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BRAIN BASICS

BRAIN BASICS. NESSA TIMONEY MEDICAL CENTER HEALTH BOWLING GREEN KENTUCKY 23 AUGUST 2019. No Disclosures. Outline. Cerebral Anatomy Clinical Neurosurgery Diagnosis Intracranial Pressure Intracranial Hypertension Management Clinical Vignettes. Anatomy. Cortical Anatomy.

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BRAIN BASICS

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  1. BRAIN BASICS NESSA TIMONEY MEDICAL CENTER HEALTH BOWLING GREEN KENTUCKY 23 AUGUST 2019

  2. No Disclosures

  3. Outline Cerebral Anatomy Clinical Neurosurgery • Diagnosis • Intracranial Pressure • Intracranial Hypertension Management • Clinical Vignettes

  4. Anatomy

  5. Cortical Anatomy

  6. Functional Anatomy

  7. Topography

  8. Internal Capsule

  9. Thalamus

  10. Cerebellum

  11. Brainstem

  12. Cerebrovascular Anatomy

  13. Cerebrovascular Anatomy

  14. Clinical Neurosurgery

  15. Diagnosis of Neurosurgical Pathology GOOD HISTORYAND NEUROLOGIC EXAM MENTAL STATUS EXAM Glasgow coma scale • Eye opening response • Verbal response • Motor response

  16. Diagnosis of Neurosurgical Pathology • CN EXAM • MOTOR EXAM • Pronator drift – must be done on every patient with cranial pathology • If patient slowly drops/pronates hand, it is a sign of contralateral UMN pathology • Tone Rigidity • Grading of Strength – cervical and lumbar • Grade 5: Full strength and resistance • Grade 4: Paritial resistance (may be graded +/-) • Grade 3: Moves limb against gravity • Grade 2: Moves limb but not against gravity • Grade 1: Muscle Twitch

  17. Diagnosis of Neurosurgical Pathology • CEREBELLAR EXAM • Evaluate rapid alternating movements, document any dysdiadochokinesia • Finger to nose to evaluate and underpointing or past pointing indicating dysmetria and ataxic movements • Evaluate tremor (intention, postural, resting, pill rolling) • Romberg test – standing, eyes closed feet together observe for sway or falls • Positive in patients with lesions of one of the 2 sensory systems remaining when eyes are closed (vestibular, proprioception) or in midline cerebellar lesions

  18. Diagnosis of Neurosurgical Pathology • SENSORY EXAM • Light touch and pin prick • Vibratory sensation • DEEP TENDON REFLEXES • Abnormal reflexes - UMN: • Triple flexion: flexion of ankle, knee, and hip • Hoffman’s sign: flexion/adduction of thumb • Babinski sign: upgoing great toe and fanning of toes

  19. Diagnosis of Neurosurgical Pathology Initial Trauma Management: • Primary Survey (ATLS guidelines) • Airway • Breathing • Circulation • Disability • Exposure/Environmental • Secondary Survey • History/Examination

  20. Diagnosis of Neurosurgical Pathology Initial Trauma Management: 3. Physiologic Parameters1 1Guidelines for the management of severe Traumatic Brain Injury 3rd ed.

  21. Diagnosis of Neurosurgical Pathology Labs Coagulopathy vshypercoaguable states Pharmacology: antiplatelet/anticoagulation assays CSF analysis Imaging CT/MRI/Cerebral angiogram

  22. Intracranial Pressure

  23. Intracranial Pressure • Monro-Kellie doctrine • Intracranial volume (fixed) = Brain + Blood + CSF • These constituents create a state of volume equilibrium, such that any increase in volume of one of these, must be compensated by a decrease in volume of another • Increased pressure within the cranial cavity is caused by an increase in the volume of either the brain tissue, blood, CSF, presence of a tumor or space-occupying lesion

  24. Intracranial Pressure • Raised ICP is the final common pathway that leads to death or disability in most acute cerebral conditions • Two major consequences of increased ICP are: • Brain shifts • Brain ischemia • Cerebral perfusion pressure (CPP) is the calculated difference between the mean arterial pressure (MAP) and the ICP. • CPP = MAP - ICP

  25. Intracranial Pressure • CPP is the main determinant of cerebral blood flow (CBF) • Normally CBF is coupled to metabolic demand of tissue with normal flow greater than 50 ml/100g/min • Less than 20 ml/100g/min is considered ischemic threshold • The process of cerebral autoregulation maintains CBF between a CPP range of 50 – 150 mmHG • Outside these ranges CBF becomes pressure-dependent

  26. Intracranial Pressure When CPP is less than the lower threshold for autoregulatory compensation, CBF progressively decreases with CPP resulting in ischemia

  27. Intracranial Pressure

  28. Space Occupying Lesions • Extra axial lesions – EDH, SDH • Neoplasms • Intraparenchymal hemorrhages • Vascular malformations • Infective pathology: abscess

  29. Clinical Features of Elevated ICP • Cardinal Symptoms: • Headache, vomiting (especially without nausea), papilledema • Cranial Nerve Palsies • Particularly abducens palsies • Cushing response • Arterial hypertension and bradycardia • Abnormal respirations • Cheyne-Stokes – damage to diencephalic region

  30. Intracranial Hypertension Management

  31. Intracranial Hypertension Management

  32. Intracranial Hypertension Management

  33. Clinical Vignettes

  34. Clinical Case -1

  35. Epidural Hematomas

  36. Epidural Hematomas

  37. Epidural Hematomas

  38. Epidural Hematomas

  39. Clinical Case 2.

  40. Acute Subdural Hematoma

  41. Acute Subdural Hematomas

  42. Acute Subdural Hematomas

  43. Acute Subdural Hematomas

  44. Clinical Case 3. 76 yo M on aspirin presented with headaches Remote h/o fall 3 weeks prior GCS 15

  45. Chronic Subdural Hematomas • Fluid collection within the layers of the dura mater • 13.1 cases per 100,000 inhabitants • Patients older than 40 years account for 80% of cases – peak incidence 8th decade • Trauma biggest risk factor • Chronic alcoholism/older age predisposition • More falls, treatment with anticoagulation, brain atrophy

  46. Chronic Subdural Hematomas TREATMENT Watch and wait Pharmacological treatment Steroids, ACEI, TXA AEDs Surgery Burr hole vs craniotomy

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