Divaldo Camara, MD, an attending neurosurgeon at Mount Sinai Morningside, presents a series of emergent neurosurgical cases including a struck pedestrian, a patient who fell from a three-story window, and a patient experiencing hypothyroidism.
Hi. Good morning, everyone. I'm the father tomorrow, your subcutaneous Montagny Morningside and I would like to review today. So I'm interesting cases that we have here, and they are interesting for educational purposes. No disclosures for this talk as, um maybe some of you know, Mount Sinai. Morningside is a very old hospital. One of the oldest in your city was built in 1946 was formally known as ST Luke's Hospital, then Mountain and Saint Lukes, and since last year, mount Sunday morning side. It's 114th Street and Amsterdam Avenue. It's pretty beautiful neighborhood. Just a few steps from Colombia, Um, campus and Riverside Park, Morningside Park in Central Park. It's primary trauma Center is we are a level two trauma center. Uh, so as you can imagine, emergencies are significant volume of our cases. However, more recently, with the great support of our hospital, especially Dr Benson doctor gotten, we have established our neurosurgical service with the goal of not only having a trauma center for months on health system, but also to expand for elective cases for spinal and cranial cases. And I think we have advancing pretty good in the next. The last few years. There's a fun fact. Um, ST Luke's Hospital dedicated some floors to Titanic survivors is the New York Times. Um, and cover from that year, and many of the survivors came here, but in front of you did not save Jack. Uh, we are blessed to work with an amazing team. Uh, we have amazing p a team. This is this is a interesting hospital because we don't have residents rotating, attaining NPR running only, And we have had great great results. Is our team during covid time during also covid when we were receiving many donations. Um, and briefly, I was just like to, uh, to show this. Uh, this is a C s American College of Surgeons report, uh, for this year where they we were compared to other hospitals with other trauma centers in the country. And as you can see here for severe TBI I we have two times patients coming here have time, chances of a better outcome than average in the US, so that was a really, really great result for us. Before I dig into cases, I would just like to bring awareness about, um, rebel. Maybe probably. You have seen around the city. And even though the season the U. S not in New York rebels. These are electric mopeds. You can very cheaply rent. As these are photos taken from their website. It seems trifle it have a good time right in the electric scooter. But that's the how it's supposed to be. This is the reality. These are some pictures that I took, um, around the city here, you can see there's a guy unhealed. It'd crossing the red line just in from just in front of a hospital. As you can imagine, this will not end good. This is also rebel patients that we have received always severe TBS and, uh, with significant. Uh, no, I should call problems. This is all over the news. Uh, many deaths and severe injuries have been reported. Uh, it was actually suspended for a few months, and then more recently it was reinstated. So right now, you can still you can already rent rebels and walk around. Just last week, we operated this lady that you can see here is 82. She was hit by, uh, she was struck by a rebel. And that's sorry for the graphic images of her brain and that brain coming out from here. That is how severe rebels can be. And we are getting together the database. Uh, and we are studying in detail all those patients, and we plan to publish that to bring awareness of this, uh, small pet. So back to our subject here, No emergencies. It's a It's a significant number of cases we do here. I would like to present some Category one cases that I had is mostly about the thought process and and And what went into the thinking of taking the patient to the war or not taking the patients there are. And that's, I think, for emergencies. That's something very critical. It may not be the surgical technique itself. The surgical technique may be straightforward, but to me, what makes it special for emergencies is your decision making process. Of course, you don't have the luxury to select the patients. You don't have any time for medical clearance, so you may have old patients with a lot of comorbidities on Coumadin, which, of course, will impact your outcome. So, uh, my first case, this was a patient. Two years ago, she was elected as unknown 19 year old female pedestrian struck by a bicycle trauma call was called. She was seen in the trauma bay. Um, she was stable with the GCS 14, so just a little bit disoriented. Primary survey agency Anything more concerning secondary sort of is also she was stable and other injuries. Noted her new examples. She she has 14. She was confused, but otherwise she was intact. Non folk. All people were equal, however, few minutes, Uh, while Steven and Trauma Bay she became much more agitated and the Arctic and required intubation. And for that I would like to pause and just bring attention for agitation. It's very common to CED patients being agitated, and as you can imagine, of course, many of the causes of the agitation can be