Case Discussion The 62 y/o man was brought to our ER on 4/3 due to severe headache for 3 days.      He had been a case of traumatic C-spine injury in 1985 s/p op at CGMH. He had C4 quadriparesis due to opacified posterior longitudival ligament months later, and he underwent laminectomy of C2, C6, and C7 at our hospital in 1987. After operation, he can stand for a while with assistance of his family, and quadriparesis improved a little. However, hypersomnia and poor cough ability ( his family should give him an abdominal thrust to complete a cough process) were noted. He underwent rehabilitation training in our rehab. department in 1987, and then he got regular follow-up at that OPD.      He was brought to our ER on 4/3 for severe headache for 3 days. The initial vital sign were as follows: BP 203/129, PR 80, BT 37.3, and SpO2 94%. Nifedipine was prescribed at first, and the follow-up BP was 161/99. However, sudden onset of apnea, lip cyanosis, and consciousness loss developed. He underwent endotracheal intubation. The initial ECG tracing showed bradycardia, and it returned to normal sinus rhythm after 1 amp of atropine. Leukocytosis, and increased infiltrate over RUL of CxR were noted.(圖一) He underwent a non-contrast head CT and it revealed hydrocephalus and diffuse brain swelling.(圖二、圖三) He was then transferred to MICU for further care.     Physically, his consciousness was clear on arrival to MICU. The vital signs were as follows: BP 186/90, T/P/R: 36.5/74/20. His conjunctiva was not pale, his neck was supple, and his heart sound was regular without murmur. The breath sound revealed crackles over right lung, no wheeze, and diffuse rhonchi. His abdomen was soft and flat, and he can move his extremities freely. The neurological status was similar to his usual condition. Laboratory:   WBC RBC Hb Hct MCV MCH MCHC PLT 0890403 18.75 3.86 12.6 36.1 93.5 32.6 34.9 112.0 0890409 13.66 3.19 10.1 30.5 95.6 31.7 33.1 121.0   PT PT Cont PTT PTT Cont INR 0890403(1404) 14.5 12.6 42.5 38.5 1.2   GLU UN CRE Na K Cl T-BIL 0890403 125.0 21.0 1.6 137.0 3.2 101.0 1.6   Ca Mg P AST CK CK-MB 0890403 2.13 0.72 2.5 37.0 200.0 11.0   TP ALB GLO T-BIL D-BIL AST ALT ALP 0890405 6.0 3.1 2.9           0890417 6.7 3.2 3.5 0.6 0.3 40.0 59.0 342.0   GGT UN CRE UA Na K Ca Mg 0890417 216.0 38.1 2.3 5.3 133.0 4.2 2.06 1.1 GLU AC 122 (4/17) CSF Appearance AFStain(AF) Gram's(GS) 0890405 (1440) W;C - Nofound 檢 體 : C.S.F. 項 目 Appearance Pandy's None-Apelt CellCount L/N 0890405 (1440) W;C + - 3 0/3 0890408(1634) R;TT W+ - 28 11 0890410 (1800) Y;C - - 5 0/5 項 目 Sugar   0890405 (1440) 40-50   0890408 (1634) 11/17   0890410 (1800) >50     PH PCO2 PO2 HCO3 BaseExcess 0890403 (1401) 7.44 32.4 80.6 21.7 -1.3 0890406 (0505) 7.42 36.0 117.6 22.8 -0.9 0890409 (0515) 7.38 32.3 80.7 18.7 -5.2 0890412 (0519) 7.37 38.8 133.0 21.8 -2.7 0890415 (0520) 7.41 37.7 122.4 23.3 -0.6 (Course and treatment): He was treated as pneumonia initially with Unasyn. A neurosurgeon was consulted, and brain atrophy with ventriculomegaly was impressed initially. His dyspnea improved soon, and he was extubated on Apr 3. However, drowsy consciousness, progressive hypoxemia, and profuse sputum were noted on 4/4. He underwent re-intubation for hypoxemic respiratory failure ( ABG 7.45/39.6/49.8/27.1/3.3) and airway protection. A lumbar puncture was performed. The open pressure was 550 mmH2O. Emergent ventriculostomy with right side EVD(Extraven-tricular drainage)  was performed in the early morning of Apr 5. His consciousness regained at that night. Vancomycin was given for suspected post-op ventriculitis. Paroxymal Af was noted during ICU stay, and it was converted to NSR by propafenone. We started EVD weaning 7 days after ventriculostomy, and a follow-up brain CT revealed improved brain swelling. EVD was removed on 4/10. We constructed end-tidal CO2, cough power, and glascow coma scale as his ventilator weaning parameter in addition to usual ones. Friquent abdominal thrusts and 束腹帶were applied to increased his cough power, and intermittent positive pressure ventilator was performed to prevent hypoventilation. His condition became stable, and he was extubated smoothly on 4/14. We had consulted a neurologist, and initially communicating type normal pressure hydrocephalus was impressed. Head MRI with CSF dynamic study to determine shunt or no shunt will be arranged at general ward, and Diamox was prescribed to reduce CSF production. 