aneurysm. Flashcards
(a) Brain encased in rigid casing, bathed in cerebrospinal fluid
(b) Sudden deceleration or acceleration of the head can lead to impact of the brain against the cranium
(c) Concussion is cognitive impairment brought on by diffuse brain injury after exposure to impact forces
(d) May occur with or without loss of consciousness
(e) Mildest subset of traumatic brain injury (TBI)
Concussion
(a) During acceleration, force is applied to the brain. This creates a shear force at white/grey matter junction
(b) In severe head injury, may rupture axons
(c) In mild head injury, mild axonal damage leads to swelling and inflammation
(d) May or may not be accompanied by contusion
(e) More discreet area of injury caused by impact as well as shear
(f) “Coup-contrecoup”
1) Injury will be present at site of impact as well as opposite side from rebound
motion
Aneurysm:
Pathophysiology
(a) Hallmarks are confusion and amnesia
1) Amnesia almost always includes the traumatic event itself, but may alsoextend to events before and after trauma
(b) May occur with or without loss of consciousness
(c) May be immediately apparent or delayed by several minutes
(d) Clues such as lack of recall or repetitious questioning should be red flags
(e) Early symptoms (minutes to hours)
1) Headache, dizziness, vertigo, imbalance, nausea, vomiting
(f) Delayed symptoms (hours to days)
1) Mood/cognitive disturbance, light/noise sensitivity, sleep disturbance
(g) Common Signs
Aneurysm:
Clinical Features
1) Vacant stare (befuddled facial expression)
2) Delayed verbal expression (slower to answer questions)
3) Inability to focus attention (easily distracted)
4) Disorientation (walking in the wrong direction, not A&O)
5) Slurred or incoherent speech (making disjointed statements)
6) Gross observable incoordination (stumbling)
7) Emotionality out of proportion to circumstances (appearing distraught, crying
for no apparent reason)
8) Memory deficits (exhibited by patient repeatedly asking the same question that
has already been answered or inability to memorize and return three of three words and three of three objects for five minutes)
Aneurysm:
Clinical Features- Common Signs
1) Seizures
a) If seizures occur within one week of head injury, much more likely to be related to TBI than epilepsy
b) Occur in 5% of TBI patients, more common with severe injury
Aneurysm:
Clinical Features- Less Common Signs
(a) Any concussion with concomitant hemorrhage
(b) May present as acute, subacute or chronic
(c) Usually arterial in origin
(d) Treat based on complication
Aneurysm:
Complicated concussion
(a) Complete history and physical (MACE within
Aneurysm:
Acute Evaluation: 48hrs
(a) Direct observation for 24 hours
(b) Awaken the patient every 2 hours to ensure normal alertness
(c) Low level of activity for 24 hours after injury
(d) No alcohol, sedatives, or pain relievers other than NSAIDs should be given for 48 hours
Aneurysm:
Management of concussion
(a) Inability to awaken the patient
(b) Severe or worsening headaches
(c) Somnolence or confusion
(d) Restlessness, unsteadiness, or seizures
(e) Difficulties with vision
(f) Vomiting, fever, or stiff neck
(g) Urinary or bowel incontinence
(h) Weakness or numbness involving body part
Aneurysm:
Immediate Referral/MEDEVAC for concussion:
1) Diffuse cerebral swelling that can develop in setting of a second concussion
2) Occurs when patient symptomatic from the 1st concussion and sustains 2nd concussion
3) Rare but potentially fatal complication
Aneurysm:
Second Impact syndrome
Headache, dizziness, cognitive impairment, psych symptoms that develop in the first few days after mild TBI and resolve in weeks to months
Aneurysm:
Postconcussion syndrome
25-78% of patients experience headaches within 7 days of the event
Aneurysm:
Posttraumatic headaches
Excessive daytime somnolence, increased sleep need, insomnia, sleep fragmentation
Aneurysm:
Sleep disturbances
1) Repeated concussions can lead to cumulative neuropsychologic deficits
a) Behavior changes, personality changes, depression, increased suicidality
b) Parkinsonism
c) Speech and gait abnormalities
Chronic traumatic encephalopathy (CTE)
Complications of concussion
Second Impact syndrome
Postconcussion syndrome
Posttraumatic headaches
Sleep disturbances
Chronic traumatic encephalopathy (CTE)
(1) Classified based on nature of injury and site of injury
(a) Linear fractures (75%)
(b) Less risk for underlying damage
(c) May be comminuted or stellate
(d) Depressed
(e) Significant force required
(f) Underlying damage likely
Cranial Trauma
(a) Open
(b) High likelihood of infection
(c) The skull is difficult to break, but is thin in several areas
1) Temporal region
2) Nasal sinuses
(d) Force must be large, meaning either:
1) Large impact or
2) Small area
(e) Scalp will bleed profusely, must clean well
(f) Presence of soft tissue swelling, hematoma, palpable fracture, crepitus
(g) Signs of basilar skull fracture
1) Battle sign
2) “Raccoon” eyes
3) Hemotympanum
4) CSF rhinorrhea/otorrhea
5) Cranial nerve deficits
Clinical features of skull fracture
1) Orogastric tube may be a more appropriate
(b) Watch for signs of swelling
(d) Oxygen, C-spine precautions and MEDEVAC ASAP (ultimately needs Head CT and Neurosurgeon)
(e) Serial neurological exams
(f) Cushing’s Triad (reflex): Bradycardia + Hypertension + Respiratory irregularity
(g) If signs show rapid increase in ICP or herniation:
1) Secure & maintain an open airway
2) Elevate head of bed (25-30 deg): “Reverse Trendelenburg”
3) Ventilate to maintain oxygenation & avoid hypercarbia (increased CO2 in blood).