intoxication, alcohol, drugs, which I think maybe the majority of those cases. However, it's not unheard of, and I've had cases where patients were just team intoxicated and that was the reason for the agitation and later on were found to have a significant to kind of bleeding, so agitation can be a sign of intracranial pressure. Increase intracranial pressure for any source so they don't take for granted those those patients, so you may lose time to diagnose a reversible neurological condition. So this patient went for a cat scan, and, uh, can you guys see the video? Okay. Okay. So this is her cat scans. So she has some interesting finest so left temporal epidural hematoma and the right subdural hematoma. Something to hemispheric subdural and some dramatic supercar hemorrhage. Um, at that time, she was sedated because she was just she had just been intubated. So, you know, I would say her new examples problem just yes, was probably 10. Her purpose were equal. And, uh, that was the bandleader showing this temporal fracture. So that's her diagnosis. So she had a left temporary girl, right? Sub zero. And, um, I would like to launch this poll. Chris, do you do you launch? Do you launch it? Okay, everybody launching a poll. So for this case, what treatment is indicated? Nonsurgical sp Both also nonsurgical right hemicrania and left craniotomy left craniotomy plus SCP both or DVD. Or write him a craniotomy. Hemi craniectomy for sub zero in SCP. Basically, don't do any surgical treatment. You treat the subzero you treat up bureau treat both Or don't do anything. I think you have to click. Submit, Chris. You know, I can just see the poll in progress. Does he have a launch button? So far, we have 21% of people. Okay, Good. Yeah. Are you able to see the results of although No. Okay. I'll give it, uh, up to a minute. It's at 50 seconds now, So go ahead and put your answer in. You got 10 seconds to answer. Okay. There you go. Can you see that? Although, no. If you can just tell me which. Okay, result is, uh, 67% said left craniotomy for epidural. Oh, here we are, sharing results. Can you see that? Yes. Yes. Again. Great. So this actually was what? Interesting result. Yes, that's actually what I also thought doing. Um and, uh, but I think it will be. I understand this case if you would treat a subdural hematoma and also the left the bureau hematoma. I know this is, uh I think both as it would be really accessible. I my thought process was to treat quickly what I thought was causing her the conversation, which, typically, just the hematoma. So she literally had that lucid interval that we all talk about the Peterson Mottama. So she was. She was taken to the over for a small cranny for left epidural hematoma, evacuation. And, of course, I placed the boat. So she was taken today. I see you. She initially You know, in the first few hours I see, I see peace were under control. However, shortly she required, she required Manito hypersonic sailing. And we repeat the scan that showed more pronounced edema on the on the left side, and the severe was not really much increased. She had a more contusions on the left on the right side. I'm sorry, but her ship is really became refractory. From that time on, we decided to do a mini craniectomy. There was just a few hours after the first procedure. And, uh, that's the Hemi craniectomy. Um, so she did, uh, initially, she was intubated for a few days in the ICU with semi CP issues. We were managing with mannitol, hypersonic ceiling or conservative treatment at that time, and she was finally exhibited. She went to rehab, had a, you know, pretty good dot com did her cranial capacity and That's her, uh, coming from a place she's going to state and doing very well right now. Um, so just a quick reveal epidural hematoma you want to treat with surgery any epidural hematoma greater than 30 ccs, regardless of GCS score you may control. You may treat conservatively if there's less than 30 CCS or less than 50 millimeters of thickness or five millimeters of million shift. If the patient has a good near exam, meaning GCS score greater than eight without any focal deficit without any particular changes, those cases you make not treat surgical. However, you have to really closely monitor in the and for subdural hematomas. You wanna treat surgically any subdural hematoma, uh, greater than 10 millimeters of signet thickness or Midlands ships more than five millimeters. Regardless, the GCS score. Uh, you may also treat surgically if the patient has, um, he subdural hematomas less than 10 millimeters or midline shift less than five. If the new exams deteriorating, which I think was in this case, um, so if the admission admission, uh, just yes, is deteriorating. If it's decreasing more than two points or you have any people, then you see the BP spiking you. You may also want to treat that some room. Cool. So that was the first case. Second case. It's a very, very sad case. She was. She is a 35 year old female bishop. Depression, anxiety. She was pregnant, and she attempts suicide by jumping through the window. And she fell from three stories. She was found on the sidewalk. CP on on cardiac arrest. CPR was done Ross achieved. Brought into the emergency room. She was known to be, um, hypertensive. Um fast was positive. Massive massive transfusion protocol was initiated, right? No material