Neurosurgery

A 29-year-old man is brought to the trauma center by helicopter 40 minutes after a high-speed frontal motor vehicle collision. On arrival, he is comatose with a Glasgow Coma Scale score of 5 (Eye 1, Verbal 1, Motor 3). Vital signs are temperature 36.5°C (97.7°F), blood pressure 180/100 mmHg, heart rate 48/min, and respiratory rate 10/min with irregular breathing patterns. Physical examination demonstrates a 7-mm right pupil that does not respond to light, and a 3-mm left pupil with a brisk pupillary light reflex. Motor examination reveals decorticate posturing on the left side in response to painful stimuli. The patient's airway was secured with an endotracheal tube by emergency medical services at the scene. Bilateral breath sounds are clear and equal. Which of the following is the most appropriate next step in management?

A 38-year-old woman is evaluated in the emergency department due to the sudden onset of a severe headache that began 4 hours ago. She describes it as the "worst headache I have ever had in my entire life." She has no significant past medical history and takes no medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 150/90 mmHg, heart rate 92/min, and respiratory rate 16/min. On physical examination, she is awake, alert, and oriented (Glasgow Coma Scale score 15). Cranial nerve function is intact, and there are no focal sensory or motor deficits in the extremities. She exhibits marked photophobia and nuchal rigidity. A computed tomography scan of the head without contrast reveals no intracranial abnormalities. Which of the following is the most appropriate next step in management?

An evaluation is requested for an 81-year-old resident of an assisted living facility who has exhibited a gradual decline in consciousness and right-sided hemiparesis over the last month. The nursing staff notes that the patient became non-verbal this morning. Medical history is significant for paroxysmal atrial fibrillation, for which the patient takes rivaroxaban. Vital signs are within normal limits except for a blood pressure of 162/95 mm Hg. Physical examination confirms dense right-sided weakness and a dilated, unresponsive left pupil. Urgent non-contrast head computed tomography reveals a 2.5-cm crescentic, low-attenuation fluid collection overlying the left cerebral hemisphere, resulting in uncal herniation and 14 mm of subfalcine shift. Which of the following is the most appropriate next intervention for this patient?

A 34-year-old woman is evaluated in the neuro-intensive care unit. She was admitted 2 days ago following a severe traumatic brain injury sustained in a motor vehicle collision. On admission, her Glasgow Coma Scale score was 6. A non-contrast head CT showed diffuse cerebral edema and multiple punctate hemorrhages at the gray-white matter junction, consistent with diffuse axonal injury, but no mass lesion requiring surgical evacuation. An external ventricular drain (EVD) and a brain tissue oxygen monitor (PbtO2) were placed. She is currently sedated, paralyzed, and mechanically ventilated. She is receiving a continuous infusion of 3% hypertonic saline.

Current vital signs:
Temperature: 37.2°C (99.0°F)
Blood pressure: 82/48 mm Hg (mean arterial pressure: 59 mm Hg)
Heart rate: 118/min

Current neuromonitoring data:
Intracranial pressure (ICP): 27 mm Hg (normal: 5-15 mm Hg)
Brain tissue oxygen tension (PbtO2): 12 mm Hg (normal: >20 mm Hg)
EVD output: 5 mL/hr of clear cerebrospinal fluid

Laboratory results:
Serum sodium: 154 mEq/L
Serum osmolality: 318 mOsm/kg H2O
Urine output: 150 mL/hr

Which of the following is the most appropriate next step in the management of this patient's intracranial hypertension?

Paramedics bring a 48-year-old previously healthy female to the emergency department. She reports the abrupt onset of an agonizing headache that began during heavy lifting, which she describes as the most severe pain she has ever experienced. She exhibits marked photophobia and neck stiffness on examination. Her vital signs are stable, and she is fully alert without lateralizing neurologic deficits. Arrange the following interventions in the most appropriate chronological sequence for her evaluation and definitive care, from initial presentation to post-treatment management.

Match each clinical presentation of acute neurologic deterioration to the most likely underlying brain herniation syndrome.

