Neurosurgery for
Neurology Residents
Dr Manas Panigrahi
Overview
Neurosurgery consultation frequently sought for
• Stroke – Ischemic and Hemorrhagic
• BIH
• NPH
• Epilepsy
• Movement disorders
• Pain
1. Neurosurgery for STROKE (ischemic stroke)
• 'Malignant MCA infarction' is the term used to describe rapid neurological
deterioration due to the effects of space occupying cerebral edema following middle
cerebral artery (MCA) territory stroke.
• Despite the utility of DECOMPRESSIVE CRANIECTOOMY , there are schools of thought
that discourage surgery because of the biased perception that patients survive but are
left with severe burdensome disability.
• “We must not accept the death we could have done anything even the less against it.”
(Prof. L. Papp. Hungarian cardiac surgeon)
Ischemic hemispheric stroke (Supratentorial)
• The prevalence of malignant ischemic stroke is reported to be between 2% and
8% of all patients with ischemic stroke.
• The mortality rate of patients with malignant stroke who undergo aggressive
non-operative management is in the range of 40% to 80%.
• Performing a DC can reduce this mortality rate to 30%
Ref:
1. Qureshi AI, Suarez JI, Yahia AM, et al. Timing of neurologic deterioration in massive middle cerebral
artery infarction: a multicenter review. Crit Care Med 2003;31(1):272–7
2. Minnerup J, Wersching H, Ringelstein EB, et al. Prediction of malignant middle cerebral artery infarction
using computed tomography-based intracranial volume reserve measurements. Stroke 2011;42(12):
3403–9
Less Mortality and Better functional outcome (mRS) in surgically treated pts
Predictors of stroke progression – malignant edema
1. Cerebral edema progresses during the first 24 to 48 hours after the onset of ischemic stroke and can
result in herniation after Day 2
2. A high initial stroke score, especially involving a score more than 1 on item 1a of the National
Institutes of Health stroke scale
3. Patients with NIHSS score of 18 or more on admission are at increased risk of developing malignant
cerebral edema
4. A large hypodensity occupying more than two thirds of the MCA territory is an important predictor
of malignant progression. (with 92% sensitivity and 94% specificity )
5. appearance of edema within 6 hours, basal ganglia involvement, dense MCA sign, and midline shift
more than 5 mm in the first 2 days
Stroke. 2017;48:00-00. DOI: 10.1161/STROKEAHA.116.014727.
Timing of Decompressive Hemicraniectomy for Stroke
• patients with space occupying infarction
who do not experience clinical
deterioration within 48 hours may
benefit from surgery if pursued before
herniation
Independent Predictors of early surgery
in ischemic stroke
• Ischemic growth rate (IGR) >
7.5mL/hr on serial CT
• temporal lobe involvement
• middle cerebral artery with
additional infarct
*mRS – modified Rankin scale
Increasing ischemic volume, however, reduced mass effect post decompression
Preventive surgeries for recurrence of stroke
• Carotid endarterectomy
• EC – IC Bypass
Posterior fossa ICH
• The American Heart Association/American Stroke Association
guidelines provide level 1, class B recommendations for direct
surgical evacuation of cerebellar ICH greater than 3 cm.
• Location of hematoma may be more influential than size per se;
close proximity and pressure on the brainstem lowers the
threshold for surgery.
2. Benign intracranial hypertension
• Pseudotumor cerebri
• Idiopathic intracranial hypertension
• Increased intracranial pressure (ICP) without evidence of dilated ventricles or a mass
lesion by imaging, normal cerebrospinal fluid (CSF) content, and papilledema occurring
in most cases
• First described by Quinke 1897
• BIH – coined by Foley
• In view of significant visual morbidity – Benign intracranial hypertension disregarded
• IIH - idiopathic intracranial hypertension (IIH) for cases of PTC that occur
in young, obese patients
• secondary pseudotumor cerebri for the rare cases in which a cause (e.g.,
drug induced) is identified
IMPORTANCE OF OBESITY in BIH
Pathophysiology
Imaging features
Empty sella sign – 70 % of patients with BIH
Optic nerve sheath distension (ONSD) in 45% pts with BIH
How to measure ONSD ?
Axial T2-wtd image of both optic
nerves reveals
• flattening of posterior sclera
• distended perioptic
subarachnoid space.
• A distension of optic nerve
sheath >2 mm is significant.
• The ONSD is measured 10 mm
anterior to optic foramen
Flattening of posterior globes – 80% of BIH pts
flattened optic nerve head (ONH) with protrusion of intra-ocular portion of ONH
• vertical tortuosity of Optic nerve
sheath.
• The distal and proximal points of
optic nerve are fixed.
• Elongation and kinking in its course
due to raised intracranial pressure
Rule out venous sinus thrombosis in all new pts with IIH
Management
Medical Surgical
Weight control Optic Nerve sheath fenestration
Acetazolamide Optic nerve decompression
Topiramate CSF diversion
Steroids Dural venous sinus stenting
Octreotide
IMPORTANT – Weight management , is recommended even after surgical
treatment.
Management
algorithm
Indications of surgery
1. No response to best medical management
2. Rapid worsening of vision
Optic nerve decompression - technique
VIDEO
KIMS – experience of BIH
1. EXAMPLE – DEEPIKA (Optic N decompression) pre and
post op images
2. EXAMPLE – TP SHUNT
Intraventricular Hemorrhage
• IVH occurs in nearly half of ICH patients.
• Isolated IVH (primary IVH) occurs rarely but more often is the result of secondary
extension of a parenchymal hematoma into the ventricular system.
• The presence of blood in the ventricles can interrupt the normal cerebrospinal fluid
(CSF) flow and cause obstructive (noncommunicating) hydrocephalus and increased
ICP.
• Placement of an EVD to drain CSF and monitor ICP should therefore be considered in
patients with acute hydrocephalus/IVH and GCS ≤ 8 or with signs of transtentorial
herniation
Intraventricular Hemorrhage
with hydrocephalus
Endoscopic ICH / IVH evacuation
ICP monitoring
Helps in deciding
• To continue conservative treatment or to go
for surgery in ICH or Ischemia
(* for timely initiation of corrective measures
– decompression / EVD/Shunt)
• Assessing response to anti edema
medication, monitor trends in ICP
• Duration of anti edema medication
• Intra-parenchymal monitors – will allow
drainage of CSF , real time measurement of
ICP
Types of ICP monitors
A. Intra-Ventricular catheter
B. Intra- Parenchymal catheter
C. Epidural Catheter
D. Subarachnoid Bolt
ICP monitors
Intraventricular ICP monitor with EVD Intra-parenchymal ICP monitor
Bedside monitor- reference point is
set at 20 mm Hg. When ICP crosses
20 mm Hg. alarm beep will come
