[Music] now uh hydrocephalus is something we see whether or not in trauma or a patient's found down brought to us unclear etiology of why but they get a head ct and this is what we see and so we're left thinking there's something about this uh scan uh you know there's something about this um hydrocephalus or ventricular megaly at this point that is related to the poor exam that we see before us so you know when we're thinking about cerebral spinal fluid diversion placing a drain into the ventricular space obviously we want to make sure that there's no obstructive lesions no obstructive masses that are apparent on our head ct so typically the first step if you see a patient found down oftentimes unclear if there was a trauma involved or not you see a patient like this we actually just had a patient like this come in this past week unclear what had happened found down on the street massive hydrocephalus and next question anything obstructive we could not appreciate anything obstructive so the patient had it a drain placed emergently in a lot of these situations too you may see some amount of intraventricular blood and so the question is always how do you manage that what do you do now the first things first you want to treat the hydrocephalus you want to treat the compression uh that the excess cerebral spinal fluid is causing on the remaining brain tissue now intraventricular hemorrhage management varies in terms of the amount of blood the location of the blood and whether it actually causes the drain to clot off i won't get into the specifics of that but i think that's something you often see so being comfortable i would say communicating and understanding that that kind of throws a monkey wrench into things is important so for instance having uh a plan in place uh you know if a patient also has an intraventricular hemorrhage being able to communicate that i would still place a drain i'm you know trying to treat hydrocephalus understanding that if the drain should clot off i might need to consider next to object steps whether it's trying to see if something could be injected through the catheter to help dislodge the clot or intermittent drainage um some folks will even do lumbar drains um that's more common not in the traumatic setting but oftentimes with with aneurysmal related uh csf diversion so i think being able to communicate that uh on the wards is always impressive just that you know there's an understanding that other issues can be at play and even if you don't have a plan in place as to how you might address every possibility you've at least thought through that there are these these um potential side effects working so this is just a schematic on external ventricular drain placement and again i think in terms of our value placing a drain in a timely fashion can truly save someone's life so we always look off the midline about 12 centimeters behind the nasion i like to go about four and a half off the midline so 12 behind four and a half across and you double check mid pupillary line and then again you want to think in your head the ventricular system and where you're aiming so you're aiming um you know they always say towards the ipsilateral medial canthus and then also the tragus on the opposite uh you want to kind of get this line in your head that tragus here uh so you're trying to um trying to basically aim you know towards it's it's almost posterior and you know inferior obviously and kind of this angle and this trajectory as if you're looking down on the person's uh scalp so i think having a sense in general where the ventricular system should lie is important getting a sense of the tragus on either side and sort of the imaginary line you can draw between them is important as well so the image on the right here you can see this this shows the angulation actually i would say better kind of shows you want to be a little bit inwards and then posterior as well so i'll just quickly go over let's quickly go over the brain trauma foundation guidelines uh so i was going to mention uh the brain trauma foundation guidelines are pretty accessible online and moving forward should actually be updated largely online as well and again it's something i think to um i would say is impossible to memorize cover to cover but the point being that you know they exist and they guide a lot of practice so important to cite that and at least know that it's you know something to have in the mix in terms of when to make a decision uh to operate or to intervene so just wanted to mention in terms of monitoring because that's always a you know a challenge especially when you're on the wards you're taking call this is a great question to be asked in terms of well should this patient get a monitor you know if we've decided the patient's not a surgical candidate they're a trauma patient found down etc what do we do you know what's our role here and what can we provide um in terms of management so you know when we think about intracranial pressure monitoring whether it's via external ventricular drain whether it's via a bolt or some combination thereof you know we think about monitoring in patients who have had a traumatic brain injury defined as gcs of you know eight or below as well as an abnormal head ct now if we think about an abnormal head ct you know may include all of these things you know brut you know contusions swelling etc we do think it's indicated in in severe cases even if the patient has a normal scan if we see a few factors whether the patient has a very poor exam motor posturing certain age range and then systolic blood pressure so we know that 50 or so patients who develop icp at some point in their hospitalization typically fairly early on may have a relatively negative scan now this is also i would take with a grain of salt because you know a lot of this some data or what's been studied is somewhat outdated with the existing scanners because that's always evolving and improving but i think the idea is even if a