Elements in Emergency Neurosurgery – serie

Emergency neurosurgery encompasses serious and high-risk cranial and spinal conditions across all ages. The authors provide an overview of the changes occurring within emergency surgery to meet the challenges provided from unscheduled care. Considering the wider landscape of emergency surgery provides a context for the changes occurring within emergency neurosurgery. The delivery of emergency neurosurgery within the UK, the Republic of Ireland, the Netherlands, and the United States of America (USA) is then described to provide an overview of different models of care.

Most traumatic brain injury (TBI) cases are considered mild. Precise definitions vary, but typically, loss of consciousness and post-traumatic amnesia duration is brief (e.g. <30 minutes and <24 hours respectively), and standard imaging is normal. Prognosis in mild TBI is generally good, but disabling persistent symptoms such as headaches, dizziness, affective and cognitive issues are common. A focussed assessment tailored to each individual symptom is crucial for management. Advanced MRI and blood-based biomarkers of mild TBI are emerging and are likely to play an increasingly important role in the assessment of patients following a head injury.

Cerebral venous sinus thrombosis (CVST) is a serious and potentially life-threatening condition, whose diagnosis is often missed or delayed due to often non-specific presentations. However, if diagnosed and managed appropriately prognosis is generally favourable. This Element covers the common presentations and epidemiology of CVST, progressing through the approach to investigation and management of this condition in the acute, sub-acute and more chronic timeframes.

On-call neurosurgery concerns practice related to urgent and emergency neurosurgical care including outside of 'normal' working hours. Being on-call involves many competing responsibilities and is regarded as one of the most demanding aspects of a neurosurgical career. The on-call work pattern has evolved over the past decade due to changes in demographics, technology and working practices, each of which have brought new and emerging challenges. These challenges aside, the on-call provides a unique and rewarding environment to make a meaningful difference to patients and to learn the science and art of neurosurgery. Success in on-call work requires not only good technical knowledge and application but also a wide variety of non-technical skills. These skills will help deal with some of the difficult situations neurosurgeons in training face when on-call to make the experience more manageable and educational.

Cauda equina syndrome is the clinical syndrome seen when there is acute compression of the cauda equina nerve roots and is a rare neurosurgical emergency. The approximate incidence in patients presenting with low back pain is 0.27% but delays in investigation and treatment can result in life-changing permanent disability. The best practice for patients presenting with potential cauda equina syndrome is urgent MRI imaging at the presenting hospital to avoid delays in diagnosis. Patients with a positive finding of cauda equina compression should proceed to decompressive surgery to restore the diameter of the spinal canal urgently to reduce the risk of developing a permanent deficit.

Central nervous system, affliction, although rare, represents one of the most severe extra-pulmonary manifestations of tuberculosis, potentially leading to substantial morbidity and mortality if not promptly addressed. Cranial tuberculosis can manifest in various forms, including tuberculomas, encephalitis, abscesses, and meningitis, with the latter being the most critical and carrying a poor prognosis if left untreated. Spinal tuberculosis, accounting for approximately 50% of musculoskeletal TB cases, can present with a spectrum of symptoms, ranging from simple back pain to more severe neurological deficits such as weakness and deformity. Anti-tuberculosis medications remain the cornerstone of treatment, and this Element offers an algorithmic approach to managing referrals of suspected tuberculosis, incorporating pertinent clinical information to facilitate effective decision-making.

Spinal infections (SIs) are rare conditions affecting the intervertebral disc, vertebral body and/or adjacent spinal tissues. The lumbar region is most commonly involved, followed by the thoracic and cervical regions. Patients present with varied, non-specific clinical features leading to diagnostic and treatment delays. Clinicians need to have a low threshold to suspect SI. In this Element, two real-life cases of patients with SIs will be presented first. Core knowledge will be reviewed next, followed by diagnostic pitfalls and clinical pearls. Finally, the 'typical' clinical workflow for a patient with SI will be presented and the various treatment options will be explored.