病案分析 此病人是個 quadriplegia, 以 severe headache 做initial  presentation , 在ER 有一個奇怪的consciousness loss,因此而導致 CPR,F/U brain CT 看起來有厲害的 brain edema, 卻沒有明顯的 focal lesion, 為了證實病人確實有 IICP, 我們冒險做 lumbar puncture, 得到一個確實非常高的ICP, 外科才願意做drainage of CSF; 而在IICP relieve 後, 在 weaning 的過程中, 這種病人除了需要一般的weaning parameter做monitor, 還需 monitor cough power 和 End-tidal CO2, 而且需要一些特殊的 procedure 來幫助病人weaning. 此 case 除了討論一般 headache 的differential diagnosis, lumbar puncture 的時機, 如果一定得做, 臨床又強烈懷疑 IICP, 可一面給予 osmotherapy (ex: Mannitol),再做 lumbar puncture, 如果得到非常高的數值, 流幾滴做必要的檢查, 而非所有的 routine 都做. 第二個討論的重點在於high cervical cord injury patient , weaning 時需注意事項. 此 case 由 MRI finding 得到最後診斷為 Cerebellar ischemic stroke with aqueduct obstruction, complicated with hydrocephalus.(圖四) 繼續教育考題 1. (B) What may not be considered as the cause of headache in this patient ? A Infection of central nervous system B Migraine C Intracranial hypertension D CVA 2. (D) What is “not” the manifestation of increased intracranial pressure ( IICP ) ? A Headache B Vomiting C Papilledema D Tinnitus 3. (D) What do you think we should do before lumbar puncture ? A Brain CT B Check eye ground C Barin MRI D All of the above 4. (C) What is the absolute contraindication for lumbar puncture ? A Subarachenoid hemorrhage B CNS infection C Brain tumor in posterior fossa D IICP ( Increased intracranial pressure ) 5. (D) What are the appropriate treatments for cerebral edema in this patient ? a. Osmotherapy ( including mannitol, glycerol ) b. Hyperventilation c. Extraventricular drainage d. Do lumbar puncture A a B ab C bcd D abc 6. (C) What do you think about the cause of intracranial hypertension in this patient? A Brain atrophy with ventriculomegaly B Communicating hydrocepalus C Obstructive hydrocephalus D CNS infection 7. (C) According to image study for this patient, the possible location of obstruction hydrocephalus is: A Foraman of Monro B The third ventricle C The aqueduct D The forth ventricle 8. (E) What is the correct answer ? a. The principle muscle of respiration is diaphragm b. Playing a lessor role in inspiration are the external intercostal musscles. c. Accessory muscles of respiration: Sternocleidomastoid muscle, scalene muscle, pectoralis major, d. The innervation of diaphragm is C1 e. The innervation of ventilatory muscles include T7. A abc B de C bcde D a E abce 9. (D) For a patient with quadriplegia, what could we do for check of weaning parameter ? a. Pimax b. Rapid shallow breathing index c. Tidal volume d. EtCO2 e. Cough power A abc B abcd C bcde D abcde 10. (D) For this patient with poor cough power, what could we do for help him in the attempt of weaning? A Frequent abdominal thrust B Pneumobelt C IPPV D All of the above

答案解說 答案解說: The points should be check for headache are character, site, mode of onset frequency/duration, timing/accompaning symptoms and precipitating factors. The onset of migraine is younger, and usually the family history is positive. The manifestations of IICP are headache, vomiting, and papilledema. Before we do lumbar puncture, brain CT to exclude intracranial mass and check eyeground to exclude extreme high intracranial pressureare needed. If this patient is not ventilated and the data of brain CT is not clear, brain MRI maybe the alternatives. The contraindication of lumbar puncture include the followings: (i) Presence