The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine
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- Venous sinus thrombosis- Dr. Hill-Norby
- 89% present with headache but can also present with altered mental status, focal neuro deficits, seizures, nuchal rigidity
- Cavernous sinus
- Ocular signs dominate d/t cranial enerve dysfunction
- Cortical vein occlusions can present with motor and sensory dysfunction
- Physical exam
- Papilledema on fundoscopic or ultrasound
- Ultrasound measurement is measured 3 mm posterior to the retina
- Dx
- LP with opening pressure can be suggestive of Dx
- Tx
- Standard care for elevated icp (HOB elevation to 30 degrees, etc.)
- PRES- Dr. McMurray
- Sx usually will have posterior cortical deficits
- 25% of people with PRES will not have HTN on presentation
- Risk factors include renal disease, autoimmune conditions and immunosuppressive Tx
- Pathogenesis
- Autoregulatory failure, endothelial dysfunction, cortical dysfunction
- Tx
- Target maximal reduction in MAP by 20-25% in the first hour
- Reduce to 160/100 over next 2-6 hours
- Then to normal over the next 24-48 hours
- Medications
- Labetalol, cardene, hydralazine, nitro
- Seizure medications for seizures, if suspect eclampsia give Mg
- Emergency management of individuals with brain tumors, a focus on steroids- Dr. Mistry
- Focus of ER management
- Control ICP (nonsurgically)
- locally high ICP can progress to a generalized ICP problem
- generalized will eventually involve the brainstem, also concerning is focal ICP that can compress the brain stem
- signs of brain stem compression
- imaging showing posterior fossa or supratentorial lesion/hydro
- hypertension (especially the diastolic pressure)
- control
- Delay MRI until after addressing ICP
- Position
- HOB > 30 degrees
- Works by increasing venous return
- Neck in anatomically free position
- Want the jugular veins to actually be able to return blood
- Vital interventions
- Hyperventilate (ETCO2 ~ 25 mmHg)
- Drugs
- Mannitol +/- furosemide
- Will break down the blood brain barrier and will only work once
- Hypertonic NaCl (>3%)
- Preferred, can be given more than once and help control ICP
- Control of tumor-related hemorrhage (ICP)
- Control of neuroendocrine related shock
- Control of seizures
- Especially vulnerable are patients with temporal lobe lesions
- Dexamethasone- “ a big problem”
- Evidence for dex was initially based on case series work
- However, there is NO evidence for dexamethasone, there is not even 1 study on dex that shows benefit
- Dexamethasone is a very potent and long acting anti-inflammatory
- Can be bad for people needing a stem-cell transplant
- Kills lymphocytes by apoptosis
- *Pre-operative dexamethasone decreases diagnostic yield from surgical samples of primary CNS lymphoma*
- Study in Brain 2016 showed that corticosteroids decreased survival in glioblastoma
- Pre-op dexamethasone in 2021 Hopkins study showed greatly decreased survival on Kaplan-Meyer survival curve
- Dexamethasone thwarts immunotherapy
- Combined corticosteroids plus immunotherapy has a higher hazard ratio than immunotherapy alone
- Dexamethasone is standard of care and now we are in a battle with reversing this narrative
- **dexamethasone does not decrease ICP emergently, it can take a week to see the ICP effects, use mannitol, Lasix, or hypertonic saline**
- **there is one type of tumor to give steroids**
- Pituitary apoplexy- a special hemorrhage
- ER treatment is counter adrenal crisis (hydrocortisone 100 or 200 mg) and give fluids
- Need to draw all endocrine labs before giving the hydrocortisone
- Need a CTA immediately because there is an aneurysm that will mimic pituitary apoplexy, r/o aneurysm first before they can take to the OR
- Consult
- NES, ENT, optho, and endocrinology