(h) IV fluids – Resuscitate with normal saline or lactated ringers, DO NOT USE solutions containing glucose or hypotonic solutions
Acute Management of skull fracture
Osmotic therapy – reduce brain volume by drawing free water out of the tissue and into circulation where it is excreted by the kidneys
1) Mannitol: 1g/kg IV as 15-20% solution, may repeat 0.25-0.5g/kg as needed,
generally every 6-8 hours.
(b) Consider hyperventilation as last resort (induces vasoconstriction by lowering CO2)
(c) Continually reassess the patient’s condition and MEDEVAC ASAP.
(d) Seizures can occur with any injury:
1) Diazepam (Valium) 10 mg IV q10min (max dose 30mg)
Management of ICP
Intracranial hemorrhage (ICH) between dura mater and skull
Epidural hematoma
Intracranial hemorrhage (ICH) between dura mater and arachnoid mater
Subdural hematoma
Intracranial hemorrhage between arachnoid mater and pia meter
High association with aneurysms or AV malformations
Subarachnoid hematoma
Bleeding in the cerebral space the brain itself
Intracerebral bleed
(a) 1-4% of head trauma cases
(b) Uncommon, but serious complication
(c) Highest among adolescents
(d) Rare in patients >50 years
(e) Usually caused by traffic accidents, falls, and assaults
(f) 75-95% have associated skull fracture
epidural space
Intracranial hemorrhage (ICH):
Epidermal Hemorrhage- Epidemiology
(a) 85% of the time, skull fracture leads to arterial injury
(b) Middle meningeal artery commonly affected
(c) Normally the epidural space is a potential space, with the dura tightly attached to
the skull
(d) Under arterial pressure, the dura slowly peels away and a blood pocket forms
Epidural Hemorrhage - Pathophysiology
(a) Classic picture involves:
1) Immediate loss of conciousness after significant head trauma
2) “Lucid interval” with recovery of consciousness
(b) After a period of hours, increasing headache with deteriorating neurologic
function
(c) May also see seizure, coma, anisocoria, respiratory collapse
(d) Evaluation incudes H&P, complete and serial neuro exams, and examination of
eyes for papilledema
Epidural hemorrhage presentation
(a) Oxygenation, prepare/initiate intubation if GCS < 8
(b) Immediate neurosurgical consultation (operation likely required- trephination,
burr hole)
(c) Closely monitor neurologic signs for increased ICP/herniation
Epidural hematoma acute management
(a) Coma
(b) Respiratory depression
(c) Death unless treated by surgical evacuation
Complications of epidural hematoma
Epidural hematoma disposition
MEDEVAC for immediate neurosurgical consultation and Head CT.
(a) More common than epidural, 20% of severe head injuries
(b) Elderly, EtOH abusers, anticoagulated at risk
(c) Underlying brain injury is often severe
(d) May occur without impact
(e) Dismal prognosis - 60% mortality
Subdural Hemorrhage
(a) Acceleration in the lateral direction tears briding veins draining the brain to the dural sinuses
(b) Lower pressure blood, but actual rather than potential space SLOWER BLEED
(c) May tamponade (squeezing) resulting in gradual progression
(d) May be chronic
Subdural hematoma pathophysiology
Acute subdural hematoma presents
1-2 days after onset
Chronic subdural hematoma presents
15 days or more after onset
(a) May or may not have history of head trauma
(b) Acute subdural hematoma presents 1-2 days after onset
1) May have lucid interval after injury
(c) Chronic subdural hematoma presents 15 days or more after onset
(d) Insidious onset of headaches, light headedness, cognitive impairment, apathy, somnolence are typical symptoms
Subdural hematoma clinical manifestations
(a) Same as epidural hematoma
(b) Non-contrast CT can help make differentiation between epidural and subdural hematoma
Subdural hematoma acute management
(a) Usually rupture of blood vessel aneurysm (~80%)
(b) Sometimes trauma or congenital anomaly
(c) Bleeding is high pressure and into subarachnoid space which normally carries CSF
Subarachnoid Hemorrhage (SAH) epidemiology
(a) Bedrest
(b) Analgesia with Tylenol
(c) Avoid drugs that can lead to anticoagulation
(d) MEDEVAC
Subarachnoid Hemorrhage treatment
(a) Hallmark “Thunder clap headache” or “worse headache of my life”
(b) Headache onset is sudden and may have meningeal irritation
1) Blood from cerebral blood vessels irritates the brain and meninges
(c) Prior to onset patient may have been doing activity that increased intrathoracic
pressure
(d) Activities that increase risk of SAH
1) Drug use (cocaine, amphetamines), smoking, hypertension, alcohol use
Subarachnoid Hemorrhage clinical presentation
(a) Very high mortality rate (51%)
(b) Rebleeding (7%) only eliminated by treating underlying cause
(c) Cerebral ischemia (30-40%) either by loss of blood flow or vasospasm
(d) Increase ICP (54%) includes due to increase blood volume and swelling from inflammation
(e) Seizures (7%), Hyponatremia, Cardiac arrhythmias
Complications of Subarachnoid Hemorrhage
