aneurysm.

Question 1

(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)

Answer 1

Concussion

Question 2

(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

Answer 2

Aneurysm:
Pathophysiology

Question 3

(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

Answer 3

Aneurysm:
Clinical Features

Question 4

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)

Answer 4

Aneurysm:
Clinical Features- Common Signs

Question 5

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

Answer 5

Aneurysm:
Clinical Features- Less Common Signs

Question 6

(a) Any concussion with concomitant hemorrhage
(b) May present as acute, subacute or chronic
(c) Usually arterial in origin
(d) Treat based on complication

Answer 6

Aneurysm:
Complicated concussion

Question 7

(a) Complete history and physical (MACE within

Answer 7

Aneurysm:
Acute Evaluation: 48hrs

Question 8

(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

Answer 8

Aneurysm:
Management of concussion

Question 9

(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

Answer 9

Aneurysm:
Immediate Referral/MEDEVAC for concussion:

Question 10

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

Answer 10

Aneurysm:
Second Impact syndrome

Question 11

Headache, dizziness, cognitive impairment, psych symptoms that develop in the first few days after mild TBI and resolve in weeks to months

Answer 11

Aneurysm:
Postconcussion syndrome

Question 12

25-78% of patients experience headaches within 7 days of the event

Answer 12

Aneurysm:
Posttraumatic headaches

Question 13

Excessive daytime somnolence, increased sleep need, insomnia, sleep fragmentation

Answer 13

Aneurysm:
Sleep disturbances

Question 14

1) Repeated concussions can lead to cumulative neuropsychologic deficits
a) Behavior changes, personality changes, depression, increased suicidality
b) Parkinsonism
c) Speech and gait abnormalities

Answer 14

Chronic traumatic encephalopathy (CTE)

Question 15

Complications of concussion

Answer 15

Second Impact syndrome
Postconcussion syndrome
Posttraumatic headaches
Sleep disturbances
Chronic traumatic encephalopathy (CTE)

Question 16

(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

Answer 16

Cranial Trauma

Question 17

(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

Answer 17

Clinical features of skull fracture

Question 18

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

Answer 18

Acute Management of skull fracture

Question 19

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)

Answer 19

Management of ICP

Question 20

Intracranial hemorrhage (ICH) between dura mater and skull

Answer 20

Epidural hematoma

Question 21

Intracranial hemorrhage (ICH) between dura mater and arachnoid mater

Answer 21

Subdural hematoma

Question 22

Intracranial hemorrhage between arachnoid mater and pia meter

High association with aneurysms or AV malformations

Answer 22

Subarachnoid hematoma

Question 23

Bleeding in the cerebral space the brain itself

Answer 23

Intracerebral bleed

Question 24

(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

Answer 24

Intracranial hemorrhage (ICH):
Epidermal Hemorrhage- Epidemiology

Question 25

(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

Answer 25

Epidural Hemorrhage - Pathophysiology

Question 26

(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

Answer 26

Epidural hemorrhage presentation

Question 27

(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

Answer 27

Epidural hematoma acute management

Question 28

(a) Coma
(b) Respiratory depression
(c) Death unless treated by surgical evacuation

Answer 28

Complications of epidural hematoma

Question 29

Epidural hematoma disposition

Answer 29

MEDEVAC for immediate neurosurgical consultation and Head CT.

Question 30

(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

Answer 30

Subdural Hemorrhage

Question 31

(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

Answer 31

Subdural hematoma pathophysiology

Question 32

Acute subdural hematoma presents

Answer 32

1-2 days after onset

Question 33

Chronic subdural hematoma presents

Answer 33

15 days or more after onset

Question 34

(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

Answer 34

Subdural hematoma clinical manifestations

Question 35

(a) Same as epidural hematoma
(b) Non-contrast CT can help make differentiation between epidural and subdural hematoma

Answer 35

Subdural hematoma acute management

Question 36

(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

Answer 36

Subarachnoid Hemorrhage (SAH) epidemiology

Question 37

(a) Bedrest
(b) Analgesia with Tylenol
(c) Avoid drugs that can lead to anticoagulation
(d) MEDEVAC

Answer 37

Subarachnoid Hemorrhage treatment

Question 38

(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

Answer 38

Subarachnoid Hemorrhage clinical presentation

Question 39

(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

Answer 39

Complications of Subarachnoid Hemorrhage