ACUTE INTRACRANIAL PROBLEMS Flashcards
1
Q
Three components of ICP
A
Brain tissue 78%
Blood 12%
CSF 10%
2
Q
Primary injury
A
occurs at the initial time of an injury
3
Q
Secondary injury
A
resulting in: -hypoxemia -ischemia -hypotension -edema -increased ICP follows the primary injury
4
Q
Monroe-Kellie Hypothesis
A
If one of the three components goes up and the other two will try to compensate
5
Q
Factors that influence ICP
A
Arterial pressure, venous pressure, intraabdominal and intrathoracic pressure, posture, temperature, blood gases
6
Q
Normal ICP
A
5 to 15mmHg
7
Q
Panic level for ICP
A
> 20mmHg for 5 minutes is considered abnormal and must be treated!!
8
Q
Purpose of CBF
A
Purpose: (1) To ensure a consistent CBF to provide for the metabolic needs of brain tissue and (2) to maintain cerebral perfusion pressure within normal limits
9
Q
Blood in milliliters passing through 100g of brain tissue in 1 minute
A
Cerebral blood flow (CBF)
10
Q
<70 mmHg means that there is low brain perfusion due to?
A
diminished blood flow
11
Q
> 150 mmHg low brain perfusion due to?
A
vasoconstriction
12
Q
How to calculate CPP
A
MAP-ICP
MAP needs to be high!!
13
Q
Normal range for CPP
A
60-100 mmHg
14
Q
When CPP is <50 mmHg-
A
brain ischemia and neuronal death
15
Q
When CPP is <30 mmHg-
A
incompatible with life
16
Q
What happens when CPP decreases
A
autoregulation fails and CBF decreases
17
Q
Cushing’s reflex body attempting to improve CBF by?
A
Increase BP
Wide pulse pressure
Bradycardia
18
Q
CBF:
↑ CO2 in the blood and ↓ O2 indicates?
A
cerebral vasodilation, increases CBF
19
Q
CBF:
↓ CO2 in the blood and ↑ O2
A
= cerebral vasoconstriction, decreases CBF
20
Q
Risk factors for increase ICP with Increased brain volume are
A
Cerebral edema
Intracerebral mass
21
Q
Risk factors for increase ICP with increased cerebral blood flow
A
Impaired autoregulation
Decreased cerebral oxygenation (hypoxemia, hypercapnia)
Increased O2 demand (seizures)
Impaired venous outflow (increased intrathoracic, intraabdominal pressure)
22
Q
Risk factors for increase ICP with increased cerebrospinal fluid (CSF)
A
Hydrocephalus
23
Q
Increased accumulation of fluid in the extravascular spaces of brain tissue; an increase in tissue volume that can also increase ICP
A
cerebral edema
24
Q
3 types of cerebral edema
A
Vasogenic Cerebral Edema
Cytotoxic Cerebral Edema
Interstitial Cerebral Edema
25
Vasogenic Cerebral Edema
Most common type of edema
Leakage of large molecules from the capillaries into the surrounding extracellular space
26
Cytotoxic Cerebral Edema
Results from disruption of the integrity of the cell membranes; fluid goes from ECF to inside the cell resulting to cellular swelling
27
Interstitial Cerebral Edema
Build-up of fluid within the ventricles and interstitium of brain
28
Causes of cerebral edema
```
Mass Lesions:
Brain Abscess
Brain Tumor (Primary or Metastatic)
Hematoma (Subdural, Epidural
Hemorrhage (Intracerebral, Cerebellar, Brainstem)
```
Head Injuries & Brain Surgery:
Contusion
Hemorrhage
Posttraumatic Brain Swelling
Cerebral Infections:
Encephalitis
Meningitis
Vascular Insult:
Anoxic and Ischemic episodes
CVA (thrombotic, embolic)
Venous Sinus Thrombosis
Toxic or Metabolic Encephalopathic Conditions:
Hepatic Encephalopathy
Lead or arsenic intoxication
Uremia
29
What are the clinical manifestations of stroke
- change in LOC
- change in vital signs
- ocular signs
- motor function
- headaches
- vomiting
30
“Waxing and Waning
when they wake up, you ask how are you? And then they go back to sleep, come back to wake them up again and they’re restless
31
Cushing’s triad
increase BP, wide pulse pressure, bradycardia
32
What are some tests to check for
- NUMBER 1 CT scan!