patient comes in with a quote-unquote normal head ct no acute blood etc if the mechanism of injury just seems like something that's pretty severe their exam is poor so for instance high speed motor vehicle accident a patient who's giving you a poor exam i think your threshold of suspicion should appropriately be high in terms of potential issues to develop high icp so in terms of other con conditions for monitoring um you know frankly this is uh i would say uh variable and still a topic of discussion and there are periodically consensus conferences or guidelines committees or you know different types of thinking around these issues uh so you know diffuse axonal injury um is is a concern as well and i didn't mention this because it's not operative but uh diffuse axonal injury is something we see again high velocity trauma so motor vehicle accidents motorcycle accidents are another um you know kind of part of the history that should you know make your ears perk up but oftentimes we see changes in white matter whether it's you know small punctate hemorrhages and frankly there are situations where mri doesn't necessarily pick up diffuse axonal injury uh reliably and so in part it may be a clinical diagnosis based upon a patient's poor neurologic exam and also um you know the absence of a clear structural reason for the poor neurologic exam uh but getting back to the milan consensus conference uh you know i think what was interesting is that you know the idea of when a patient should be monitored and who who would be an appropriate candidate was somewhat broadened you know the idea that uh if patients are even after a surgery would they be appropriate for monitoring some folks feel yes some folks say well they've had their decompressive craniectomy it may not necessarily be valuable information diffuse axonal injury again something we didn't think was appropriate for monitoring uh perhaps and there's some who argue that that is a appropriate indication for monitoring i just mentioned that because there is variability and i would say some disagreement in terms of what the ideal candidate for a monitor uh could and should be so this continues to evolve um now there's also some kind of practice based i would say issues excuse me and i would say one thing i remember from uh being a student on the wards is it's always difficult because there's clinical practice that's often institutional um the way an institution has functioned there's practice based on excuse me there's practice based on guidelines you know things that are in the literature that you can access uh during your training and then there's other things that folks pick up either due to the medical legal environment in their area or just kind of how they think practice should be so it can often be very confusing because you're told oh you always have to do this then you go to another site and up you always have to do this and those two things are in complete contradiction so i bring up these points only to say that i think if you're asked you know when should i put in a monitor and do you think monitoring is appropriate for this patient you know you're assessing someone on the floor i think the goal and the idea is you're being able to convey that you understand that there is some variability guidelines such as the brain trauma foundation exists and can maybe help guide your practice but they aren't necessarily the firm and fast rules for what you will see when you're on the wards uh and the other example too is that um you know if you have a trauma patient taken emergently urgently to the operating room for diffuse injuries whether it's blood in the abdomen a big hip fracture something like that and there's not a great neurologic assessment unclear if the patient's been sedated they had a breathing tube placed in the field unclear how much of that is medication related there is a role for monitoring when you have a patient like this that you're concerned about but needs other cares now what's interesting too is when we think about intracranial monitoring and the parameters you know we talk about elevations above 20 or 22 that are persistent lasting more than two minutes uh we are concerned and would administer hyperoz molar therapy whether it's mannitol hypertonic saline or a combination thereof uh intractable icp elevations there's a role for surgery if the patient has just diffuse brain swelling horribly elevated icps you failed all the non-operative management strategies whether it's hybris molar therapy obviously head of the bed positioning you know a short-term um hyperventilation uh you've tried you know even phenobarb coma to try to relax and relieve as much compression and swelling excuse me as possible there's a role for decompressive craniectomy now again i would say that after a craniotomy uh when a icp monitor may be used may be associated with other factors if there's any concerns about brain swelling at the time of surgery whether a patient is hypoxic or has any issues with issues with hypertension some would suggest an ic p monitor placed intraoperatively or immediately postoperatively would be helpful and that's with a craniotomy or even a craniectomy uh but again i think um the last point here is still an area of controversy in terms of monitoring in the setting of patients without a bone flap so just understand that your local environment may have a very strong dogma in terms of how they approach these patients and they might say this is it and this is the way you should be doing it there is in the broader community a little bit of variability and certainly some controversy in terms of what the best approach would be i'll just kind of briefly talk about this and really skip over this but you know when we think about monitoring patients with traumatic brain injuries imaging is a workhorse invasive monitoring you know we briefly touched on just kind of i think of it in two buckets [Music] hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world