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Neurosurgical Case Scenarios

Neurosurgical Case Scenarios. SNS Intern Boot Camp Course - 2014. Case #1 – FC, 38yoF. 38 year old female Sudden headache 7 days ago Brought in comatose, 8 hours after ictus: GCS 8 Moves extremities symmetrically PERRLA, no cranial deficits What would you do next?. Case #1 – FC, 38yoF.

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Neurosurgical Case Scenarios

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  1. Neurosurgical Case Scenarios SNS Intern Boot Camp Course - 2014

  2. Case #1 – FC, 38yoF • 38 year old female • Sudden headache 7 days ago • Brought in comatose, 8 hours after ictus: • GCS 8 • Moves extremities symmetrically • PERRLA, no cranial deficits • What would you do next?

  3. Case #1 – FC, 38yoF • Right MCA aneurysm • Clipped on post-hemorrhage day #2 • Awake and following commands • Extubated on day #3 • Oriented x2, no deficits

  4. Case #1 – FC, 38yoF • Right MCA aneurysm • Post-clipping day #6 • Hemorrhage day #7 • Paged by ICU RN • “Acting funny” • On exam: • Localizes with right arm • Withdraws on left, less active • Opens eyes to pain • Mumbles, non-comprehensible • GCS 9 • EVD working, ICP = 23mmHg

  5. Case #1 – FC, 38yoF • CT • What next?

  6. Case #2 – CCB, 18yoM • 18 year old Male • Dove into Lake Michigan, intoxicated • 3 hours ago • Hit head, neck pain • Tingling in hands • Transferred from another hospital • On exam: • GCS 15 • Collar and board • Intact • Normal head CT • Neck pain to palpation

  7. Case #2 – CCB, 18yoM • 18 year old Male • What next?

  8. Case #2 – CCB, 18yoM • Transferred from another hospital • CT (unavailable), MRI • What next? L R

  9. Case #2 – CCB, 18yoM • Gardner-Wells tongs applied • Started with 15 lbs

  10. Case #2 – CCB, 18yoM • Gardner-Wells tongs applied • Started with 15 lbs • Increased 5 lbs / 10min, XR • At 45 lbs: tingling in all 4 extremities, hand grip weakness? • What next?

  11. Case #3 – RD, 6yoM • 6 year old male • Myelomeningocele • Correction + shunt at birth • 3 revisions, most recent 3 months ago • “Fussy” all day, fever 104 F, vomiting • Called by peds ER • Sleepy • Became apneic and unarousable in the CT scanner

  12. Case #3 – RD, 6yoM • 6 year old male • Myelomeningocele • Correction + shunt at birth • 3 revisions, most recent 3 months ago • “Fussy” all day, fever 104 F, vomiting • Called by peds ER • Sleepy • Became apneic and unarousable in the CT scanner CT – 1 month ago www.neuroradiologycases.com

  13. Case #3 – RD, 6yoM • 6 year old male • Myelomeningocele • Correction + shunt at birth • 3 revisions, most recent 3 months ago • “Fussy” all day, fever 104 F, vomiting • Called by peds ER • Sleepy • Became apneic and unarousable in the CT scanner • What next? CT today Alfayate et al., 2011

  14. Case #4 – 55yoM • 55 year old male • Hypertension • Did not wake up at usual hour, family called EMS • On exam • Unarousable • Localizes bilaterally • PERRL • What next?

  15. Case #4 – 55yoM • 55 year old male • EVD inserted, no noticeable change • What next?

  16. Case #5 – 65yoF • 65 year old female • Obese, coronary artery disease (ASA 81mg + Plavix daily) • Admitted to Internal Medicine because of low back pain • Neuro exam: normal • Imaging: diffuse disc degeneration • Medical management of LBP • Narcotics • Lumbar epidural steroid injection

  17. Case #5 – 65yoF • 65 year old female • You are called to Internal Medicine floor 2 hours post-LESI • Patient drowsy since arrival (sedation received during injection) but following commands • Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities • What next?

  18. Case #5 – 65yoF • 65 year old female • You are called to Internal Medicine floor 2 hours post-LESI • Patient drowsy since arrival (sedation received during injection) but following commands • Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities • What next? Ahn et al., 2009

  19. Case #6 – 43yoM • 43 year old male • Smoker, hypertensive, obese • Right hemiparesis, aphasia • Acute onset, 2 hours ago • Received IV tPA at outside hospital, 1 hour ago • No improvement • Initial CT is provided www.radiopaedia.org

  20. Case #6 – 43yoM • 43 year old male • Options? www.radiopaedia.org

  21. Case #6 – 43yoM • 43 year old male • Options? • Neurology team orders MRI, now 2:30 since onset • What next? www.radiopaedia.org

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