Advertisement

Central Nervous System

  • Peter B. Letarte

Abstract

A construction worker falls from a scaffold that was positioned at the second-story level of a building. He has a severe closed heal injury with a Glasgow Coma Scale of 6. Admission computed tomography (CT) scan demonstrates diffuse axonal injury. No other injuries were found on secondary evaluation and CT evaluation of the cervical spine, chest, and abdomen. Which of the following is the preferred management for this patient?
  1. (A)

    Forced diuresis

     
  2. (B)

    Barbiturate administration

     
  3. (C)

    Hyperventilation (72 hours)

     
  4. (D)

    Craniotomy

     
  5. (E)

    Intracranial pressure monitoring

     

Keywords

Spinal Cord Injury Cervical Spine Subdural Hematoma Peripheral Nerve Injury Gunshot Wound 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Miller J. Lectures on the Approach to Neurotrauma. Unpublished work, 2005.Google Scholar
  2. 2.
    American College of Surgeons. Advanced Trauma Life Support. Chicago: American College of Surgeons, 2004.Google Scholar
  3. 3.
    Doyon S, Roberts JR. Reappraisal of the “coma cocktail.” Dextrose, flumazenil, naloxone, and thiamine. Emerg Med Clin North Am 2005; 12(2):301–316.Google Scholar
  4. 4.
    Greenberg MS. Seizures. In Handbook of Neurosurgery. New York: Thieme, 2001: 254–284.Google Scholar
  5. 5.
    American Spinal Injury Association. International Standards for Neurological and Functional Classification of Spinal Cord Injury. Chicago: American Spinal Injury Association, 1996.Google Scholar
  6. 6.
    Holmes JF, Mirvis SE, Panacek EA, Hoffman JR, Mower WR, Velmahos GC, et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma 2002; 53(3):524–529.CrossRefGoogle Scholar
  7. 7.
    Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974; 2:81.CrossRefPubMedGoogle Scholar
  8. 8.
    Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28:14–20.CrossRefPubMedGoogle Scholar
  9. 9.
    Karnofsky DA, Burchenal JH. In: Macleod M, ed. Evaluation of Chemotherapy Agents. New York: Columbia University Press, 1949: 191–205.Google Scholar
  10. 10.
    Narayan RK, Greenberg RP, Miller JD. Improved confidence of outcome prediction in severe head injury: a comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 1981; 54:751–762.CrossRefPubMedGoogle Scholar
  11. 11.
    Narayan RK, Kishore PR, Becker DP. Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 1982; 56:650–659.CrossRefPubMedGoogle Scholar
  12. 12.
    Brain Trauma Foundation. Management and Prognosis of Severe Traumatic Brain Injury, 2nd ed. New York: Brain Trauma Foundation, 2000.Google Scholar
  13. 13.
    Monroe D, Maltby GL. Extradural hemorrhage: a study of forty four cases. Ann Surg 1941; 113:192–203.CrossRefGoogle Scholar
  14. 14.
    Stein SC, Ross SE. Moderate head injury: a guide to initial management. J Neurosurg 1992; 77:562–564.CrossRefPubMedGoogle Scholar
  15. 15.
    Biffl WL, Moore EE, Ryu RK, Offner PJ, Novak Z, Coldwell DM, et al.The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg 1998; 228(4):462–470.CrossRefPubMedGoogle Scholar
  16. 16.
    Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 1999; 47(5):845–853.CrossRefPubMedGoogle Scholar
  17. 17.
    Biffl WL, Ray CE Jr, Moore EE, Franciose RJ, Aly S, Heyrosa MG, et al.Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg 2002; 235(5):699–706.CrossRefPubMedGoogle Scholar
  18. 18.
    Biffle WL, Moore EE, Offner PJ, Brega KE, Francoise RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma Inj Infect Crit Care 1999; 47(5), 845.CrossRefGoogle Scholar
  19. 19.
    Biffl WL, Moore EE, Elliott JP, Ray C, Offner PJ, Franciose RJ, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg 2000; 231(5):672–681.CrossRefPubMedGoogle Scholar
  20. 20.
