?

?

?? 70 %

19 %

8 %

3 %

Emergency room care ABC first (Airway)(Breathing)

(Circulation) -

Initial radiological studies () Foley, NG tube, Laboratory studies ( ABG, . ) EKG

The Glasgow Coma Scale

: GCS score 13-15 : GCS score 9-12 : GCS score 3-8

ATLS, 8th edition

Neurological examination /, EOM, MP/ DTR

- 5 %

MP

5

4

3

2

1

0

Guideline 2 GCS score15 ,

-

Options 2 65 2 30

1 5

Monitoring cerebral physiology Intracranial pressure (ICP) monitor

1.2. IICP

hyperventilation PCO2 30 -35mmHg mannitol sedation barbiturate coma CSF

3.

10-15 mmHg 3-7mmHg 1.5-6 mmHg

Monro-Kellie Hypothesis Brain + CSF + Blood =

(1,400+150+150=1,700ml)

Cerebral blood flow: regional or global cerebral blood flow and metabolismJugular venous oxygen saturation: indirect assessment of global cerebral blood flow and metabolism; SjvO2

Transcranial Doppler: traumatic vasospasm EEG EP

(IICP)1.2.(byperemia)3.(traumatic induced mass)4.(EDHSDHICHcontusion

hemorrhage)5.(hypoventilation)6.(systemic hypertension)7.(venous sinus thrombosis)8.(hydrocephalus)9.(fever)10.(ischemia)

1.2.(GCS) 83.4.

Mannitol1.2.3.mass effect(hemiparesis)4.brain CTIICP5.brain CT

Mannitol

(Second Tier Therapy)1. Hypertonic saline :

2. Barbiturate coma :

3. Hyperventilation PaCO2 30 mmHg

4. Hypothermia : 5. Steroid :

Hemodynamic support and CPP management Guideline 1. 0.9% (Saline)

(Lactate Ringer's) (Level ) 2. (Level )

(Sedation) Options 1. GCS score 3-8

2. GCS Score 3-8

(Seizure Prophylaxis) Options 1.

2. GCS score 10 24

Nutritional Support Guideline 1.

15% 2.

(resting metabolic expenditure) 100% 140%

Intracranial Complications1. Posttraumatic seizures: one week2. Ventriculostomy-related complications

- parenchymal injury, hemorrhage: 1.4 %- ventriculitis: +1 % per day, 2 weeks

Systemic or Extracranial Complications1. Electrolyte derangements2. Pneumonia3. Thromboembolic events4. Gastrointestinal hemorrhage

8%20%

20-30%

40358750(6.1%)356

: CT \ MRI \ Angiography

MRI

CBCPT \ APTTelectrolyte EKG chest x-ray

ABC

compartment syndromes

130

mmHg 110

mmHg

ICP

ICP>20mmHg ICP20mmHgCPP

70mmHg

CT1/2

10 mL

ICH3 GCS< 5

3cm30cc

AneurysmAVMcavernous hemangioma

60lobar or basal ganglion hemorrhage50cm3GCS1430-50cm3GCS1230cm3

/

11.6%(1992 ) 1993

54.614.356.513.855.714.02:3

199326.7%22.0%20.1%19.6%12.2%8.1%3.2%2.9%

2492%

CTA

MRA

TCD

(1)(2)(3)(4)(5)

(1)()

1. 3~4%(24)1~2%33%

2.( level of evidence to grade B )

3.Antifibrinolytic therapy /( level of evidence to grade A )

4.ligation( level of evidence to grade A )

()1.

