Wilson: Neurosurgery for Everyone

•

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SMACC Conference

Unforgettable live-on-stage demo of remote critical care neurosurgery in action.

Salud y medicina Meditación

Neurosurgery for Everyone
M A R K W I L S O N
@markhwilson

Extracting the Stone or
The Cure of Folly
Hieronymous Bosch 1494
“Master, cut away the stone
My name is Lubbert Das”

France 6000 BC
40/120 skulls
!
Peru 1000AD
66/411 skulls

Engraving of trephination from
Hieronymus Braunschweig’s Buch
der Cirgia 1497
Dr
Dr John Clarke (American) 1664 18th Century, France

Bart Hughes 1962
Children have a higher state of consciousness and
since children's skulls are not fully closed one can
return to an earlier child like state of consciousness
by self trephination

Heartbeat in the brain
Amanda Fielding,
Countess of Wemyss
Ran for MP for
Chelsea 1978

But what about
Neuro
tRaum
a
If you’re not dead -
you should not die

E X T R A D U R A L
M A N A G E M E N T
Tension Pneumothorax in your head

I N D I C AT I O N S
• Brain Injury with CT evidence of
Extradural Haematoma
• Midline shift / severe effacement
• Pupil dilatation
• Delay in Neurosurgical availability

B U R R H O L E
E VA C U AT I O N
Is a thoracostomy for the head…
• Correct side
• Correct location
• Local anaesthesia
• Incision
• Self retainer
• Drill
• Remove inner table

P U P I L S
Fixed
Unreactive
Comatosed
Dilated

F U C D
• Recent Met analysis n=68
• EDH
• Mortality 30.9% (CI 15.2-49.3)
• Good Outcome 57% (CI 39.-75)
• SDH
• Mortality 73% (CI = 58-85)
• Good Outcome 5.6% (0.9-13.8)
• Prospective Study Needed

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INTRODUCTION TO NEURO NURSING

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This hybrid operating room combines interventional radiology and neurosurgery with a Siemens bi-plane angiography system at its core. See how the staffing and procedures are set up to use the room for the different modalities. This project was delivered using 3D building information modeling (BIM) which is a process that parallels the work being done in the room itself. We use sophisticated 3D imaging to evaluate the building systems and then surgically remove and replace systems.

Stanford Hybrid OR - Interventional Radiology + Neurosurgery

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BRAIN GATE TECHNOLOGY INTRODUCTION: Brain-computer interface (BCI) is a fast-growing emergent technology, in which researchers aim to build a direct channel between the human brain and the computer.  It is abbreviated as BCI. DEFINATION:  Brain Gate Technology is a ‘brain-computer interface’ that uses internal neural signal sensor and external processors to convert neural signals into an output signal under the users own control.  This system that allows a quadriplegic man to control a computer using his Thoughts.  Brain Gate is a brain implant system developed by the bio-tech company “Cyber kinetics” in 2003 in conjunction with the Department of Neuroscience at Brown University. WORKING PRINCIPLE: • The Brain computer interface that consist of an Inter neural signal sensor and External Processors. • When a work is done through any part of body then a potential difference is created in the brain. This potential difference is captured by the Sensor. • The sensor is implanted on the surface of brain in the motor cortex area that controls our movement. • The sensor consists of a silicon array about the size of small Aspirin tablet that contain about 100 electrodes each thinner than a human hair that detect brain cell electrical activity. • Brain electrical activity transmitted via fiber optic to the external processor (call Digitizer) convert neural signals into an output signal under the users own control. • The computers translate brain activity and create the communication output using custom decoding software. TYPES 1: Brain Computer interface is of three types based on its features  1-Invasive BCI: Invasive BCIs are implanted directly into the grey matter of the brain during neurosurgery and has the highest quality signals -provide functionality to paralyzed people.  2-Non Invasive BCI: Non-Invasive BCIs do not involve neurosurgery. They are just like wearable virtual reality devices.  3-Partially Invasive BCI: Partially invasive BCI devices are implanted inside the skull but rest outside the brain rather than within the grey matter. -gives a patient the ability to move muscle implants and restore partial movement. Based on the communicative Pathway BCI is classified as follows One Way BCI: Computers either accept commands from the brain or send signals to it (for example, to restore vision) but not both. Two Way BCI: Brains and external devices can exchange information in both directions but have yet to be successfully implanted in animals or humans. APPLICATION: 1. Bionic Eye: Bionic eye is an experimental visual device which will help blind people to see what they want to see. 2. Honda Asimo Control: Honda's Asimo is a robot. Anyone can control its simply by thinking. -Kevin Warwick – The First Human Cyborg Gaming Control: Gaming control using a wearable and wireless EEG-based brain-computer interface device with novel dry