    Management of vertebral artery injuries after nonpenetrating cervical trauma. Neurosurgery 2002; 50(3 Suppl):S173–S178.Google Scholar
  21. 21.
    Schneider GH, Bardt T, Lanksch WR, Unterberg A. Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome. Acta Neurochir Suppl 2002; 81:77–79.PubMedGoogle Scholar
  22. 22.
    Eisenberg HM, Frankowski RF, Contant CF. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 1988; 69:15–23.CrossRefPubMedGoogle Scholar
  23. 23.
    Part 1: Guidelines for the management of penetrating brain injury. Introduction and methodology. J Trauma 2001; 51(2 Suppl):S3–S6.Google Scholar
  24. 24.
    Part 2: Prognosis in penetrating brain injury. J Trauma 2001; 51(2 Suppl):S44–S86.Google Scholar
  25. 25.
    Kaufman HH, Levy ML, Stone JL, Masri LS, Lichtor T, Lavine SD, et al. Patients with Glasgow Coma Scale scores 3, 4, 5 after gunshot wounds to the brain. Neurosurg Clin North Am 1995; 6(4):701–714.Google Scholar
  26. 26.
    Shaffrey ME, Polin RS, Phillips CD, Germanson T, Shaffrey CI, Jane JA. Classification of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality. J Neurotrauma 1992; 9 Suppl 1:S279–S285.PubMedGoogle Scholar
  27. 27.
    Polin RS, Shaffrey ME, Phillips CD, Germanson T, Jane JA. Multivariate analysis and prediction of outcome following penetrating head injury. Neurosurg Clin North Am 1995; 6(4):689–699.Google Scholar
  28. 28.
    Levy ML, Rezai A, Masri LS, Litofsky SN, Giannotta SL, Apuzzo ML, et al. The significance of subarachnoid hemorrhage after penetrating craniocerebral injury: correlations with angiography and outcome in a civilian population. Neurosurgery 1993; 32(4):532–540.CrossRefPubMedGoogle Scholar
  29. 29.
    Kaufman HH. Treatment of civilian gunshot wounds to the head. Neurosurg Clin North Am 1991; 2(2):387–397.Google Scholar
  30. 30.
    Surgical management of penetrating brain injury. J Trauma 2001; 51(2 Suppl):S16–S25.Google Scholar
  31. 31.
    Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50(3 Suppl):S7–17.Google Scholar
  32. 32.
    Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group [see comment; erratum appears in N Engl J Med 2000; 344(6):464]. N Engl J Med 2000; 343(2):94–99.CrossRefPubMedGoogle Scholar
  33. 33.
    Marion DW, Domeier R, Dunham CM, Luchette FA, Haid R, Erwood SC. EAST Practice Management Guidelines for Identifying Cervical Spine Injuries Following Trauma. East Northport, NY: Eastern Association for the Surgery of Trauma, 2000.Google Scholar
  34. 34.
    Radiographic assessment of the cervical spine in asymptomatic trauma patients. Neurosurgery 2002; 50(3 Suppl): S30–S35.Google Scholar
  35. 35.
    Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998; 32(4):461–469.CrossRefPubMedGoogle Scholar
  36. 36.
    Velmahos GC, Theodorou D, Tatevossian R, Belzberg H, Cornwell EE, III, Berne TV, et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing. J Trauma 1996; 40(5):768–774.CrossRefPubMedGoogle Scholar
  37. 37.
    Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery 2002; 50(3 Suppl): S36–S43.Google Scholar
  38. 38.
    Daffner RH, Dalinka MK, Alazraki N, DeSmet AA, El-Khoury GY, Kneeland JB, et al. Suspected Cervical Spine Trauma. ACR Appropriateness Criteria. Reston, VA: American College of Radiology, 2002.Google Scholar
  39. 39.
    Pharmacological therapy after acute cervical spinal cord injury. Neurosurgery 2002; 50(3 Suppl):S63–S72.Google Scholar
  40. 40.
    Blood pressure management after acute spinal cord injury. Neurosurgery 2002; 50(3 Suppl):S58–S62.Google Scholar
  41. 41.
    Treatment of subaxial cervical spinal injuries. Neurosurgery 2002; 50(3 Suppl):S156–S165.Google Scholar
  42. 42.
    Initial closed reduction of cervical spine fracturedislocation injuries. Neurosurgery 2002; 50(3 Suppl):S44–S50.Google Scholar
  43. 43.
    Spinal cord injury without radiographic abnormality. Neurosurgery 2002; 50(3 Suppl):S100–S104.Google Scholar