Intra-dural spinal tumours are a rare, yet diverse group of neoplasms, which may occur anywhere along the spinal neuroaxis. Their clinical presentations are typically slow and progressive in nature. Signs and symptoms are dictated by tumour location and size, and occur due to the sequalae of mass effect, oedema, ischaemia and subsequent metabolic dysfunction of neural tissue occurring secondary to compression of neural elements and neural vasculature. Back/neck pain and stiffness are the most common presenting complaint for patients presenting with intra-dural spinal tumours. Further symptoms are dependent on the location of the tumour. Lesions that compress or develop within the spinal cord are associated with upper motor neuron (myelopathic) signs and symptoms, whilst lesions compressing spinal nerves alone are associated with lower motor neuron (radicular) signs and symptoms. In some circumstances, a mixed picture of both upper and lower motor neuron symptoms may also be observed.

Whilst thoracic myelopathy secondary to degenerative disease is relatively uncommon, left untreated it carries significant morbidity. It is thus of critical importance that patients are correctly diagnosed and managed expediently and effectively. Unfortunately, the management of thoracic myelopathy can be challenging, not least due to the technical difficulty accessing the site of compression and indeed optimum management is also debated. In this Element the authors present background, clinical features, diagnosis, and pitfalls and then a handy management algorithm for this critical neurosurgical condition.

The ruptured aneurysm with an intracerebral haematoma is a commonly encountered neurosurgical emergency. The options for management of this situation have evolved with the changes in neurovascular surgery training and widespread use of endovascular techniques for aneurysm occlusion. This Element will discuss the differences between subarachnoid haemorrhage with or without an intracerebral haematoma including presentation, imaging and outcomes. The authors present their preferred surgical strategy including practical guidance on how to handle difficult situations such as the intra-operative rupture.

The management of patients with moderate and severe traumatic brain injury (TBI) is centred on the intensive care management to limit the extent of secondary injury to the brain, following the primary trauma. This management aims to optimise the homeostatic environment of the brain after injury and can be guided by multi-modality monitoring, including intracranial pressure (ICP) monitoring. This management often follows a tiered approach to introducing more aggressive interventions to correct physiology, based on evidence for ongoing secondary injury, such as raised ICP. The balance between risk and benefit for these interventions for individual patients is difficult, particularly in the absence of high quality randomised trials for many interventions in this area. In this Element, the authors outline both the approach to intensive care management of moderate and severe TBI, as well as the evidence base available for the interventions discussed.

Emergency management of intracranial haemorrhage due to AVMs, DAVFs, and cavernomas involves addressing both the haemorrhage consequences and the underlying vascular lesion. Clinical evaluation and diagnostic workup identify factors necessitating urgent intervention and define the vascular lesion. Urgent intervention may involve ICH management with increased ICP or CSF drainage for acute hydrocephalus. Definitive intervention for the vascular lesion may coincide with or follow evacuation of the intracranial haematoma. Careful considerations and precautions are taken independently or concurrently with the vascular lesion. Indications and timing for AVM intervention involve determining the bleeding source, evaluating mass effect, and assessing the utility of existing ICH for microsurgical AVM resection. Modified microsurgical techniques ensure safety. DAVF intervention with ICH or ASDH requires urgent endovascular treatment and surgical nuances. Cavernoma intervention follows straightforward indications and timing, while brainstem cavernomas require careful consideration of early intervention. Aftercare and a team approach are vital.

Functional Neurosurgery modifies CNS circuits to effect change within or outside the nervous system. Most commonly, Functional procedures are performed to treat movement disorders, chronic pain, spasticity and epilepsy. Whilst regarded as a predominantly elective subspecialty, emergent scenarios are encountered. The combination of their relative rarity couple with the niche nature of the subspecialty may engender anxiety amongst neurosurgery trainees. This Element overviews some more common emergency scenarios which may be encountered comprising suspected malfunction of intra-thecal drug delivery devices, deep brain and spinal cord stimulators. Status Trigeminus and an approach to investigations with a neuromodulation device in situ are also covered.

