement after 6 mos. MRI with minimal nerve

compromise on side of weakness Offered L3-4 fusion

Saw me for second opinion

Case 2

Case 2

Brain MRI Non-enhancing right

frontal/motor strip mass with edema

Brain biopsy—low-grade astrocytoma

Chemotherapy

Case 2

Cervical spine MRI Severe central

stenosis Kyphosis Foraminal stenosis

Case 2

C3-7 ACDF for stenosis, deformity, radiculopathy

Case 3

30 yo male inmate assaulted Rapid decline in

mental status at outside ER

Large extra-axial hematoma

Case 3

Apparent difficulty transferring out ER doctor attempted a

burr hole Patient worsened

afterward Intubated and sent to CT

with retractor in place Transferred to FW

Case 3

Epidural Hematoma Bi-lenticular Arterial injury (MMA) Usually associated with

fracture Lucid interval

Subdural Hematoma Crescent Torn bridging vein Often associated with

underlying brain injury

Case 3

Craniotomy Epidural hematoma Temporal bone

fracture Bleeding from MMA Complete recovery

within 24 hours

Case 4

Presentation 66 yo female Comatose for about 2 weeks and unresponsive and

on ventilator Found to have R > L subdural hematomas Recent diagnosis of leukemia Being treated by another neurosurgeon without any

improvement in spine of multiple procedures Further surgery was being recommended I was asked to give a third opinion

Case 4

5/15presentation

5/16R crani

5/25enlargement

5/25drain placed

6/3scalp swelling

Case 4

Upon further investigation, Had severe headaches immediately following LP 5

days prior to presentation, as well as getting intrathecal chemotherapy

Headache worsened with standing/sitting and improved with laying flat

Progressive nausea Progressive lethargy; obtunded at presentation

Case 4

Intracranial hypotension Spontaneous vs. post-traumatic vs. iatrogenic Orthostatic headache classically Other presentations—encephalopathy, myelopathy, parkinsonism “CSF hypovolemia” Low or normal intracranial pressure Imaging—brain and spine

± Pachymeningeal enhancement ± Sagging brain/tonsils ± Subdural hygromas/hematomas ± Small ventricles/cisterns ± Obvious site of CSF leak

Case 4

MRI spine without obvious CSF leak MRI brain

BilateralSDH’s

Cisternaleffacement

Brainsagging

Low-lyingtonsils

Case 4

Treatment options for intracranial hypotension HOB flat/bedrest Pain control Hydration Caffeine Epidural blood patch Fix underlying leak

Case 4

Our patient Epidural blood patch 17 days after admission and of being

comatose No obvious response in first 24 hours

ICP monitor insertion for 24 hours Essentially normal pressures with occasional low readings

Patient turned back over for comfort care, possible tracheostomy/G-tube

Slowly became more responsive over next couple of weeks Subsequent removal of R bone flap for possible infection

cultures negative Following commands and talking 2 weeks after blood patch

Case 5

18 yo female College-bound athlete Occipital headaches Numbness/tingling

bilateral upper extremities

Worsening with coughing/sneezing

Chiari I Malformation Herniation of cerebellar

tonsils Brainstem typically normal

30-70% with associated syrinx

Young adult presentation

Case 5

Case 5

PCPEvaluation

MRI withherniated“tonsils”

PCPrefers to

ENT

ENTEvaluation

ENTrefers to

Ortho Spine

Ortho Spinestarts

migraine meds

Patient’sgrandmother

(former patient)recommends

me

Neurosurgeryevaluation

with surgeryoffered

Case 6

67 yo female s/p MVC Sizeable

intraparenchymal hematoma

Taken to OR emergently Congenital occipital

encephalocele

References

Chiari and Syringomyelia Foundation website. Greenberg, M.S. Handbook of Neurosurgery.

Thank you.

Questions?