A 52-year-old man is brought to the emergency department by his wife due to the sudden onset of an excruciating headache and vomiting that began 2 hours ago. He also complains of blurry vision and difficulty seeing objects in his peripheral vision. His medical history is significant for decreased libido and profound fatigue over the last 6 months. On arrival, his blood pressure is 80/50 mmHg, and his heart rate is 118/min. Neurologic examination reveals a bitemporal hemianopsia. He appears lethargic but is oriented. Arrange the following steps in the most appropriate chronological order for the emergency evaluation and management of this patient:

A 42-year-old man presents with a 10-day history of worsening headaches and new-onset mild right-hand clumsiness. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, and pulse is $76\text{/min}$. He is fully awake, alert, and oriented with a Glasgow Coma Scale score of 15. Neurologic examination shows mild right upper extremity pronator drift but no other focal deficits. MRI of the brain with gadolinium reveals a single $3.2\text{ cm}$ centrally necrotic, ring-enhancing lesion in the left frontal lobe with moderate surrounding vasogenic edema and $3\text{ mm}$ of midline shift. There are no signs of impending brain herniation.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each classic clinical and radiographic presentation with the most likely neurosurgical diagnosis or herniation syndrome.

A 62-year-old female with a history of hormone receptor-positive breast cancer treated with a mastectomy four years ago visits an outpatient clinic due to progressively worsening mid-back pain over the past three weeks. The pain is localized to the thoracic region and worsens when she coughs or lies flat. Over the last 48 hours, she has noticed increasing heaviness in both legs and had an episode of urinary incontinence earlier today. Her temperature is 37.0°C (98.6°F), blood pressure is 138/86 mmHg, and heart rate is 82/min. Neurologic examination reveals 3/5 muscle strength in the bilateral lower extremities. Deep tendon reflexes are 3+ at the patellae and ankles, and bilateral plantar reflexes are extensor. Pinprick sensation is diminished below the level of the umbilicus. Which of the following is the most appropriate initial step in management?

A 22-year-old man is brought to the emergency department by emergency medical services after being ejected from a motorcycle at high speed. He was not wearing a helmet. Upon arrival, he does not open his eyes to pain, makes incomprehensible sounds, and exhibits abnormal extension of his upper extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while the left is 3 mm and reactive. Blood pressure is 165/95 mmHg, heart rate is 55/min, and respiratory rate is 10/min and irregular.

Arrange the following interventions in the correct chronological order from FIRST to LAST in the acute management of this patient.

A 42-year-old man is brought to the emergency department by emergency medical services after his roommates found him unable to walk. The patient states he has had severe, constant mid-back pain for the past two weeks, which became excruciating over the last 48 hours. Today, he developed profound weakness in both legs and has not been able to urinate since yesterday morning. His past medical history is significant for intravenous heroin use and a recent hospitalization for a cutaneous abscess that he left against medical advice. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and heart rate is $112/\text{min}$. Neurologic examination reveals $1/5$ strength in the bilateral lower extremities, absent patellar and Achilles reflexes, and decreased sensation to all modalities below the umbilicus. Digital rectal examination shows decreased anal sphincter tone. A bladder scan reveals $800\text{ mL}$ of retained urine. Which of the following is the most appropriate immediate next step in the diagnostic or therapeutic management of this patient?

A 27-year-old man is brought to the emergency department via ambulance after a high-speed motorcycle collision. He was found approximately $6 \text{ meters}$ ($20 \text{ feet}$) from his motorcycle without a helmet. Upon arrival, the patient is unresponsive. His temperature is $36.2^\circ \text{C}$ ($97.2^\circ \text{F}$), blood pressure is $72/40 \text{ mmHg}$, heart rate is $145\text{/min}$, and respiratory rate is $28\text{/min}$ with shallow breaths. Oxygen saturation is $92\%$ on high-flow oxygen. The patient is immediately intubated for airway protection. Physical examination reveals a large, actively bleeding scalp laceration over the right parietal area. Neurological evaluation demonstrates a Glasgow Coma Scale score of 3T. The right pupil is $8\text{ mm}$ and nonreactive to light; the left pupil is $3\text{ mm}$ and reactive. The abdomen is grossly distended and rigid. A focused assessment with sonography for trauma (FAST) exam reveals a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Arterial blood gas analysis on $100\%$ FiO2 reveals:

pH: $7.15$
PaCO2: $38\text{ mmHg}$
PaO2: $210\text{ mmHg}$
HCO3: $12\text{ mEq/L}$

What is the most appropriate next step in management?