Emergency Neurosurgery is a constantly evolving specialty, resulting in ever increasing challenges posed on the higher specialty trainee. The focus of this Element is to guide the reader on the application of robust and easily applicable management strategies whilst dealing with the most challenging aspects of their professional workload. The authors have categorised the various subgroups of emergency neurosurgical workload, devised a comprehensive management algorithm, included case scenaria related to the most challenging emergency situations and highlighted easily overlooked clinical information. In summary, this Element will provide robust and easily applicable management strategies whilst dealing with the most challenging aspects of the emergency neurosurgical workload.

On-call neurosurgery concerns practice related to urgent and emergency neurosurgical care including outside of 'normal' working hours. Being on-call involves many competing responsibilities and is regarded as one of the most demanding aspects of a neurosurgical career. The on-call work pattern has evolved over the past decade due to changes in demographics, technology and working practices, each of which have brought new and emerging challenges. These challenges aside, the on-call provides a unique and rewarding environment to make a meaningful difference to patients and to learn the science and art of neurosurgery. Success in on-call work requires not only good technical knowledge and application but also a wide variety of non-technical skills. These skills will help deal with some of the difficult situations neurosurgeons in training face when on-call to make the experience more manageable and educational.

Non-traumatic posterior fossa haemorrhage accounts for approximately 10% of all intracranial haematomas, and 1.5% of all strokes. In the posterior fossa, a small amount of mass effect can have dramatic effects, due to its small volume. This can be due to immediate transmission of pressure to the brainstem, or via occlusion of the aqueduct of Sylvius or compression of the fourth ventricle, leading to acute obstructive hydrocephalus, with the risk of tonsillar herniation. Timely investigations and management are essential to maximise good outcomes. This Element offers a brief overview of posterior fossa haemorrhage. It looks at the anatomy, aetiology, management, and surgical options, with a review of the available evidence to guide practice.

Non-traumatic posterior fossa haemorrhage accounts for approximately 10% of all intracranial haematomas, and 1.5% of all strokes. In the posterior fossa, a small amount of mass effect can have dramatic effects, due to its small volume. This can be due to immediate transmission of pressure to the brainstem, or via occlusion of the aqueduct of Sylvius or compression of the fourth ventricle, leading to acute obstructive hydrocephalus, with the risk of tonsillar herniation. Timely investigations and management are essential to maximise good outcomes. This Element offers a brief overview of posterior fossa haemorrhage. It looks at the anatomy, aetiology, management, and surgical options, with a review of the available evidence to guide practice.

Most traumatic brain injury (TBI) cases are considered mild. Precise definitions vary, but typically, loss of consciousness and post-traumatic amnesia duration is brief (e.g. <30 minutes and <24 hours respectively), and standard imaging is normal. Prognosis in mild TBI is generally good, but disabling persistent symptoms such as headaches, dizziness, affective and cognitive issues are common. A focussed assessment tailored to each individual symptom is crucial for management. Advanced MRI and blood-based biomarkers of mild TBI are emerging and are likely to play an increasingly important role in the assessment of patients following a head injury.

Emergency neurosurgery encompasses serious and high-risk cranial and spinal conditions across all ages. The authors provide an overview of the changes occurring within emergency surgery to meet the challenges provided from unscheduled care. Considering the wider landscape of emergency surgery provides a context for the changes occurring within emergency neurosurgery. The delivery of emergency neurosurgery within the UK, the Republic of Ireland, the Netherlands, and the United States of America (USA) is then described to provide an overview of different models of care.

The authors start with definitions and classification of a depressed conscious state and proceed to detail practical tips in the initial assessment of patients with coma, focussing on the history and examination. They impress the number of non-neurological causes of coma, which may need to be considered. The assessment of pupillary responses, eye movement abnormalities and abnormal breathing patterns are described. They also explore the utility of basic initial investigations, including blood gases and briefly discuss specialist neuro-imaging and electroencephalography.

Emergency Neurosurgery is a constantly evolving specialty, resulting in ever increasing challenges posed on the higher specialty trainee. The focus of this Element is to guide the reader on the application of robust and easily applicable management strategies whilst dealing with the most challenging aspects of their professional workload. The authors have categorised the various subgroups of emergency neurosurgical workload, devised a comprehensive management algorithm, included case scenaria related to the most challenging emergency situations and highlighted easily overlooked clinical information. In summary, this Element will provide robust and easily applicable management strategies whilst dealing with the most challenging aspects of the emergency neurosurgical workload.