was found and I saw this patient myself. This wasn't on the recovery time on Monday. She was just She has four left side in South Korea. Recognized. And she had extensive possum. So very concerning neurological finance. So for this patient with severe TBI and and seemed like very severe trauma, what would you do? Mhm. This one just in 30 seconds. Yeah, I think especially for a cat scan and plan says you're according to results straight to the O. R. For exploratory laparotomy straight to the O. R. And doing it explores her left corner to me because she has a left side in South Korea. Even the old placement in the war. I mean, in the A D. Or I see your commission and goes off there 85 seconds. Yeah. I would love to get a cat scan this case, and I think that would have helped a lot. However, she wasn't stable. She was requiring massive transfusion protocol. And she was hypertensive and fast. Positive. So this was not a stable patient to be taken to the cat scan. No time. We could not lose time, uh, to get how can I get this? Can you? Can you closing your end, Chris? Yes. Thank you. Uh, I'm not. Okay. So this patient needed to go to the water without any entrepreneur. Any neural image that one should have pretty much died from from her heaven dynamically stability. So she was able to work for spectral Apple Army, and then later on, right after she was about to cat scan, um, which, you know, showed some diffuse Dema maybe from the related to, uh, anoxic encephalopathy. And a small right. Peter hematoma. Some small confusions, but really no entrepreneurs. No significant cranial mass. And, uh, I was concerned about her left and Zakaria Meaning Did she have epidural hematoma that we were delaying that treatment? And, uh, you know, briefly, I thought about in explore the liberal exploratory craniotomy while she was in the the, you know are for her abdominal surgery. I'm glad I didn't proceed with that. But maybe, you know, there would also be acceptable. This is just a cat scan showing she had many school based fractures. And then the reason for her left in South Korea was actually orbital fracture, injuring the optic nerve. Okay, so she went through into the war to the I C u. I see people it was placed in these recipes were, you know, just a little bit increased that time with I'd like to know what people would do. So they should be used to be in CQ She was now stable. Him or dynamically. I see both was in place, ranging from 22 to 29. So what would you do right now? Right here. McRaney left handed Cranie Absolutely. Compression school friends, school fracture, elevation, medical management of increased I C p. Okay, so yes, correct. So she didn't have any any significant local stories finding a cat scan that would prompt a decompression at that moment. Chris, can you close? Okay, good. So that's exactly what we did. We follow the A. C s, uh, guidelines, and I This is a very interesting paper on the right side of the screen, this, uh, expert opinion expert panel that tried to stratify an algorithm for severe TB treatment. And we follow that we have reviewed north with our team. It's gratifying tears from tears. Year 212 or 20 or three for these These are for severe TBS patients with I C p monitoring either i e v d or C P both in the ICU. So basically, how to manage those that patients those patients and tear zero is basically, you know, you're not activate treated an entrepreneur. Um, any raising SCP and then from 21222 or three. These are ranging, uh, increasing. Um, treatment keeps medical management of chips in one of them being the compressive craniectomy. So this patient initially okay, you know, giving her already very concerning prognosis. But the CPS was very much control. She did receive some some receiving Manitoba hypersonic sailing um, but she she held throughout the next days. We did need to place in the DVD to fry city control. Which one of the one of the things you can do or than than than than surgery to control her. SCP She did respond well with the DVD. She was Brady correct That she would prove from that, uh, DVD was effective to provide some relief for SCP. However, she was the compensating much more. We was around with the name a team. This is John Young and I, John Yang is under with the robot around remotely from Montana west. That day she that was this day six. Since her admission, we were maxed out in Manitoba Hypersonic sailing you're already doing, um, hypothermia. And we were not being able to control her. Uh, entrepreneur pressure. This is her cat scan. The show's already some much more face mint of the suicide and the right, uh, posterior temporal ischemic area and a new right to left Milan shift. She also, as you can see, a left frontal confusion in a small epidural hematoma. So we discussed the case with the family and the family was element about all treatment to be done. And with that cat scan, what time do they compress? She has a right ischemic area and the left frontal epidural hematoma and a confusion. Can you play the scan again? Sure. Five seconds left. Yeah. Um, yes. So that's what we did, actually, so, you know, she didn't have left sided concern finds as well. But the Midland shift was right to left, and that that right ischemic area was much more post year. Should we have done a bi frontal craniotomy, which could be an alternative