NEUROSURGERY

OVERVIEW

Arwinder Singh
ANATOMY AND PHYSIOLOGY
ANATOMY OF SCALP
 Skin
 firmly bound to the 3rd layer by perpendicular
fibers
 Connective tissue (Dense)
 Contain arteries, veins & nerves supplying scalp
 cut/injury >> profuse bleeding
 Aponeurosis
 fibrous sheet, found over much of the vertex
 attaches occipitalis to frontalis muscle
 Loose connective tissue
 Separates aponeurosis to pericranium
 accounts for the mobility of the scalp >>due to its
consistency >>blood tracks freely in this layer
 Periosteum/pericranium
 adheres to the suture lines of the skull
 collection of blood beneath this layer 
cephalohematoma (children)
ANATOMY OF THE SKULL

 The skull has 22 bones excluding the ear ossicles

 Bones of the skull are attached to each other by
sutures, are immobile and form the cranium
 Cranium subdivided into:
 Upper doomed part (calvaria) which covers the cranial
cavity
 Base that consist of floor of cranial cavity
 Lower anterior part – facial skeleton
ARRANGEMENTS OF  Extradural space (dura – bone) –
potential space
MENINGES AND SPACES  Become fluid filled space in a traumatic event
 Bleeding into extradural space due to rupture of
meningeal artery or dural venous sinus
 Subarachnoid space – deep to
arachnoid
 Actual normally occurring fluid filled space
 Contain csf & blood vessels
 SAH occur in patient having significant cerebral
trauma or ruptured intracerebral aneurysm arise
from vessels supplying and around circle of wilis
 Subdural space – (dura-arachnoid)
 Hematoma results from venous bleeding usually
from torn cerebral vein
BLOOD SUPPLY

 Brain receive arterial

blood supply from 2 pairs
of vessels:
 Vetebral arteries
 Internal carotid arteries
 These 2 pairs of vessels
interconnected in cranial
cavity forming circle of
wilis which give rise to all
major cerebral arteries
SPINE AND
SPINAL
CORD
CSF CIRCULATION
 MONRO-KELLIE DOCTRINE

Venous Art. Brain CSF

Volume Vol.

Ven. Art.
Brain Mass CSF
Vol. Vol.

75 mL Arterial 75 mL
Brain Mass CSF
Volume
INTRACRANIAL PRESSURE

 10 mmHg = Normal
 >20 mmHg = Abnormal
 >40 mmHg = Life threatening

Cerebral Blood Flow

 50 mL/100 g/min = Normal.
 < 25 mL/100 g/min = EEG
abN
 < 5 mL/100 g/min = cell
death
Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
INCREASED ICP
HERNIATION

Ropper, 1998
Management
 Make plans to correct the underlying pathophysiology if possible.
 Airway control and prevention of hypercapnea are crucial:
- When intubating patients with elevated ICP use thiopental, etomidate, or intravenous lidocaine to
blunt the increase in ICP associated with laryngoscopy and tube passage.
 ICP monitoring usually needed to guide therapy
 Avoid jugular vein compression
- Head should be in neutral position
- Cervical collars should not be too tight
 Elevation of the head and trunk may improve jugular venous return.
Pharmacologic options
 Mannitol 0.25 gm/kg q4h (may need to increase dose over time)
 Hypertonic saline (requires central line)
- 3%
- 7.5%
- 23.4% (30 mL over 10 min)
 Steroids only for edema around tumors or abscesses (not for use in trauma or cerebrovascular disease)
Sedation
 Benzodiazepines
 Propofol
 Neuromuscular junction blockade
High-dose barbiturates
Surgical options
 Resect mass lesions if possible
 Craniectomy
- Lateral for focal lesions
- Bifrontal (Kjellberg) for diffuse swelling
TRAUMATIC BRAIN INJURY
S
S
I
F
I
C
A
 NEUROLOGIC EXAMINATION