  44. 44.
    Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert TJ, Balderston RA, et al. Steroids and gunshot wounds to the spine. Neurosurgery 1997; 41(3):576–583.CrossRefPubMedGoogle Scholar
  45. 45.
    Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH, Stillerman CB. Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 1996; 39(6):1141–1148.CrossRefPubMedGoogle Scholar
  46. 46.
    Prendergast MR, Saxe JM, Ledgerwood AM, Lucas CE, Lucas WF. Massive steroids do not reduce the zone of injury after penetrating spinal cord injury. J Trauma 1994; 37(4): 576–579.CrossRefPubMedGoogle Scholar
  47. 47.
    Greenberg MS. Peripheral nerves. Handbook of Neurosurgery. New York: Thieme, 2001: 525–546.Google Scholar
  48. 48.
    Goodrich JT. Acute repair of penetrating nerve trauma. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadows, IL: American Association of Neurological Surgeons, 1994: 299–312.Google Scholar
  49. 49.
    Robertson SC, Traynelis VC. Acute management of compressive peripheral nerve injuries. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadows, IL: American Association of Neurological Surgeons, 1994: 313–326.Google Scholar
  50. 50.
    Greenberg MS. SAH and aneurysms. In Handbook of Neurosurgery. New York: Thieme, 2001: 754–803.Google Scholar
  51. 51.
    Greenberg MS. Intracerebral hemorrhage. In Handbook of Neurosurgery. New York: Thieme, 2001: 815–832.Google Scholar
  52. 52.
    Kaufman HH. Spontaneous intracerebral hematoma. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadow, IL: American Association of Neurological Surgeons, 1994: 101–128.Google Scholar
  53. 53.
    Kothari RU, Hacke W, Brott T, et al. Cardiopulmonary resuscitation and emergency cardiovascular care. Stroke. Ann Emerg Med 2001; 37(4 Suppl):S137–S144.CrossRefPubMedGoogle Scholar
  54. 54.
    Mielke O, Wardlaw J, Liu M. Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke. [Update of Cochrane Database Syst Rev 2000; 2:CD000514; PMID: 10796381.] Cochrane Database Syst Rev 2004; 4:CD000514.Google Scholar
  55. 55.
    Greenberg MS. Occlusive cerebrovascular disease. In Handbook of Neurosurgery. New York: Thieme, 2001: 833–860.Google Scholar
  56. 56.
    Loftus CM. Emergency surgery for stroke. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadow, IL: American Association of Neurological Surgeons, 1994: 151–164.Google Scholar
  57. 57.
    Mouw LJ, Vangilder JC. Emergency Treatment of Brain Tumors. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadow, IL: American Association of Neurological Surgeons, 1994: 183–194.Google Scholar
  58. 58.
    Post KD, Shiau JSC. Pituitary apoplexy. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadow, IL: American Association of Neurological Surgeons, 1994: 129–136.Google Scholar
  59. 59.
    Greenberg MS. Infections. In Handbook of Neurosurgery. New York: Thieme, 2001: 200–253.Google Scholar
  60. 60.
    Hall WA. Cerebral infectious processes. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadows, IL: American Association of Neurological Surgeons, 1994: 165–182.Google Scholar
  61. 61.
    Greenberg MS. Hydrocephalous. In Handbook of Neurosurgery. New York: Thieme, 2001: 173–199.Google Scholar
  62. 62.
    McComb JG. Acute shunt malfunction. In Loftus CM, ed. Neurosurgical Emergencies. Rolling Meadows, IL: American Association of Neurological Surgeons, 1994.Google Scholar
  63. 63.
    Greenberg MS. Differential diagnosis by signs and symptoms. In Handbook of Neurosurgery. New York: Thieme, 2001: 864–901.Google Scholar
  64. 64.
    Greenberg MS. Spine and spinal cord. In Handbook of Neurosurgery. New York: Thieme, 2001: 285–351.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Peter B. Letarte
    • 1
  1. 1.Department of NeurosurgeryHines Veterans HospitalLa Grange ParkUSA

Personalised recommendations