3mm3mm

2. ( level of evidence to grade B )early surgerydelayed surgeryearly surgery ( level of evidence to grade B)wrappingcoating

(2) Hypertension/hypervolemia/hemodilution (triple H)

( level of evidence to grade C )hemodynamic function

Nimodipine()5cc/hr10cc/hr( level of evidence to grade A )( level of evidence to grade B )

Transluminalangioplasty

(3) 20%

( level of evidence to grade C )

( level of evidence to grade C )

(4) 10

27.5%( level of evidence to grade C )

(level of evidence to grade C )

(5) volume

contraction( level of evidence to grade C )

volume statuscentral venous pressurepulmonary capillary wedge pressurefluid balance

cerebral salt wasting syndrome SIADS

1%

3%4%1%

1.2.(radiosurgery)3.

Spetzler-martin 3

Spetzler-Martin AVM

6 3 0 1 0 1

Astrocytic tumors Oligodendroglial tumors Mixed gliomas Ependymal tumors Choroid plexus tumors Neuronal and mixed neuronal-glial tumors Pineal parenchymal tumor Embryonal tumors Meningeal tumors Germ- cell tumors Tumors of the sellar region Metastatic tumors

A.

B. C.

D.

: A. XB. (CT)C. (MRI)

CTMRIMRA(MRI)MRI

D. (EEG)EEGMRI

(MSI)E.

()MRACTA

1.

a)b)

c)d)

()bromocriptone

e)

2.: a)

(brain mapping)(electrocortico-graphy)

b)c)MRI

(mural nodule)d)

(1)(2)Karnofsky(3)

e)CTMRI1

1.10%

BBBBCNU2.(anaplastic

oligodendroglioma)

3.(medulloblastoma)(pinealoblastoma)

4.FDA1996BCNUGliadel

1.

a)b)

c)(germinoma)

d)Medulloblastoma, ependymoma, germinoma(seeding)HCG, AFP, CEA

2.(Brachytherapy)a)125192b)32

3.(Stereotactic radiosurgery)a)

b)6015~25Gy

c)

d)(boost)e)

()

()

Hydrocephalus ex vacuo()

Communicating

non-obstructive hydrocephalus Non-communicating

obstructive hydrocephalus

1,0003-4

1,0000.9-1.5(sping bifida)(myelomeningocele) 1,0001.3-2.9

(/cytomegalicinclusion virus/toxoplasmosis)

A.

(/setting-sun sign)

(cracked pot)Macewens sound 91

B.

()

()

(suprapineal recess)

Parinaud

C.(Normal Pressure Hydrocephalus; NPH)

()

(classicfriad)(dementia)

(incontinence)(disturbance of gait) (presenile demenlia)

(senile dementia)

()

(Endoscopic 3rd Ventriculostomy )

suprasellar cistern

(50%)

A.(Ventriculo-Peritoneal Shunt; VP

Shunt) B.(Ventriculo-Pleural Shunt) C.(Ventriculo-Atrial Shunt; VA

Shunt) D.(Lumboperitoneal Shunt)

()

(pseudocyst)

7-10%()

(5-48%)()()()()

1.

-

-

2. /

20292049

Classification of Spinal Cord Injury

Cervico-medullary syndrome ( Upper cervical cord to medulla syndrome ) Schneider, respiratory arrest, hypotension,

tetraplegia, and anesthesia Sensory loss over the face conforming to the onion

skin or Dejerine pattern ( pain and temperature loss )

Mimic the central cord syndrome ( Syndrome of cruciate paralysis of Bell )

Central Cord Syndrome Within the centrum of the cervical spinal cord more weakness in the upper extremities, when

compared with the lower extremities sensory loss is minimal DTR - UE: absent ; LE: preserved Edema and hemorrhagic contusion, mechanical

disruption, ischemia Hyperextension, in elderly patient with cervical

spondylosis and a stenotic spinal canal

Anterior Spinal Cord Syndrome anterior 2/3 of the spinal cord ( corticospinal tract

and the anterolateral spinothalamic system ) Loss of all voluntary motor activity Absence of sensation to pain and temperature Preserved posterior column function