Ellenbogen RG, Abdulrauf SI, Sekhar LN. Principles of Neurological Surgery 3rd ed. Philadelphia. Elsevier. 2012
CT SCAN
 New Orleans Criteria
CT is recommended for patients with minor head injury (GCS 15) with any one of
the following findings:
1. Headache.
2. Vomiting.
3. Age more than 60 years.
4. Drug or alcohol intoxication.
5. Persistent anterograde amnesia.
6. Visible trauma above the clavicle.
7. Seizure

Qureshi NH, Kopell BH. Skull fracture. Available at http://emedicine.medscape.com/article/248108-overview#a8. Date of citation 1 Aug 2015
MEDICAL MANAGEMENT

1. Head up 15-30 degree

2. Airway assured : prevent hypercarbia and hypoxia.
3. Assisted ventilation : PaCO2 30 mmHg
4. Prevent Hypotension. MAP 90 – 100 mmHg
5. Euvolemia
6. Mild hypotermia ???
7. Manitol 0,25- 1 g/kgBB
8. Pentobarbital 2-2,5 mg/kgBB/hour  
 SURGICAL
1. ICP insertion
2. Craniotomy evacuation: EDH, SDH, ICH
3. CSF diversion for hydrocephalus
4. Decompressive craniectomy –
Medical fail  hemicraniectomy
5. Emergency burr hole ???

TBI guideline.www.braintrauma.org.2016
ACUTE STROKE
Intravenous thrombolysis is indicated for patients with: ISCHEMIA
 A clinical diagnosis of ischemic stroke
 A CT scan excluding intracerebral hemorrhage
 Onset of symptoms less than 3 hours before starting treatment
 No contraindications (see ACLS text for list)

rt-PA 0.9 mg/kg (up to 90 mg)

 10% bolus, remainder over 60 min

Between 3 and 6 hours, intra-arterial therapy may be an option

No role for acute heparin in evolving or completed stroke

 May be needed later for secondary prevention in patients with atrial fibrillation
NIHSS SCORE !!!
Hypertensive hemorrhages occur in the: HEMORRHAGE
 Putamen
 Thalamus
 Pons
 Cerebellum

Patients with hemorrhages elsewhere, or without a history of hypertension, need to be worked up for underlying
vascular lesions or a bleeding diathesis.
For supratentorial hemorrhage, the major determinant of survival is hemorrhage volume:
 < 30 mL usually survive
 > 60 mL frequently die

Patients with cerebellar hemorrhages often benefit from surgical evacuation

 Proceed before cranial nerve findings develop.
Most commonly due to ruptured aneurysm
SAH
Present with sudden headache, often diminished consciousness
 Focal findings suggest intracerebral hemorrhage, which may occur due to dissection
of blood from the bleeding aneurysm into the cortex.

Early definitive aneurysm obliteration

Nimodipine or nicardipine to relieve or ameliorate the effects of vasospasm

Interventional neuroradiologic techniques (e.g., angioplasty and intra-arterial verapamil
or nicardipine infusion) to treat vasospasm

Ventricular drainage to treat hydrocephalus

VS
SPINE INJURY
 Prevention of further injury
 Cervical Collar
 Spine Board
 Urgent Radiological Assesment
 Management of Autonomic Dysfunction
 Prevention of Pressure Sore
 Prevention of TE complication
AMERICAN SPINAL INJURY
ASSOCIATION SCALE

A = Complete
B = Sensory Function
C = Motor < 3
D = Motor > 3
E = Normal
 NEXUS Criteria :
 Fully alert
 No spinal pain
 No neurologic deficit
 No alcohol or drug intoxication
 No distracting injuries
 Traumatic Fracture – Dislocatio L1

Post Pedicle screw fixation + Laminectomy

TUMOR AND MASS
HYDROCEPHALUS
Hydrocephalus is a condition in which excess cerebrospinal fluid (CSF) builds up
within the fluid-containing cavities or ventricles of the brain.

Communicating Hydrocephalus: The condition arises either due to inadequate

absorption or due to an abnormal increase in the quantity of CSF produced.

Non-communication (Obstructive) Hydrocephalus:  It occurs when the flow of CSF

is blocked along one of more of the passages connecting the ventricles.
THANK
YOU