Approach to Approach to Intracranialemergency Intracranialemergency

Neurologic symptoms

Weakness, difficulty speaking, concentrating, swallowing, or thinking, imbalance, sensory changes, visual problems, and headache.

Altered mental status

Dizziness and vertigo

HeadacheHeadache

KEY CONCEPTS

Headache is a common presenting complaint in the emergency department. The emergency physician must distinguish between benign primary headache disorders and the more serious and potentially life-threatening secondary causes of headache.

The majority of patients do not have abnormal neurologic findings; therefore, the key to a successful diagnosis is a thorough and systematic history.

Patients with the following headache presentations are at risk for serious underlying disease:

• sudden explosive headache; • first or worst headache; • new-onset headache after age 50; • headache associated with papilledema, alteration

in or loss of consciousness, or focal neurologic symptoms;

• headache after head trauma; • subacute headache with increasing frequency or

severity; • headache associated with fever, cancer, or

immunosuppression; • headache triggered by exertion, sexual activity, or

Valsalva maneuver.

The need for diagnostic studies is dictated by the suspected secondary cause of headache

Historical danger signs in patients with headache

SeizuresSeizures

Stroke

Stroke means “ rapidly developed clinical signs of focal (global)

disturbance of cerebral function lasting more than 24 hours or

leading to death, with no appearance cause other than a

vascular origin.”

KEY CONCEPTS

• Patients presenting with the signs and symptoms of an acute ischemic stroke within 3 hours of symptom onset should be evaluated for thrombolytic therapy within the following recommended target time frames: Door to physician: 10 minutes Door to CT completion: 25 minutes Door to CT reading: 45 minutes Door to drug treatment: 60 minutes

• Carotid Doppler, MRA, or CT angiography studies are recommended before discharging a patient with TIA.

• Avoid overaggressive blood pressure management in patients with acute ischemic stroke.

• Accurate time of symptom onset should be documented for all patients with stroke.

• Assessment of gait is essential to rule out posterior circulation stroke in patients presenting with vertigo.

KEY CONCEPTS

• Patients presenting with the signs and symptoms of an acute ischemic stroke within 3 hours of symptom onset should be evaluated for thrombolytic therapy within the following recommended target time frames: Door to physician: 10 minutes Door to CT completion: 25 minutes Door to CT reading: 45 minutes Door to drug treatment: 60 minutes

Figure 99-2 A, CT scan taken 2 hours, 50 minutes after large right middle cerebral artery occlusion. There are subtle, ultra-early ischemic changes, including loss of the gray-white interface (arrows) and subtle evidence of sulcal effacement. B, CT scan of same patient approximately 8 hours after symptom onset shows acute hypodensity (arrows) and more prominent sulcal effacement.

ผปวย subarachnoid hemorrhage โรคทพบบอยคอ ruptured cerebral aneurysm ,

ruptured ateriovenous malformation

ผปวย intraventricular hemorrhage ทไมพบกอนเลอดใน

เนอสมอง ควรพจารณาสงตรวจ

Cerebral angiography ,CT angiography . MR angiography

ผปวย intracerebral hemorrhage อาจแบงเปน lobar hemorrhage , non-

lobar hemorrhage

Lobar hemorrhage หมายถง intracerebral hemorrhage ทอย

ในตำาแหนง cortical ,subcortical ไดแก

frontal,parietal,occipital,temporal lobes สาเหตของเลอดออกในตำาแหนงนมกไมใชเกดจากความ

ดนโลหตสง

แตมสาเหตอน เชน cerebral amyloid angiopathy,

aneurysm, AVM จงควรสงตรวจวนจฉยความผดปกตของ

หลอดเลอด ดวย cerebral angiography, CT angiogram, MR angiogram และปรกษา

ประสาทศลยแพทย

Non-lobar hemorrhage หมายถง intracerebral hemorrhage ท basal

ganglia mostly at putamen, thalamus,cerebellum,brainstem

mostly at pons

Figure 99-1 The CT slice with the largest area of hemorrhage is identified. The largest diameter of the hemorrhage on this slice is measured in centimeters (A). The largest diameter 90 degrees to A on the same slice is measured (B). C is the approximate number of 10-mm slices on which the intracerebral hemorrhage was seen. The volume of the hemorrhage equals A multiplied by B, multiplied by C, divided by 2 (ABC/2).