- MRI is 2nd!
- Transcranial doppler studies
- EEG for brain wave and SEIZURES
- skull xray
- spinal xray
- lumbar puncture contraindicated for increased ICP
33
Ventriculostomy
Gold standard on monitoring ICP
Catheter inserted into lateral ventricle connected to a transducer projected into monitor
Facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration
A reference point ventriculostomy is the tragus
34
Inaccurate ICP readings can be caused by:
- CSF leaks around the monitoring device
- Obstruction of the intraventricular catheter
- Difference between the height of the catheter and the transducer
- Kinks in the tubing
- Incorrect height of the drainage system
- Bubbles or air in the tubing
35
Examples of mass lesions include
Brain Abscess
Brain Tumor (Primary or Metastatic)
Hematoma (Subdural, Epidural
Hemorrhage (Intracerebral, Cerebellar, Brainstem)
36
What’s the difference between hemorrhagic stroke vs ischemic stroke?
Hemorrhagic- bleeding occurs inside or around the brain tissue
Ischemic-clot blocks the blood flow to an area of the brain
37
Causes of Ischemic stroke are
Large Artery Thrombosis (20%)
Small Penetrating Art.Thrombosis (25%)
Cardiogenic emboli (20%) Cryptogenic (no known cause) (30%)
Other (5%)
38
Causes of Hemorrhagic stroke are:
Intracerebral
Subarachnoid
Cerebral aneurysm
AV Malformation
39
Clinical manifestations for ICP :
```
Changes in LOC
Changes in VS
Ocular signs (CN || and |||)
Decrease in motor function
Headache
Vomiting
Seizures
```
40
Decorticate posturing
BUE: Adduction, flexion of
arms, wrists, fingers
• BLE: extension, internal rotation, plantar flexion
41
Decerebrate posturing
• BUE, BLE rigid extension, with hyperpronation of forearms and plantar flexion of feet
42
Herniation syndrome that Shift of brain tissue from one cerebral hemisphere under the falx cerebri to the other
Cingulate
43
Downward shift cerebral hemisphere, basal ganglia, through tentorial notch compressing brainstem
Central
44
Unilateral lesion forces uncus to displace through tentorial notch
Uncal
45
Displacement of cerebella tonsil through foramen magnum, compressing pons and medulla; Changes on breathing and cardiac functions
Cerebellar tonsil
46
Management for ICP
Elevation of head of bed to 30 degrees with head in a neutral position
47
Infection is a serious complication with ICP monitoring.
* Routinely assess the insertion site
* Use aseptic technique
* Monitor CSF for a change in drainage color or clarity
48
Possible association with air in forehead tissue, CSF rhinorrhea, or pneumocranium (air between cranium and dura mater)
Frontal skull facture
49
Periorbital ecchymosis (raccoon eyes), optic nerve injury
Orbital skull fracture
50
Oval-shaped bruise behind ear in mastoid region (Battle's sign), CSF otorrhea, middle meningeal artery disruption, epidural hematoma
Temporal skull fracture
51
Deafness, CSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, facial paralysis, loss of taste, Battle's sign
Parietal skull fracture
52
Occipital bruising resulting in cortical blindness, visual field defects, rare appearance of ataxia or other cerebellar signs
Posterior fossa
53
CSF or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, Battle's sign, tinnitus or hearing difficulty, rhinorrhea, facial paralysis, conjugate deviation of gaze, vertigo
Basilar skull fracture
54
P1 percussion wave
Arterial pulsation
55
P2 rebound/tidal wave
Intracranial compliance or brain volume; If P2 higher that P1, intracranial compliance compromised
56
P3 dicrotic wave
Follows dicrotic notch , AV valve closure
57
Two testing to determine whether fluid leaking from the nose or ear is CSF
➢ Dextrostix
| ➢ Tes-Tape strip
58
Risk for meningitis is?
