There are very few oncologic emergencies. Neoplastic epidural spinal cord compression is one of them. The delay in diagnosis and treatment is often explained by the non-specific nature of the presenting signs and symptoms.

The patient developed urinary retention a couple of weeks prior to presentation. On the morning of admission he was fully functional. Later he sat down to have a cup of coffee and boom – he couldn’t feel his legs. He couldn’t get up either.

Ideally, this patient should be rushed to the Hospital with an emergent neurosurgery consult. Prompt surgical decompression of the spinal cord or radiation treatment could improve his chances for functional recovery.

The patient lives on a 500 acre farm in a remote part of the country and getting to the closest ER took some time. It did not take the ER physician a long time to recognize the potential problem. Intravenous steroids were administered. MRI of the spine clearly showed an epidural mass with spinal cord compression at T6 level (see the image above).

No neurosurgeon was available in the small outlying hospital. That means that the patient had to be transferred to a bigger hospital. More time spent on arranging the transfer and getting the patient to the neurosurgeon.

All in all, it took 12 hours from the onset of symptoms to the neurosurgical evaluation. The patient had an urgent laminectomy with spinal cord decompression. The likely diagnosis is metastatic prostate cancer with T6 epidural metastasis and spinal cord compromise.

Despite the treatment with steroids and an “emergent” surgical decompression the patient remains paraplegic. His PSA is > 300. The final pathology is yet pending.

This is an unfortunate case. Despite appropriate actions and management, the patient did not receive the needed care for 12 hours after the onset of symptoms. Had he lived closer to an urban area and a bigger hospital, he might have been able to walk.

This is true not only for trauma and oncology patients. Same goes for the patients with coronary conditions and other emergencies. The unfortunate truth is that access to medical care often decreases the further you go from a major urban center.

We have come a long way since the old days when ground ambulance was the only way to transport critically ill patients. Helicopters and fixed-wing aircrafts are readily available now for transfer.

Everything takes time, though. Packing the patient for the ambulance ride or even picking up the phone and waiting for the answer on the other end wastes the precious time that could make a big difference in the patient’s outcome. The bottom line is - in the case of a medical emergency the distance from the Hospital could be a deciding factor between life and death.

(Click on the image above to see a full version)

When I was called to see the patient, it sounded just like another trauma admission. The patient in her forties fell at home. CT head, obtained in the Emergency Room, showed right sided subdural hematoma and intracerebral hemorrhage. The patient was somewhat confused yet readily arousable and conversant.

She was taken to the ICU and the neurosurgeon was consulted. Further questioning of the patient and her family, however, raised some red flags. Apparently, she had been complaining of a severe headache for a couple of weeks prior to the admission. This raises the concern for a previous sentinel bleed from a cerebral aneurysm causing a headache.

Most ruptured aneurysmal bleeds cause subarachnoid or intracerebral hemorrhage. Subdural hematoma from a ruptured aneurism is rare (3 to 5%). The question is what was the primary – did the patient fall and had a bleed or the bleed caused her to fall?

MRA (MR angiography) was performed and showed what looks like a right sided AVM (arterio-venous malformation). See black arrow on the upper image above. These are not uncommon and sometimes they bleed. Yet, the neurosurgeon wasn’t convinced that we weren’t dealing with a cerebral aneurysm. MRA is a good study to image larger aneurysms, yet its sensitivity declines when the aneurysm is less than 3-5mm. The clot adjacent to the aneurysm might obscure the image as well.

Cerebral four-vessel angiogram is considered a gold standard for the diagnosis of cerebral aneurysms and AVMs. The procedure is riskier and more involved than CT or MR angiography. In current practice, it has been, for the most part, replaced by CTA and MRA – those test are “good enough” to image most aneurysms and AVMs.

In this case there was no choice but to proceed with a cerebral angiogram. Cerebral angiogram showed a small aneurysm arising from the supraclinoid right internal carotid artery (ICA). See bottom image with a white arrow pointing to the aneurism. The patient was transferred to a facility with a neuro-interventional radiologist available. She underwent a successful coiling of the aneurysm.

Less invasive and, thus, less risky tests have substituted the original or “gold standard” test for the diagnosis of various conditions. We order CT angiography of the chest instead of pulmonary angiogram to diagnose pulmonary embolism. Doppler ultrasound is used instead of venography to diagnose deep vein thrombosis. Soon, we probably will be doing virtual colonoscopy and virtual coronary angiography as well. There is nothing wrong with this trend since the patient’s safety is the primary concern. Sometimes though, anything less than a gold standard is simply not good enough.

I see quite a few patients in a neurovascular ICU after a craniotomy for various reasons. It is very important to identify even very subtle neurological changes which could be an early sign of a developing complication requiring another surgery. Often, I am being asked by the patient’s family when another CT scan is going to be done to see if anything has changed.
My answer is always that a good neurological exam is better that an imaging study to detect early neurological changes. If the patient is less responsive or developing new neurological deficits, urgent CT scan would be indicated.

A recent single-center study published in the Journal of Neurosurgery addresses an issue
of an optimal timing for a follow-up CT scan after a cranial surgery. None of the patients who had a follow-up scan without any neurological changes require another craniotomy. Thirty percent of the patients with new neurological deficits needed a repeat neurosurgery.
The optimal timing of the follow-up scan is unclear as well. In my practice it pretty much depends on an individual neurosurgeon. The same study suggested that early (within eight hours) study might fail to identify post-operative complications all together.

Even though, computed tomography provides physician with a high resolution image of the brain, it’s expensive and associated with an exposure to radiation. Transferring a critically ill patient to the radiology department to perform a CT scan can lead to complications as well.

This a single-center study with has its own limitations. It does not mean that there is no role for a follow-up computed tomography following craniotomy. It might help to decide on the timing of anticoagulation therapy for DVT prophylaxis or aid in determining the patient’s prognosis for recovery.

It’s like ordering any other test – the physician should have a very good understanding of why the test is being ordered and how that could change the management.

Traumatic brain injury (TBI) is a major health burden in US and worldwide. It’s shocking how many young people die or get disabled from TBI every year. One of the aspects of the management of these patients that I was always interested in is a decompressive craniectomy. The concept behind this procedure is to remove a part of the patient’s skull to prevent secondary brain damage from swelling and edema that often complicates brain injury.  Unfortunately, the evidence to support this treatment option is inconsistent.
Reviewing the Journal of Trauma I came across an article “Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury?”. I found it encouraging that patients treated with craniectomy (removing part of their skull) did at least no worse (adjusted for severity of illness/trauma) than the rest of the patients. It would be interesting to see any future trials on this matter to proof of disproof any benefits of this procedure.
Meanwhile should we be offering prophylactic craniectomy to our patients or not???