for this case, we wouldn't have the compressed this area here. That's where I was concerned. So we did the right sided compressing the Hemi craniectomy. You can see here her interrupt findings and proper, um, temporary compression. Um, that is her post cat scan. Um, after the compression, her bradycardia really resolved. As you can see there on the 23rd when she That was the day when she had him a craniectomy. From that day on, she was not requiring any man. It's all about the results of that was really effective. Unfortunately, she didn't have any meaningful recovery. That's her MRI showing extensive. You know, injuries. Both sides of the brain also brings them. But no, we honored the family wishes. Okay, My third case, this was an interesting case. 96 year old female D n r D and I When you hear that call when you are a call for 96 d n r. G and you don't think that's a surgical candidate, right? However, there was a very healthy 96 year old. She just had hypothyroidism. And she was She went to M s m e d complained of headaches and visual changes, and on upon exam, she was, you know, anytime. Three full strength with by temporary an option. Her lips were drowned and later on came in high poverty, tourism, and she was placed on steroids because of this finding. So these are cat scan that showed a large cellar mess with some right sided hemorrhagic component. And that's her MRI, um, which showed large system large macro adenoma. Uh, marbles had terrible quality. She was moving at that time. She was more agitated, Um, and right after those right, after a few hours after admission, she starts to have new finance. She was having a third of policy and six nerves and few hours after left side blindness. She was an erotic on the left side, so she was progressing for her pituitary apoplexy. So with that clinical findings, 96 year old what would you offer for this patient? She's 9 16 identity, but healthy, fully functional with ongoing pituitary apoplexy. And that's what we're gonna We're gonna have you go to 805 Okay, so that's six minutes left. Okay, So did you offer endoscopic financial surgery because of care, pollution, comfort, neural for surgery, medical management of the pituitary apoplexy or cause of care? You discuss and offer goals of care, comfort, medical management and eventually endoscopic TSS. Yeah. Ah, that's what we ended up doing, however, in this case, And remember calling Dr Gaetan for, uh, to see, you know, if my crazy to consider surgery for this and then he said, Well, you're not but discussed with the family and the patient, all choices they have and the patient was very, very reasonable. And instill her family. The patients said, Dr, I don't want to be blind if I'm dying. If I die during the surgery or after surgery, I'm fine. but I don't want to lose my independency. So I would do. I'd like to do everything I can to preserve my vision. So she was emergency transfer to Montana West, Same day, uh, and then we took her. I took her to the O. R. Overnight right after she arrived. By the time she she got Montana West, she was already blinded right as well. She she went to the war with She was fully blind, which was very scary. I never thought I would see that progression shot such a short time. Uh, we did have, um we just had navigation from the cat scan because her MRI was didn't have good, good study. The volumetric was was non existent. But, you know, given her very concerning findings of blindness, I didn't want to lose time to review to get an MRI. And it sells. Just proceed with the CAT scan. And during the case, actually, the navigation was totally off. We had no navigation, which also points. How important is for you to be prepared to, you know, complete the case without the aid of navigation. If for some reason it fails, you got to know the anatomy in the Skopje cases for pituitary, you have to know all the, you know, important landmarks to be able to complete the case. Uh, if you don't have the luxury of the navigation, that's her post op MRI still left. But it was not my intention to provide a full total resection. Uh, I just want to compress and improve her vision and Colonel Nerve deficits. Uh, that's her post op, uh, images she regained beautifully. Her vision. The left side third owner is now fully resolved. Some are a little bit of a single six years. How much time do we have? Chris? I think this should probably be the last case We have just a few minutes, so yeah, so maybe another opportunity can review the other cases. So just a review of the two triplex. She really have the classic presentation of pituitary apoplexy. You know, um, she had it was a macro adenoma. She had headaches, vision, laws, fatigue and pain. Hyper militarism. Uh, and then she approved, as expected, from the vision loss and headaches, and her induction status also got better. Okay, So for the interest of time, I'm not able to review the other cases. But, uh, I guess those three kids are example how how we can the thought process, the thought process that goes into dealing with category one cases and what you have to put in consideration when you are planning the treatment of those, uh, those cases. Thank you. Follow. This was great and very educational. And I think we should definitely have you back to your other cases and maybe bring some more in the future. Sure, please.