ผปวย nonlobar hemorrhage ขอบงชในการปรกษาประสาทศลยแพทย

คอ coma score less than 13 , volume more than 30 cc. ,

midlineshift more than 0.5 cm. ยกเวน ผปวย cerebellar hemorrhage ควรปรกษาประสาทศลยแพทยทก

ราย

การคำานวณปรมาตรกอนเลอด = 0.524 . x .y. z มลลลตร

(X,Y,Z = ความยาวของเสนผาศนยกลางของกอนเลอดในแนว

แกน X,Y,Z หนวยเปน เซนตเมตร)

การรกษาภาวะความดนในกะโหลกศรษะสง

• Clear airway ใสทอชวยหายใจ และ Floey’s Catheter

• ใหนอนยกศรษะและสวนบนของรางกายสง 20 – 30 องศา

• จดทำาผปวยโดยใหหลกเลยงการกดทบหลอดเลอดดำาทคอ (jugular vein)

• Hyperventilation เพอให PaCO2 = 30 – 35 mmHg แตวธนมประโยชนในชวงสน ๆ กอนผาตด

• พจารณาใหยา

การรกษาภาวะความดนในกะโหลกศรษะสง (ตอ)

• 20% mannitol : loading dose 1 gm/kg ทางหลอดเลอดดำาภายใน 20 นาท ตามดวย 0.25 – 0.5 gm/kg ทก 6 ชวโมง ควรตรวจ serum osmolarity ทกวน ควบคม serum osmolarity ≤ 320 mOsm/l (grade C) หรอ10% glycerol 250 ml ทางหลอดเลอดดำา ภายใน 30 นาท ทก 6 ชวโมง หรอ50% glycerol 50 ml ทางปาก วนละ 4 ครง หรอFurosemide 1 mg/kg ทางหลอดเลอดดำา (grade C)

• หลกเลยงการให hypotonic solution• การใช steroid ยงไมมหลกฐานทางคลนกสนบสนน

วาไดประโยชน (grade A)

Pre test

DDx of isolated CN III palsy

1.Uncal brain herniation

2.Pcom aneurysm rupture

3.CN III neuritis

ICP

VOLUMECOMPENSATE

DECOMPENSATE

INCREASED INTRACRANIAL PRESSURE

BRAIN HERNIATION

1.Subfalcine

2. Uncal

3. Central

4.Tonsilar

Uncal herniation sings

1.CN III palsy

2.Hemiparesis

Impaired light reflex

Ipsilateral

Contralateralmidbrain

uncus

PHYSICAL EXAMINATION

VITAL SIGNS

GCS

PUPILS

MOTOR

MANAGEMENT

Of

HEAD INJURY

MINOR HEAD INJURY

GCS 15 NO LOSS OF

CONSCIOUSNESS

NO AMNESIA

NO SKULL FRACTURE

DISCHARGE

TRANSIENT LOSS OF CONSCIOUSNESS

Or AMNESIA

SKULL FRACTURE

OBSERVE NS.

Or GCS 14

WITH HEADACHE

CT BRAIN

MODERATE HEAD INJURY

( GCS 9-13)

CT BRAIN

6Hr. Not improved Repeat CT

(GCS < 8)

CT BRAIN NOT DELAYED

CONSIDER INTUBATION

AND MINITOL

SEVERE HEAD INJURY

IMMEDIATE CONSULTATION

GCS DECREASE < 2

ANISOCORIA

HEMIPARESIS

LUCID INTERVAL

Clinical risk of head- injured patients

1.Secondary expanding lesions ICP

Transtentorial brain herniation

2.Operation after transtentorial herniation with

Severe brain stem compression make poor results

3.EDH and SDH common occur within 6 hr.

4.ICH may delayed after 24 hr

Common pitfalls

Inaccurate GCS Score

Drunken patients

Not worse but not full GCS

Neglect open wounds

Operation within 6 hr hematomasat other sites may develop

Common pitfalls (cont.)

Progression of extra cerebral hematoma within 6 hr and intracerebral hematomamay delayed to 24 hr