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Jo Anna Leuck discusses how to learn from error in paediatric sepsis. Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis. Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness. He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit. This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future. Jo Anna’s intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error. When considering paediatric sepsis Jo Anna asks - Was this preventable? Were there clues? Why was this missed? Jo Anna discusses what we can we do better. Recognition is the first step. Often procedures are used in this case. The Paediatric Sepsis Score is one such example. Jo Anna talks about vital signs and how they are tricky in kids due to the changing reference ranges depending on age. Jo Anna recommends having easily accessed charts and stresses thinking twice about the size and age of the child in front of you. The physical exam is as important as always. In kids, there are certain signs that should raise suspicion such as skin mottling. And in terms of treatment Jo Anna stresses rapid access, rapid fluid boluses and thorough re-evaluation alongside age-appropriate empirical antibiotics. Lastly, Jo Anne touches on the errors that this case highlights. She provides some strategies to improve your practice. Before discharge consider three main components. Vital signs, diagnostic studies, and communication! Simple, but careful attention to these components of care will lead to the medical profession learning from errors and preventing them in the future. For more like this, head to our podcast page. #CodaPodcast

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CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION By Toby Jeffcote Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury. It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.

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Andrew Udy talks about Brain Tissue Oxygen Monitoring: It’s Not What You’ve Got It’s What You Do With It The BONANZA Trial Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail! More on BONANZA here More on BOOST3 here

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Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

SMACC Conference

Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations

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SMACC Conference

Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.

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Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics. However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.

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Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus. So why do we do cEEGs for patients with suspected SE? To confirm the diagnosis To see if patient just post ictal or still seizing To establish that the clinical and electric seizures have stopped To see if burst suppression is achieved To exclude other differential diagnoses She makes a good argument for why cEEG is such an important tool in managing SE. In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.

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Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means. Severe disability is more common than many realise - about 6% of the Australian population. Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated. He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being. Stuart also covers how severely disabled people face various forms of discrimination.

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After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference. Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways. Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions. Hypertensive therapy is relatively safe and easy to implement but not without risk. Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.

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Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.

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Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.

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Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources. However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task. Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome. Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models. There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases. We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.

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Wilson: Neurosurgery for Everyone

1. Neurosurgery for Everyone M A R K W I L S O N @markhwilson

2. Extracting the Stone or The Cure of Folly Hieronymous Bosch 1494 “Master, cut away the stone My name is Lubbert Das”

3. France 6000 BC 40/120 skulls ! Peru 1000AD 66/411 skulls

4. Engraving of trephination from Hieronymus Braunschweig’s Buch der Cirgia 1497 Dr Dr John Clarke (American) 1664 18th Century, France

5. Bart Hughes 1962 Children have a higher state of consciousness and since children's skulls are not fully closed one can return to an earlier child like state of consciousness by self trephination

6. www.holeintheheadmovie.com

9. Heartbeat in the brain Amanda Fielding, Countess of Wemyss Ran for MP for Chelsea 1978

10.

11. But what about Neuro tRaum a If you’re not dead - you should not die

12. E X T R A D U R A L M A N A G E M E N T Tension Pneumothorax in your head

13.

14. Thanks @karelhabig!

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22. I N D I C AT I O N S • Brain Injury with CT evidence of Extradural Haematoma • Midline shift / severe effacement • Pupil dilatation • Delay in Neurosurgical availability

23. B U R R H O L E E VA C U AT I O N Is a thoracostomy for the head… • Correct side • Correct location • Local anaesthesia • Incision • Self retainer • Drill • Remove inner table

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25.

26.

27. TheFuture

28. V O L U N T E E R ?

29. P U P I L S Fixed Unreactive Comatosed Dilated

30. F U C D • Recent Met analysis n=68 • EDH • Mortality 30.9% (CI 15.2-49.3) • Good Outcome 57% (CI 39.-75) • SDH • Mortality 73% (CI = 58-85) • Good Outcome 5.6% (0.9-13.8) • Prospective Study Needed

31.

32.

33. @markhwilson

34. www.goodsam.co.uk

Wilson: Neurosurgery for Everyone

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Wilson: Neurosurgery for Everyone