Acquired Brain Injury Flashcards
What age group in children has the highest incidence of TBI
Less than 5 years old
What age group in children has the highest rate of TBI requiring hospitalization?
15 years and older
What is the leading cause of TBI requiring hospitalization in children less than 10 years old?
Falls
What is the leading cause of TBI requiring hospitalization in children older than 10 years old?
Motor vehicle accidents
What is the most common CT finding in children with moderate to severe TBI?
Contusion
What brain imaging finding is more common in children with abusive head trauma?
Subdural hematoma
What mechanism is consistent with a hemispheric hypodensity on head CT?
Abusive head trauma
What is the most common cause of cardiac arrest in children?
Respiratory arrest
What is the most common etiology for childhood arterial ischemic stroke?
Arteriopathy
What vessels does focal cerebral arteriopathy most commonly affect? (3 segments)
Terminal internal carotid, Proximal ACA, Proximal MCA
What risk factor puts a child at increased risk for hemorrhagic conversion of ischemic stroke?
Underlying cardiac disease
By what mechanism does cerebral venous thrombosis lead to brain injury?
Backpressure causing venous hypertension, edema, and possible hemorrhage
What are the most common vascular malformations in children with hemorrhagic stroke?
Arteriovenous malformations (AVMs)
What should be suspected in a child who experience trauma and whose neurological examination is not explained by head CT?
Blunt cerebrovascular injury
What are three craniofacial anomalies required for the diagnosis of fetal alcohols syndrome?
Flattened philtrum, thin upper lip, railroad-track ears
What brain imaging findings are seen in fetal alcohol syndrome? (3)
Corpus callosum a genesis, small/atypical white matter, small grey matter
What is the ICP target in TBI?
Less than 20mmHg
What is the most important treatment for moyamoya?
Surgical revascularization
In addition to arterial ischemic stroke, what brain abnormality are children with congenital heart disease at risk for?
White matter injury
What is the definitive treatment for arteriovenous malformations?
Surgical excision
Besides surgical excision, what other treatment has good outcomes for AVMs?
Radiation therapy
What may be suspected in a child with new onset of seizures in the setting of a sinus infection?
Intracranial abscesss
What is the most common vision impairment in children after TBI?
Decreased visual acuity
What is the treatment for vision deficits related to TBI?
Teaching compensatory strategies (scanning etc.)
What type of hearing loss is more common in children with temporal bone fracture?
Conductive
What is the prognosis for conductive hearing loss in the setting of temporal bone fracture?
Good, hearing often improves with time as fluids in the middle air space resolve.
Referrals to what specialties should be made for a child with a temporal bone fracture?
ENT, Audiology
What should be suspected in a child with impaired language acquisition after TBI?
hearing loss
Why is referral for cochlear implantation time-sensitive in children with bacterial meningitis induced sensorineural hearing loss?
Infection-related labyrinthine ossification can prevent electrode implantation
What should be suspected with a change in eating habits after acquired brain injury?
Anosmia
What class of medications can cause obstructive olfactory dysfunction?
Anticholinergics
What are the two main causes of acquired ventriculomegaly?
Hydrocephalus and ex vacuo ventricular dilation
What type of acquired ventriculomegaly usually requires intervention?
Hydrocephalus
What are typical imaging findings in ex vacuo ventricular dialation?
Diffuse cerebral atrophy and sulcal prominence
What type of hydrocephalus typically shows enlargement of all ventricles?
Communicating
Which area is typically first to expand in communicating hydrocephalus?
Temporal horns of the lateral ventricles
What are signs of hydrocephalus in individuals with severe brain injury? (4)
Emesis, failure to progress as expected/decline, PSH, unexplained spasticity
What is the definition for early seizures after TBI?
After 24 hrs but within 7 days
What are 5 risk factors for post traumatic epilepsy in children after traumatic brain injury?
Young age, early seizures, severe TBI, penetrating injury, hemorrhage
What is one risk factor for development of epilepsy in children with arterial ischemic stroke?
Early seizures
For at least how long should patients have seizure prophylaxis after TBI?
7 days
What are signs of PSH? (6)
Diaphoresis, posturing, tachycardia, tachypenea, hypertension, hyperthermia
What type of brain injury more commonly is associated with PSH?
Anoxic
What are two outcomes associated with PSH in the setting of anoxic brain injury?
Worse functional outcomes, prolonged hospitalization
What are two life-threatening conditions that may mimic PSH?
Infection, pulmonary embolism
What conditions can trigger PSH? (6)
Full bladder, constipation, fracture, skin breakdown, renal/bladder stones, cholelithiasis
What is one of the most common endorcrinologic finding associated with pediatric TBI?
Growth hormone deficiency
What is the prognosis for endocrine abnormalities after pediatric TBI?
Many resolve by 1 year post injury
What may be suspected in a child with fatigue, cognitive changes, and mood changes after TBI?
Growth hormone deficiency
Why are children with acquired brain injury at risk for early pubertal development?
Brain injury can interfere with normal inhibition of gonadotropin release
What condition after TBI presents with decreased ADH?
DI
How can one distinguish between CSW and SIADH?
In CSW, patients are hypovolemic whereas in SIADH patients are isovolemic
When should a child with a severe TBI be assessed for a endocrine dysfunction?
At one year as abnormalities found then are more likely to be permanent
What presents with joint pain, warmth, swelling, and decreased range of motion in a TBI patient?