Misdiagnosis of brain death in GCS=3with operable hematoma

Waiting for consent

20 year old male

MC rider collision with Taxi

Unconscious ,try intubation by EMS

but failed

½ Hr. to ER GCS E2 M6 V3

1 Hr to CT brain 1 Hr to OR

Pre op condition

BP 180/100 P 100 GCS E2 M5 V3

Pupils RT 5mm sluggish RTL

Lt 3mm. Sluggish RTL

Lt Hemiparesis Grade II

Male 38 year old ขบสามลอเครองชนแทกซ

BP 140/80 P 80 R 20

GCS E3 M6 V4 Pupils 3mm RTL both

Male 41y ขบสามลอเครองชนแทกซ

แรกรบรตวด ไมสลบ ใหคำาแนะนำา กลบบานได

12 ชวโมงตอมาปวดศรษะมาก พดสบสน

BP 150/90 P 80 R20

GCS E4 M 6 V4

Post op persistent headache

and hyponatremia

Right frontal craniotomy

post op good recovery

Male 21 year old ถกตทศรษะไมรสกตว

½ Hr to ER BP 130/70 P60 R20

GCS E1 M3 V1 Pupils R2mm L 3mm RTL

½ Hr to CT

GCS E1 M3 V1 Pupils R2mm L 5mm Fixed

Post op good recovery

51yr Male MCA

GCS E4 V4 M6

30 min change to

GCS E2 V2 M5

Pupils Rt 5mm

Lt 3mm sluggish RTL

30 min. to OR Good recovery

57y.old male Passenger on a car collision with a truck

Initial GCS =E3,M6,V3

Pupil 3mm. RTL both

Periorbital swelling & ecchymosis

Bloody rhinorrhea

No other sinificant injury

CT scan at 2hr after injury

2hr.later GCS change to E1,M5,V2

BP 160/90 P 50 RR 20

Pupil R 2 mm. L3 mm. well RTL both

Motor : equally move both sides

Repeated CT scan 2hr after the first

Before After

Post op good recovery

32 y old male GCS =15

Suture scalp wound and discharge

½ Hr readmission with GCS E1 M5 V1

Pupil 5mm fixed Rt Lt hemiparesis

Suddenly change to GCS E1 M2 Vt

1 Hr CT scan at center outside hospital

Consult neurosurgeon

Bolus dose of mannitol

GCS E1 M2 Vt

Waiting for consent

GCS 3 BP 80/40

Death

Male 22y.MCA,GCS E1M2V1

Pupils Rt 5mm Lt 3mm sluggish RTL

CT brain

Sudden change to GCS 3 and pupils fixed dilated both

Diagnosis of brain death

6 hr later improved to GCS E1 M3 Vtafter mannitol infusion

Pupils Rt 3mm sluggish react to light Lt 5mm fixed

Operated but not recovered

2CASE

ผปวยชายไทย อาย 15 ป ข MC ชนรถเกง 10 . MIN PTA

: 110/70 , 70 , 20PE BP P R = GCS E3 M5 V1 3 . Pupils mm Sluggish RTL both

Rt Hemiparesis grade II

Immediately change to GCS=3

Go on to OR within 30 min

Post op good recovery

45 y old man MC rider collision with MC

First seen at a private hospital BP 150/100 P 100

GCS E2 M5 V3 Pupils 3mm RTL both

1 hr refer to Lerdsin hospitalGCS E2 M4 Vt pupils 3mm RTL both

BP 155/60 P 50

BP130/70 P60

Conservative treatment GCS E4 M5 Vt Rt hemiparesis

BP 130/70 P57BP 135/70 P54

17 น. 22 น.

Sudden change to GCS E1 M1 Vt dilated fixed pupils on the 5thday

Operated but not recovered death

Multiple Intracranial Hemorrhage

Male 30 y GCS = 3 BP 80/50

Severe Primary Brain Injury

Male 30 y Decerebrate GCS=3

47y.old Male

Acute confusional state

Headache with vomitting for 3wkDiagnosis to migrain at ER two times

History of minor head injury admitted for 3days at2 months ago

Misdiagnosis as brain tumor by CT

27y old maleSevere headache for 1wk

Diplopia for 3days

History of minor head injury 1mo ago

CT brain showing bilateral SDH

The first physician advice conservative treatment

then the patient came to Lerdsin hospital

17y.old female

Sudden headache then unconsciousPE at ER : BP 130/90 P80 R20

GCS=E1M3V1 Pupils Rt 5mm Lt 2mm sluggish RTL

CT not available in hospital Then exploratory craniotomy was performed immediately

SDH about 50 ml

ICH about 50ml

Cortical AVM at temporoparietalabout 3cm in diameter

AVM was totally excised

The patient recovered well with mild left hemiparesis

Female 37 y old presented with severe headache and vomiting without localizing sign

History of headache for 10 months

2day after CT evaluated by neurosurgeon

ลกษณะอาการปวดศรษะทควรระวง

อาการปวดทไมเคยปวดรนแรงเชนนมากอน

อาการปวดททเลาบางครงแตไมหายเปนปกต

อาการปวดททำาใหไมสามารถไปทำางานหรอมกจวตรไดปกต

อาการปวดทมความรนแรงมากขน

อาการปวดรวมกบมอาเจยนรวมดวย

อาการปวดทมลกษณะปวดทวไปทงศรษะเหมอนจะระเบด

อาการปวดบรเวณหนาผาก หรอทายทอย

อาการปวดรวมกบอาการตงบรเวณตนคอ

เคยมประวตบาดเจบทศรษะมากอน

สญเสยการไดยน การดมกลน เดนเซ กระตกของกลามเนอ