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Difficulty: MediumNeurosurgery

A 62-year-old man is evaluated in the neurosurgical intensive care unit due to a sudden decline in consciousness. He underwent an uncomplicated right frontotemporal craniotomy for resection of a meningioma 48 hours ago. Over the past hour, the nurse noted that he became increasingly difficult to arouse. His temperature is 38.1°C (100.6°F), blood pressure is 180/100 mm Hg, pulse is 48/min, and respirations are 10/min and irregular. Glasgow Coma Scale score is 7 (E2, V2, M3), decreased from a baseline of 14. Neurologic examination reveals a 7-mm, unreactive right pupil and a new profound left-sided hemiparesis. The surgical incision site appears clean and intact. Which of the following is the most appropriate next step in management?

  1. Endotracheal intubation and administration of intravenous mannitolAnswer
  2. B
    Immediate transport for a computed tomography scan of the head
  3. C
    Performance of a lumbar puncture for cerebrospinal fluid analysis
  4. D
    Initiation of empiric intravenous vancomycin and cefepime
  5. E
    Continued observation with hourly neurologic assessments

Answer

Endotracheal intubation and administration of intravenous mannitol
The correct answer combines the two most urgent priorities in a patient with active uncal herniation and a GCS less than 8: securing the airway and medically reducing intracranial pressure. The patient's Cushing triad (hypertension, bradycardia, irregular respirations), declining GCS, ipsilateral fixed and dilated pupil (due to oculomotor nerve compression), and contralateral hemiparesis (due to cerebral peduncle compression) are classic signs of uncal herniation. Endotracheal intubation protects the airway and allows for controlled ventilation, while mannitol (an osmotic diuretic) acutely reduces cerebral edema and intracranial pressure, buying critical time for diagnostic imaging and surgical intervention.

Step-by-Step Solution

1
Analyze the patient's vital signs and neurologic examination.
The patient has Cushing triad (hypertension, bradycardia, irregular respirations), a declining Glasgow Coma Scale score of 7, a dilated right pupil, and left-sided hemiparesis.
These findings are pathognomonic for right-sided uncal herniation, a life-threatening neurologic emergency often caused by postoperative hemorrhage or edema.
2
Determine the most critical immediate intervention.
The patient requires immediate airway protection and medical reduction of intracranial pressure before any diagnostic imaging is performed.
A GCS under 8 combined with irregular respirations necessitates immediate intubation to secure the airway. Mannitol is an osmotic diuretic that rapidly decreases cerebral edema, buying critical time for a subsequent CT scan and definitive surgical decompression.

Key Concept

In patients with active uncal herniation, securing the airway and administering osmotic therapy take precedence over diagnostic imaging.
Estimated Time:1m 0s
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Topics

Neurosurgery

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