mismanagement of the neurosurgical patient: case studiesce.unthsc.edu/assets/2618/mismanagement -...
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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
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
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 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
Brain MRI Non-enhancing right
frontal/motor strip mass with edema
Brain biopsy—low-grade astrocytoma
Chemotherapy
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
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
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