high with a CSF leak
59
GCS Scale includes
* Minor (GCS 13 to 15)
* Moderate (GCS 9 to 12)
* Severe (GCS 3 to 8)
60
Classic signs of epidural hematoma:
```
• Initial period of unconsciousness at
the scene
• Brief lucid interval followed by a decrease in LOC
• Headache
• Nausea and vomiting
```
61
Subdural hematoma
Occurs from bleeding between the dura mater and arachnoid layer of the meninges
Results from injury to the brain tissue and its blood vessels
May be caused by arterial hemorrhage May be acute, subacute, or chronic
62
Acute subdural hematoma
manifests within 24 to 48 hours of injury
63
Subacute subdural hematoma
usually occurs within 2 to 14 days of the injury
64
Chronic subdural hematoma
develops over weeks or months after a seemingly minor head injury
65
Drug therapy for Ischemic/Hemorrhagic stroke
Alteplase (clot buster) will not decrease ICP
Osmotic diuretic (mannitol) big molecule of sugar
Hypertonic saline (use this instead)
NaCl 3%
Antiseizure drugs (e.g., phenytoin [Dilantin])
Corticosteroids (dexamethasone)
Histamine (H2)-receptor antagonist (e.g., cimetidine) or proton pump inhibitor (e.g., pantoprazole [Protonix]) to prevent GI ulcers and bleeding
66
Management for ICP
Elevation of head of bed to 30 degrees with head in a neutral position
Intubation and mechanical ventilation
67
Most common cause of ischemic/hemorrhagic stroke
uncontrolled hypertension
68
Ventriculostomy includes
Gold standard on monitoring ICP
Catheter inserted into lateral ventricle connected to a transducer projected into monitor
Facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration
A reference point ventriculostomy is the tragus
ICP >20 mmHg for 5 minutes should be reported to physician
69
How often should you do neuro assessment for a patient with ICP
Q15 mins x 2 hours, Q30 mins x 2, Q1 hr until discontinued
70
Two testing to determine whether fluid leaking from the nose or ear is CSF:
when its bleeding??
Dextrostix
Test-Tape strip
If there’s bleeding from the CSF, test for halo sign
71
GCS measures ...
eye opening
motor response
verbal response
Minor (GCS 13 to 15)
Moderate (GCS 9 to 12)
Severe (GCS 3 to 8)
GCS less than 8= intubate!!
72
Typical signs of concussion:
Brief disruption in LOC (woke up for a little bit and goes back to sleep)
Amnesia regarding the event (retrograde amnesia)
Headache
73
Classic signs of epidural hematoma:
Initial period of unconsciousness at the scene
Brief lucid interval followed by a decrease in LOC
Headache
Nausea and vomiting
Focal findings
74
Occurs from bleeding between the dura mater and arachnoid layer of the meninges
subdural hematoma
75
the most common primary tumor from the CNS
Meningiomas
76
Brain tumor management includes
- Surgical therapy
- Ventricular Shunts
- Radiation Therapy and Stereotactic Radiosurgery
- Chemotherapy and Targeted Therapy
77
Opening into the cranium with a drill. Used to remove localized fluid and blood beneath the dura.
craniotomy
78
Excision into the cranium to cut away bone flap
craniectomy
79
Repair of cranial defect Artificial material used to replace damaged or lost bone
cranioplasty
80
the leading cause of bacterial meningitis
Streptococcus pneumoniae and Neisseria meningitidis
81
test used to rapidly diagnose viral meningitis
Xpert EV test
82
Ticks and mosquitoes transmit ..
encephalitis
83
Kernig’s sign
pain at the back of the neck (meningitis)
84
Brudzinski’s sign
pain in the back of the lower back in the lumbar area; stretching the meninges
(meningitis)
85
Most common causes of viral meningitis:
Enteroviruses
Arboviruses
HIV
Herpes simplex virus
86
Accumulation of pus within the brain tissue that can result from a local or systematic infection
brain abscess
87
Shift of brain tissue from one cerebral hemisphere under the falx cerebri to the other; no specific symptoms
cingulate
88
Downward shift cerebral hemisphere, basal ganglia, through tentorial notch compressing brainstem; Decrease LOC, Motor weakness, Cheyne-Stoke respiration, small reactive pupils (late: dilated) posturing
central/tentorial herniation
89
Unilateral lesion forces uncus to displace through tentorial notch; Increase muscle tone, Babinski, ipsilateral dilated pupil
Uncal
90
Displacement of cerebella tonsil through foramen magnum, compressing pons and medulla; Changes on breathing and cardiac functions
cerebellar tonsil