Match each patient's clinical presentation and characteristic neuroimaging findings with the most likely primary intracranial tumor diagnosis.

A 52-year-old man is brought to the emergency department complaining of agonizing mid-back pain that has progressively worsened over the last week. This morning, he developed weakness in both legs and has been unable to urinate for the past 12 hours. He has a history of type 2 diabetes mellitus and had a central venous catheter placed during a hospitalization two weeks ago. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $105/\text{min}$. Neurologic examination shows $2/5$ strength in the bilateral lower extremities, patellar hyperreflexia, a sensory loss below the umbilicus, and a palpably distended bladder.

Arrange the following management steps in the most appropriate sequential order for this patient:

A $45$-year-old man is brought to the emergency department by his partner due to the sudden onset of an excruciating headache that began $2$ hours ago. He also reports blurred vision and extreme dizziness upon standing. The patient's medical history is significant for a known $2.5\text{-cm}$ nonfunctioning pituitary macroadenoma, which was being evaluated for elective surgical resection. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $118/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals bitemporal hemianopsia and a dilated, unresponsive right pupil with a "down and out" gaze deviation. The patient is lethargic but oriented. Which of the following is the most appropriate next step in the management of this patient?

Paramedics rush a 24-year-old male to the trauma bay following a high-velocity car crash. He is comatose upon arrival. Vital signs show a blood pressure of 185/100 mm Hg and a heart rate of 48/min. His Glasgow Coma Scale score is 6 (Eyes 1, Verbal 2, Motor 3). Neurological assessment reveals a left pupil that measures 7 mm and does not react to light, whereas the right pupil is 3 mm and reactive. The patient's right arm and leg exhibit rigid extension when a painful stimulus is applied.

Arrange the following interventions in the optimal chronological order for managing this patient:

While recovering in the surgical intensive care unit, a 35-year-old male patient demonstrates a precipitous decline in his level of consciousness. He sustained a severe traumatic brain injury in a high-speed vehicular collision $48$ hours prior. Current vital signs reveal a blood pressure of $185/110 \text{ mmHg}$, a heart rate of $46 \text{ min}^{-1}$, and an irregular respiratory rate of $8 \text{ min}^{-1}$. Neurologic evaluation reveals that the right pupil is $8 \text{ mm}$ and nonreactive to light, whereas the left pupil is $3 \text{ mm}$ and briskly reactive. The right globe is deviated inferiorly and laterally. Application of a painful stimulus elicits rigid extension of the left arm and leg. What is the most appropriate immediate pharmacologic or procedural intervention for this patient?

In the setting of severe traumatic brain injury and elevated intracranial pressure, various brain herniation syndromes can occur depending on the primary vector of the mass effect. Match each specific brain herniation syndrome with its precise anatomical mechanism and characteristic clinical or radiologic sequelae.

A 38-year-old man is transported to the trauma center by helicopter emergency medical services following a high-speed motorcycle crash. He was intubated at the scene due to a Glasgow Coma Scale score of $6$. Upon arrival, his blood pressure is $78/40$ mmHg, and his heart rate is $135$/min. Physical examination reveals a rigid, distended abdomen and a large boggy hematoma over the left temporal region. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large volume of free fluid in the hepatorenal recess and pelvis. While the trauma team is administering a transfusion of uncrossmatched type O-negative blood, the patient's left pupil becomes fixed and dilated at $8$ mm, and he develops extensor posturing of the right upper and lower extremities in response to painful stimuli. Which of the following is the most appropriate next step in the management of this patient?