Seizures are a presenting feature of many neurosurgical disorders, and can arise as a result of neurosurgical treatment or its complications. Recognition and effective management of seizures can be life-saving, and will minimise long term seizure induced morbidity. In this Element the authors describe seizure diagnosis, emergency and ongoing management, and considerations in neurosurgical conditions.

Seizures are a presenting feature of many neurosurgical disorders, and can arise as a result of neurosurgical treatment or its complications. Recognition and effective management of seizures can be life-saving, and will minimise long term seizure induced morbidity. In this Element the authors describe seizure diagnosis, emergency and ongoing management, and considerations in neurosurgical conditions.

Intraventricular lesions are uncommon, and they can arise from numerous structures around the ventricular system, including the ependyma, septum pellucidum and choroid plexus. Pineal region lesions may arise from the pineal gland parenchymal/supporting cells or glial cells of the midbrain/medial thalamus. Many of these lesions are either found incidentally or present with symptoms of hydrocephalus. Careful assessment of the clinical and radiological features of each case can help to narrow the differential diagnosis in this heterogenous group of tumours.

Intraventricular lesions are uncommon, and they can arise from numerous structures around the ventricular system, including the ependyma, septum pellucidum and choroid plexus. Pineal region lesions may arise from the pineal gland parenchymal/supporting cells or glial cells of the midbrain/medial thalamus. Many of these lesions are either found incidentally or present with symptoms of hydrocephalus. Careful assessment of the clinical and radiological features of each case can help to narrow the differential diagnosis in this heterogenous group of tumours.

Adult cerebral infections are a common neurosurgical emergency presentation in the UK. This Element provides a comprehensive guide for clinicians, detailing the epidemiology, aetiology, and risk factors associated with the various types of cerebral infections including cerebral abscess, subdural empyema, epidural abscess and cranial fungal and parasitic infections. The clinical presentation, diagnostic methods, and treatment options, including surgical and antibiotic management, are discussed. Emphasis is placed on the importance of early diagnosis and tailored treatment plans. Flow diagrams summarizing the management of cerebral infections are also provided in this Element.

Spinal infections (SIs) are rare conditions affecting the intervertebral disc, vertebral body and/or adjacent spinal tissues. The lumbar region is most commonly involved, followed by the thoracic and cervical regions. Patients present with varied, non-specific clinical features leading to diagnostic and treatment delays. Clinicians need to have a low threshold to suspect SI. In this Element, two real-life cases of patients with SIs will be presented first. Core knowledge will be reviewed next, followed by diagnostic pitfalls and clinical pearls. Finally, the 'typical' clinical workflow for a patient with SI will be presented and the various treatment options will be explored.

The ruptured aneurysm with an intracerebral haematoma is a commonly encountered neurosurgical emergency. The options for management of this situation have evolved with the changes in neurovascular surgery training and widespread use of endovascular techniques for aneurysm occlusion. This Element will discuss the differences between subarachnoid haemorrhage with or without an intracerebral haematoma including presentation, imaging and outcomes. The authors present their preferred surgical strategy including practical guidance on how to handle difficult situations such as the intra-operative rupture.

Central nervous system, affliction, although rare, represents one of the most severe extra-pulmonary manifestations of tuberculosis, potentially leading to substantial morbidity and mortality if not promptly addressed. Cranial tuberculosis can manifest in various forms, including tuberculomas, encephalitis, abscesses, and meningitis, with the latter being the most critical and carrying a poor prognosis if left untreated. Spinal tuberculosis, accounting for approximately 50% of musculoskeletal TB cases, can present with a spectrum of symptoms, ranging from simple back pain to more severe neurological deficits such as weakness and deformity. Anti-tuberculosis medications remain the cornerstone of treatment, and this Element offers an algorithmic approach to managing referrals of suspected tuberculosis, incorporating pertinent clinical information to facilitate effective decision-making.