B7.055 Prework: Traumatic Brain Injury Flashcards by Lauren Sinik

types of TBI

penetrating: gunshots and severe blunt trauma, severe damage and a high incidence of infection
nonpenetrating: blunt trauma

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primary injury

at the time of trauma

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secondary injury

complications subsequent to trauma (why patients get worse)

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types of primary brain injury

concussion
CNS axonal injury
cranial nerve injury
contusion
laceration

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causes of concussion

freely moving head struck
OR
rapid acceleration of head without impact

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damage done in concussion

partly tethered brain rotates
rotational motion > shearing stresses
worst in high brainstem
shear may also affect gray white junction
torque to RAS causes loss of consciousness

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severity of shearing lesions

torque causes transient stretching without transection with rapid recovery of consciousness (concussion)
torque tears axons with slow recovery and permanent disability (diffuse axonal injury)
torque lacerates upper brainstem with no recovery

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concussion definition

reversible traumatic paralysis of nervous function
defined by:
-LOC
-amnesia
OR
-other brain dysfunction (headache)
effects immediate
can have long term sequelae

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clinical manifestations of concussion

unconsciousness
loss of body tone (fall)
transient arrest of resp
bradycardia and hypotension
sometimes convulsions
anterograde amnesia

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post concussion syndrome

recovery from concussion may be followed by recurrent headache, impaired ability to concentrate, and other minor neurologic symptoms
symptoms are usually transient but in some cases may persist for months or years

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diffuse axonal injury

predominant abnormalities in severe head injury
occur in:
-midbrain/ diencephalon
-corona radiata
-gray white junction

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cranial nerve injury in head trauma

often associated with basilar skull fractures
any nerve can be affected
CN I, VII, and VIII most susceptible

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olfactory nerve injury

anterior skull

common without a fracture

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CN 7 injury

transverse petrous

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CN 8 injury

petrous pyramid

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CN 12 injury

hypoglossal canal

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CN 4 injury

most common extraocular muscle nerve damaged

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cerebral contusion

more severe trauma
loss of consciousness longer than with concussion
may lead to death or severe residual neurologic deficit

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findings associated with cerebral contusion

edema
hemorrhage
necrosis
subarachnoid bleeding

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mechanism of contusion

blunt trauma to specific portions of the brain

underlying brain tissue crushed

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coup-contrecoup

coup injury- under the site of impact with an object contrecoup injury- on the side opposite the area that was hit

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what portions of the brain are selectively vulnerable to contusions

areas near rough, bony prominences
-anterior temporal
-subfrontal
-corpus callosum
falx

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cognitive symptoms of contusion

apathy and short term memory deficits

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laceration

grossly visible tear in brain
blunt or penetrating trauma
brainstem avulsion

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types of secondary injuries

``` edema bleeding herniation CSF derangements seizures infection ```

mechanism of edema

vasogenic and cytotoxic cytotoxic cascade increases during the first 24-72 hrs may be massive and lead to herniation

types of brain bleeds

epidural subdural intracerebral subarachnoid

cause of acute epidural hemorrhage

tear in meningeal artery, vein, or dural sinus

symptoms and signs of epidural hemorrhage

headache, confusion, somnolence, seizures, and focal deficits can lead to coma, resp depression, and death unless evacuated

location of epidural hematoma

lateral cerebral convexities

presentation of epidural hematoma

classically lucid interval then coma

age at risk of epidural hematoma

children | young adults

radiologic features of epidural hematoma

acute bulging epidural clot bounded by cranial sutures lenticular in shape

treatment of epidural hematoma

urgent evacuation

cause of acute subdural hemorrhage

tearing of bridging pial veins and arteries

location of acute subdural hemorrhage

lateral cerebral convexities

evolution of acute subdural hemorrhage

many hours

symptoms of acute subdural hematoma

similar to epidural | interval before onset of symptoms is longer

age at risk of acute subdural hematoma

all

radiologic findings of acute subdural hematoma

acute blood rimming broad region of cerebral convexity

treatment of acute subdural hematoma

urgent evacuation if large enough to cause symptoms

cause of chronic subdural hematoma

trauma | can expand over time as large proteins in blood break down into smaller ones, increase osmolality and draw more fluid

risk factors for chronic subdural

coagulopathy | severe brain atrophy

evolution of chronic subdural

days to weeks

signs and symptoms of chronic subdural

headache, progressive alteration in mental status +/- focal neuro signs

age at risk of chronic subdural

elderly

radiologic findings of chronic subdural

hyper- or isodense | unilateral or bilateral

treatment of chronic subdural

evacuation in some circumstances

etiology of intracerebral hemorrhage

develops immediately after injury often evolves from contusion clinically resembles hypertensive hemorrhage

cause of intracerebral hemorrhage

shearing of parenchymal vessels

risk factors for intracerebral hemorrhage

coagulopathy | amyloid vasculopathy

location of intracerebral hemorrhage

inferior frontal and temporal lobes

evolution of intracerebral hemorrhage

expand over 12-48 hours

age at risk of intracerebral hemorrhage

any

radiologic findings in intracerebral hemorrhage

multiple, confluent regions of edema intermixed with focal, acute blood

treatment of intracerebral hemorrhage

evacuate if large

cause of traumatic subarachnoid hemorrhage

bleeding of pial vessels

location of subarachnoid hemorrhage

typical basilar cisterns

evolution of subarachnoid hemorrhage

minutes to hours

symptoms and signs of subarachnoid hemorrhage

headache, meningismus, delayed manifestations, vasospasm

age at risk of subarachnoid hemorrhage

any

radiologic findings in subarachnoid hemorrhage

acute blood lining cortex in subarachnoid space

treatment for subarachnoid hemorrhage

generally supportive

what is herniation

mass effect of edematous brain or hematoma compression of diencephalon, midbrain, pons, medulla rostral caudal deterioration of function

syndrome of central herniation

bilateral midsize, nonreactive pupils diffuse edema or midline lesion para and sym affected

syndrome of lateral herniation

unilateral dilated, nonreactive pupil | CN III affected (para)

traumatic hydrocephalus

flow of CSF disrupted by subarachnoid and intraventricular blood

communicating hydrocephalus

obstruction outside of brain

non-communicating hydrocephalus

obstruction within brain

CSF leak

tear of dura and arachnoid leads to extracranial CSF leakage and CSF hypotension (headache)

results of CSF leak

increased risk of infection | tension pneumocephalus

post traumatic seizures

common do not increase risk of subsequent seizures may increase ICP prevent with acute prophylactic anti-seizure meds

post traumatic infection

penetrating injuries and CSF leak increase risk of post traumatic infection meningitis abscess empyema

glascow coma scale

``` 3= worst 15= best ```

treatment of TBI

ICU care prevent infection treat seizures control ICP

what is ICP

``` intracranial pressure proportional to volume of: -blood -CSF -brain ```

how to decrease ICP

decrease - blood - CSF - brain

CPP

cerebral perfusion pressure must be maintained CPP = MAP - ICP

ways to decrease blood volume

``` evacuate hematoma hyperventilation -decreased CO2 -vasoconstriction -decreased cerebral perfusion ```

ways to decrease CSF volume

external ventricular drainage

ways to decrease brain volume

decreased fluid hyperosmolar therapy (mannitol, hypertonic saline) steroids

give swollen brain more room?

craniectomy

chronic sequelae of TBI

``` post concussion syndrome post traumatic encephalopathy post traumatic epilepsy permanent vegetative state dementia pugilistica ```