Hospitalists increasingly comanage neurosurgical conditions as part of a multidisciplinary care team. This chapter will present the management of common neurosurgical conditions, including brain tumors, hydrocephalus, stroke and other vascular diseases, traumatic brain injury, spinal cord injury, and degenerative spine disease.
Both primary and metastatic brain tumors can cause significant morbidity and mortality due to their location within the central nervous system. Recognition of the common symptoms including headache, seizures, and altered mental status is important for general physicians. MRI helps to define the location and extent of the tumor and provides a diagnosis. Surgery is often required to confirm the definite pathology and guide further treatment (Table 63-1).
Table 63-1 Imaging Characteristics and Survival of Patients with (1) Glioblastoma Multiforme, (2) Low Grade Glioma, (3) Meningioma, and (4) Metastasis |Favorite Table|Download (.pdf)
Table 63-1 Imaging Characteristics and Survival of Patients with (1) Glioblastoma Multiforme, (2) Low Grade Glioma, (3) Meningioma, and (4) Metastasis
|Glioblastoma multiforme||These tumors typically have irregular ring-like contrast enhancement; significant brain edema and the mass effect, which can be severe enough to cause herniation. They typically involve white matter and can spread across the corpus callosum and involve both hemispheres.||12–15 months|
|Low grade glioma||On MRI, these tumors are usually hypointense on T1-weighted imaging and hyperintense on FLAIR and T2-weighted imaging. These lesions rarely enhance. Cystic changes are not uncommon.||7.3–12.0 years|
|Meningioma||Adjacent to bone and usually have a “dural tail.” This finding indicates that the tumor is anchored to the dura and growing along it. They have a characteristic diffuse pattern of enhancement.||5-year survival 69% 10-year survival 63%|
|Metastasis||These lesions are usually located in the white-grey matter junction and will avidly contrast enhance.||2.3–7.1 months|
Benign tumors (meningiomas, pituitary adenomas, acoustic neuromas) often have a favorable outcome with surgical resection or radiation therapy including stereotactic radiation. Skull base tumors are more difficult to handle with surgery alone and might require multimodality treatment. Primary malignant brain tumors (gliomas, medulloblastomas) benefit from radiation and chemotherapy. Brain metastases remain a frequent complication of systemic tumors but are temporarily controlled with surgery or radiation therapy. Unfortunately, the mortality rate from malignant brain tumors remains high.
Brain tumors can cause either focal or generalized neurological symptoms. Generalized symptoms include headache, nausea, and vomiting, which are suggestive of increased intracranial pressure. Headache occurs in about half of the patients. When focal headache occurs, it may indicate the precise location of the tumor. The headache may be more severe on awakening in the morning (the so-called “morning headache”). It can be difficult to differentiate from tension headache, cluster headache, and migraine. Seizures occur at presentation in 15–95% of patients with brain tumors, depending on the type of tumor. The seizures are mostly focal but may become generalized and cause loss of consciousness. Focal ...