of infection in skin overlying the spine (ii) Preexisting brain tumor (iii) Thrombocytopenia or bleeding diastheses ( If PLT <20000, platelet transfusion is recommended ) Intracranial hypertension is not absolute contraindication for lumbar puncture. If the risk of brain herniation and extreme intracranial pressure is predicted, consider this procedure after osmotherapy ( Glycerol, mannitol infusion etc.) Management of hydrocephalus: (1). Acute deterioration- ventricular drainage or ventricular-peritoneal (VP)/ ventriculoatrial shunt; lumbar puncture while communicating hydrocephalus following SAH or alternative treatment of cryptococcal meningitis (2). Gradual deterioration- VP or VA shunt; removal of a mass if present. (3). Symptomless ventricular dilatation require no treatment, but regular follow up is needed. Treatment of IICP will be started while mean ICP > 30 mmHg: (1). Mannitol infusion-iv bolus 100ml 20% mannitol infused over 15 minutes, reduces intracranial pressure by establishing an osmotic gradient between the plasma and brain tissue. However, repeated infusion would lead to lethal rises in BP and ATN. (2). Hyperventilation: keep PaCO2 below 35 mmHg, and resultant vasoconstriction and redustion in cerebral blood volume. (3). CSF withdraw: limited value (4). Steroids: important in treatment of intracranial mass with surrounding edema.  Hydrocephalus is an increase in CSF volume, usually resulting from impaired absorption, rarely from excessive excretion. This definition excludes ventricular expansion secondary to brain shrinkage from diffuse atrophic process( hydrocephalus ex vacuo). The classification including two types: (1). Obstructive hydrocephalus- obstruction of CSF flow within ventricular system. (ex: Dandy-walker syndrome, tumor) (2). Communicating hydrocephalus- ventricular CSF ‘ communicates’ with the subarachnoid space.( ex: increased CSF viscosity ) CSF forms at a rate of 500ml/day, secreted by choroid plexus, the direction: lateral ventricle -> third ventricle -> fourth ventricle -> foramina of Luschka and Magendie -> Subarachnoid space; absorption by arachnoid granulation. CT scan show the pattern of ventricular enlargement helps to determine the cause: (1).Lateral & 3rd ventricular enlargement --& normal 4th ventricle—suggests aqueduct stenosis; if with deviated or absent 4th ventricle, suggests a posterior fossa mass (2).Generalized dilatation: suggested communicating hydrocephalus (3). The presence of periventricular lucency and absent sulci suggest raised CSF pressure. The major inspiratory muscle is the diaphragm, it accounts for 70% of tidal volume. Playing the lessor role in inspiratory activities are the external intercostal muscles. The accessory muscles of respiration are called into play with increased effort breathing which include scalene muscles, sternomastoid muscle , and pectoralis major. The innervation of diaphragm is phrenic nerve, which arises from C3-5. The innervation of ventilatory muscle (abdominal muscle ) include spinal nerves, which arise from T7 through L1. Usual weaning parameters include Oxygenation( PaO2>70 mmHg on FiO2<0.5; PEEP of 5cmH2O ); Ventilation( ex: PaCO2 35-45 mmHg ); Ventilatory demand(ex: minute ventilation ); Respiratory mechanics( ex: tidal volume ); Respiratory frequency and pattern (f/Vt <105breaths/min/L ). In this patient, the cause of respiratory failure is CO2 retention. So in addition to usual weaning parameter (PiMax, tidal volume, rapid shallow breathing index, we have to check the cough power, and end-tidal CO2. Despite of high cervical cord injury, even C3 and C4 injury, they are candidate for weaning. A successful weaning programme requires increasing time off the ventilator and a passive muscle strengthening programme. Use of rocking beds, and pneumobelt and frequent abdominal thrusts have proved to be of value in the process of weaning.