( proprioceptive response ) Direct trauma Poor recovery, 10~20%

Brown-Sequard Syndrome Ipsilateral loss of lower motor neuron Ipsilateral loss of strength and proprioception Contralateral loss of pain and temperature

sensation Most commonly observed secondary to penetrating

injury

Reversible, transient syndrome Spinal cord injury without radiological

abnormality ( SCIWORA ) Spinal cord injury without radiological

evidence of trauma ( SCIWORET ) Anterior spinal artery syndrome

Imaging X-ray film

Lateral plain film - 75~85% of CSI AP, open-mouth odontoid, flexion-extension 93% Downward pull on the arms or swimmers view- C7- T1 15~20% of C-SCI - Negative Flexion-extension - conscious & gross stability

CT scan Thin-section 3-D

CT myelography MRI

soft tissue myelographic-equivalent image does not image cortical bone

Occipital-Atlantal Dislocation high fatality rate distraction with neck hyperflexed Types

C1 arch fracture - Jefferson Fracture axial load 3~13% of cervical spine injuries lateral displacement of the lateral mass of C1 on

C2 , > 6.9 mm transverse ligament ( rigid external fixation or

surgical )

Atlantoaxial Instability adult > 3 mm ; child > 4.5 mm ( transverse lig )

Odontoid Fractures

C2 traumatic Spondylolisthesis Hangmans Fracture 1913, Wood-Jones, judicial hanging 1965, Schneider et al, 8 injuries resulting from

motor vehicular accidents -- Hyperextension bilateral pars interarticularis fractures most are not associated with neurological injury stable and heal in a cervical collar

Subaxial Spine ( C3~C7 ) Compression injuries

Flexion teardrop fracture Extension unilateral arch fracture

Distraction injuries Flexion hyperflexion sprain, bilateral interfacetal

dislocaation Extension whiplash

Lateral flexion injuries

Management Systemic

Neurogenic shock Systemic hypotension, bradycardia Volume expansion and /or pressor agents

Loss of thermal regulation Hypothermal regulation

Loss of skin sensation, motor function Pressure sore and decubitus ulcer

Deep vein thrombosis, pulmonary embolization Early mobilization

GI function ( Ileus, UGI bleeding ) Nutrition

Methylprednisolone treatment regimen(1) NASCIS-II ( National Acute Spinal Cord Injury

Study ) ( 24 hours ) Within 8 hours of the injury Closed injuries, not in penetrating injuries and below

conus medullaries Loading 30 mg/kg, bolus, > 15 min , followed by a

45 min pause Maintain 5.4 mg/kg/hour, the nest 23 hours

Methylprednisolone treatment regimen(2) NASCIS-III ( 48 hours )

Within 3 hours of the injury Loading 30 mg/kg, bolus, > 15 min , followed by a 45 min

pause Maintain 5.4 mg/kg/hour, the nest 23 hours

Within 3 ~ 8 hours Loading 30 mg/kg, bolus, > 15 min , followed by a 45 min

pause Maintain 5.4 mg/kg/hour, the nest 47 hours

Alignment and immobilization of the spine Neck collar Gardner-Wells tongs Halo vest Surgical intervention

Decompression Fusion and Fixation

Surgical intervention Goal Dural sac decompression Spinal stability

Avoidance of non-neurological complications that are shown to develop in patients not mobilized quickly following their injury

Surgical intervention Early surgery ( emergency surgery ) ? Delayed decompressive surgery Indications for emergency decompressive surgery

( incomplete lesions ) Progression of a neurological deficit Bone fragments or soft tissue elements ( hematoma ) Penetrating trauma Non-reducible fracture dislocations from locked facets Timing - 8~12 hrs ( 24 hrs )

Surgical intervention Contraindications to emergent operation

Complete spinal cord injury > 24 hrs Medically unstable patient Possibly central cord syndrome

Prognosis Patients neurological grading at admission to the

hospital 5% of SCI patients deteriorate in the early

postinjury period ( cervical spine ) Majority of neurological improvement occurs

within the 1st year ( ~ 18 months ) ( 2 years, 10% )