HO
What is the most frequent site for HO in the child and adult TBI patient?
Hip
What is the standard for diagnosis of HO?
Triple phase bone scan
What are three factors associated with development of HO in children with acquired brain injury?
longer duration of DOC, older age (over 11 yo), long bone or multiple extremity fractures
Within what time frame is establishing enteral feeding in TBI recommended?
72 hours
What are risks of nasogastric feeding tubes?
Displacement into airway, blockage, esophageal/nasopharyngeal irritation
What is recommended maintenance therapy for constipation in brain injury?
Polyethylene glycol (PEG)
What is the typical cause of urinary incontinence in brain injury?
Disinhibited/overactive bladder
What is a common treatment for bladder incontinence in TBI?
Timed voiding
What type of pediatric patient is most at risk for VTE?
Postpubertal, congenital heart disease (single ventricle in particular), post-surgery, CVC in place
What is gold standard for diagnosis for pulmonary embolism?
CT pulmonary angiography (CTPA)
For how long is VTE prophylaxis usually continued in a non-ambulatory brain injury patient?
3 months
Which outcome measure is associated with worse outcomes after pediatric TBI?
Time to follow commands greater than 26 days
What imaging finding in children with cardiac arrest places a child at high risk for a poor outcome?
Restricted diffusion on DWI in the first two weeks
General step-wise approach to treating DOC patients?
1) Wean sedating medications
2) Optimize sleep: melatonin, trazodone
3) Evaluate and optimize hearing and vision
4) Await stabilization of medical issues
5) Consider neurostimulant trial
What differentiates unresponsive wakefulness from a coma?
Sleep-wake cycles
Denotes minimally conscious minus state?
Visual fixation, localization of noxious stimuli
Denotes minimally conscious plus state?
Command following, yes/no response
Denotes emergence to a conscious state?
Functional object use or functional communication
What are two factors associated with better outcomes in children with acquired brain injury?
Higher level of function on admission/discharge from IPR, traumatic etiology
What are two of the most common behavioral/emotional disorders in children after TBI?
ADHD, anxiety
What academic discipline has been shown to be most affected after TBI?
Math
What are three categories for factors related to increased risk for neurobehaviorial difficulties after TBI?
Preinjury, injury-related, family
Injury related factors for poor cognitive and behavioral outcomes?
More severe injury (GCS score), more extensive damage on imaging, length of PTA
How is age related to development of neurobehavioral impairments in the setting of TBI?
Those younger than 2 have more impairment than those over 7
Are preinjury family factors related to cognitive outcomes in anoxic brain injury?
No
What are the cognitive findings with ACA stroke?
Impaired judgement, flat affect
What are the cognitive outcomes with dominant MCA stroke?
Aphasia
What is the cognitive outcome with PCA strokes?
Alexia without agraphia
What types of children with pediatric brain injury are likely to respond to family based problems-solving?
Older, with lower IQ and with lower socioeconomic status
What is the mechanism for stimulant medications managing attention?
Increasing dopamine and/or norepinephrine in the frontal cortex
What medication has been shown to help adolescents with severe TBI with memory?
Donepezil
What is the mechanism of amantadine for arousal?
Dopamine agonist, NMDA antagonist
What are the typical side effects for dopamine agonists?
Nausea, vomiting
What are three dopamine agonists used for arousal in TBI?
Amantadine, bromocriptine, carbidopa/levodopa
What is the mechanism of action of modafinil?
Inhibits dopamine reuptake
What is the mechanism of valproic acid for treating agitation?
GABA agonist
What is the mechanism of methylphenidate?
Dopamine and norepinephrine agonist
What is the mechanism of action for donepezil?
Inactivates acetylcholinesterase
What is the mechanism of action of donepezil?
Inactivates acethylcholinesterase
What class of medication is duloxetine?
SNRI
What class of medication is escitalopram?
SSRI
What is the mechanism of action of trazodone?
Histamine and alpha-adrenergic receptor antagonist. At higher doses it inhibits serotonin reuptake
What motor impairment is seen with ACA stroke?
Hemiparesis with the leg more affected than the arm
What motor impairment is seen with stroke of the superior division of the MCA?
Hemiparesis with the arm and face more involved than the leg
Are there consensus guideline for return to sport after severe TBI?
No
What is the leading cause of death in children over 1 year old?
traumatic brain injury
Is the presence of skull fractures generally indicative of the severity of pediatric TBI?
No
GCS consistent with a moderate brain injury
9-12
GCS - eye scale (4)
spontaneous, to speech, to pain, none
GCS - verbal scale (5)
appropriate, confused, inappropriate, incomprehensible, none
GCS - movement (6)
follows commands, localize to pain, withdraw to pain, flexion to pain, extension to pain, no response
Length of PTA consistent with a moderate brain injury?
1-24 hours
Duration of unconsciousness consistent with a moderate brain injury?
15 min to 24 hours
What contributes most to disability in TBI?
cognitive/communication deficits
Why is use of etidronate contraindicated in growing children?
can cause rachitic syndrome
What are 4 lab values that can be elevated in HO?
alk phos, GGT, creatine phosphokinase, and ESR
For a unilateral oropharyngeal dysphagia, which direction should one turn the head when swallowing?
Towards the WEAK side
For unilateral oropharyngeal dysphagia, which way should one tilt the head when swallowing?
Towards the STRONG side (and maybe forward)
DOC medications to avoid with feeding intolerance?
amantadine, levodopa-carbidopa
