1. Neurosurgical Case Scenarios SNS Intern Boot Camp Course - 2014

2. Case #1 – FC, 38yoF 38 year old female Sudden headache 7 days ago Brought in comatose, 8 hours after ictus: GCS 8 Moves extremities symmetrically PERRLA, no cranial deficits What would you do next?

3. Case #1 – FC, 38yoF Right MCA aneurysm Clipped on post-hemorrhage day #2 Awake and following commands Extubated on day #3 Oriented x2, no deficits

4. Case #1 – FC, 38yoF Right MCA aneurysm Post-clipping day #6 Hemorrhage day #7 Paged by ICU RN “Acting funny” On exam: Localizes with right arm Withdraws on left, less active Opens eyes to pain Mumbles, non- comprehensible GCS 9 EVD working, ICP = 23mmHg

5. Case #1 – FC, 38yoF CT What next?

6. Case #2 – CCB, 18yoM 18 year old Male Dove into Lake Michigan, intoxicated 3 hours ago Hit head, neck pain Tingling in hands Transferred from another hospital On exam: GCS 15 Collar and board Intact Normal head CT Neck pain to palpation

7. Case #2 – CCB, 18yoM 18 year old Male What next?

8. Case #2 – CCB, 18yoM Transferred from another hospital CT (unavailable), MRI What next? R L

9. Case #2 – CCB, 18yoM Gardner-Wells tongs applied Started with 15 lbs

10. Case #2 – CCB, 18yoM Gardner-Wells tongs applied Started with 15 lbs Increased 5 lbs / 10min, XR At 45 lbs: tingling in all 4 extremities, hand grip weakness? What next?

11. Case #3 – RD, 6yoM 6 year old male Myelomeningocele Correction + shunt at birth 3 revisions, most recent 3 months ago “Fussy” all day, fever 104 F, vomiting Called by peds ER Sleepy Became apneic and unarousable in the CT scanner

12. Case #3 – RD, 6yoM 6 year old male Myelomeningocele Correction + shunt at birth 3 revisions, most recent 3 months ago “Fussy” all day, fever 104 F, vomiting Called by peds ER Sleepy Became apneic and unarousable in the CT scanner www.neuroradiologycases.com CT – 1 month ago

13. Case #3 – RD, 6yoM 6 year old male Myelomeningocele Correction + shunt at birth 3 revisions, most recent 3 months ago “Fussy” all day, fever 104 F, vomiting Called by peds ER Sleepy Became apneic and unarousable in the CT scanner What next? Alfayate et al., 2011 CT today

14. Case #4 – 55yoM 55 year old male Hypertension Did not wake up at usual hour, family called EMS On exam Unarousable Localizes bilaterally PERRL What next?

15. Case #4 – 55yoM 55 year old male EVD inserted, no noticeable change What next?

16. Case #5 – 65yoF 65 year old female Obese, coronary artery disease (ASA 81mg + Plavix daily) Admitted to Internal Medicine because of low back pain Neuro exam: normal Imaging: diffuse disc degeneration Medical management of LBP Narcotics Lumbar epidural steroid injection

17. Case #5 – 65yoF 65 year old female You are called to Internal Medicine floor 2 hours post-LESI Patient drowsy since arrival (sedation received during injection) but following commands Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities What next?

18. Case #5 – 65yoF 65 year old female You are called to Internal Medicine floor 2 hours post- LESI Patient drowsy since arrival (sedation received during injection) but following commands Strength 5/5 in upper extremitiies, 3/5 in bilateral lower extremities What next? Ahn et al., 2009

19. Case #6 – 43yoM 43 year old male Smoker, hypertensive, obese Right hemiparesis, aphasia Acute onset, 2 hours ago Received IV tPA at outside hospital, 1 hour ago No improvement Initial CT is provided www.radiopaedia.org

20. Case #6 – 43yoM 43 year old male Options? www.radiopaedia.org

21. Case #6 – 43yoM 43 year old male Options? Neurology team orders MRI, now 2:30 since onset What next? www.radiopaedia.org