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Management of neuropsychiatric disorders > Brain injury management > Flashcards

Brain injury management Flashcards

1
Q

What are the risk factors for TBI?

A

Male (1.5-2.5x)
Age 15-24 or 75+
Alcohol
Risk taking behaviour
Lower socioeconomic status
Psychiatric history

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2
Q

What are the types of TBI?

A

Direct impact - damage to tissue underlying the impact area

Coup-contre coup - usually after hitting stationary object (generally contre coup is worse)

Acceleration-deceleration - shearing forces cause diffuse axonal injury (road accidents)

Blast injury - damage from shockwave

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3
Q

What are the two types of cerebral hypoxia?

A

Hypoxic brain injury - due to loss of oxygen supply

Hypoxic-ischaemic injury - due to compromise of blood supply (cardiac arrest/respiratory depression)

Brain scans may look normal in the first few days, over time damage will arise

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4
Q

What areas of the brain are affected most by hypoxia?

A

Basal ganglia
Thalami
Highly metabolic areas

Worsened by antipsychotics or alcohol withdrawal

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5
Q

What factors affect the recovery in hypoxia?

A

Duration of hypoxia
Speed of emergency care delivery
Pre existing health status

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6
Q

What is a contusion?

A

Mix of cortical necrosis and haemorrhage

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7
Q

Where are contusions most common?

A

Orbital PFC
Medial PFC
temporal pole
Occipital contre coup

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8
Q

What are the pathological outcomes of DAI?

A

Axonal tear
Myelin resorption
Retraction ball formation

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9
Q

What GCS score indicates severe TBI?

A

8 or less (comatose)

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10
Q

What is the application of GCS?

A

Useful in acute scenario
Not a reliable indicator of prognosis

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11
Q

What are symptoms of mild TBI?

A

Confusion, disorientation
Altered mental state
Headache
Transient loss of function

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12
Q

What is the definition of mild TBI/concussion?

A

Immediate transient alteration or loss of consciousness after force to the head

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13
Q

How might mild TBI be treated acutely?

A

Anxiolytics or analgesics
May not need hospital admission

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14
Q

How might severe TBI be treated acutely?

A

Ventilation and life support
Neurosurgical intervention (eg evacuation of haematoma)

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15
Q

What are the psychiatric consequences of moderate to severe TBI?

A

25-50% of survivors

Confusion and disorientation
Memory impairment
Dysexecutive syndrome
Affective outbursts: emotional lability
Chronic irritability
Epileptic episodes
Hallucinatory episodes
Paranoia
Intellectual impairment

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16
Q

How long might post traumatic amnesia last?

A

Minutes to weeks
(Onset might be delayed, such as in extradural haemorrhage)

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17
Q

What is the watershed for PTA and memory improvement?

A

6 weeks

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18
Q

How does PTA link to long term outcome?

A

1hr - return to work within a month
More than 2 weeks - residual cognitive impairments
PTA explains 25-50% of outcome

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19
Q

What is the last function to return usually in patients that fully recover?

A

Anterograde amnesia

20
Q

What are indicators of severity of head injury?

A

GVS
Duration of loss of consciousness
Duration of PTA
Delirium
Neurological signs and symptoms
Skull fracture or imaging abnormalities
Blood in CSF

21
Q

What percentage of people suffer mood and anxiety disorders after brain injury?

A

20-30% in the first year (particularly in left frontal lobe damage)

Anxiety - 10-15%

PTSD - 10-30% (less common if PTA was 1hr+)

22
Q

How does psychosis typically present post-TBI?

A

Much less common
Occurs in predisposed individuals
May interact with cognitive deficits (losing things may fuel persecutory delusions)

Confusional states and confabulation are not strictly psychosis

23
Q

What are the risk factors for suicide?

A

3-4x more common than general population

Risk factors for TBI
Alcohol
Substance use
Male
Risk taking behaviour
Lower socioeconomic status

24
Q

What is the prognosis for postconcussional syndrome?

A

50% better at 2 months
90% better at 12 months

25
Q

What is the possible aetiology for postconcussional syndrome?

A

Pre morbid personality
Emotional factors
Possible damage to white matter tracts (diffusion tensor imaging)
Compensation/litigation?

26
Q

How common is personality change/behavioural disturbance post brain injury?

A

~50% (10-70%)
Associated with long term changes, particularly with frontal lobe damage

27
Q

What factors affect personality change?

A

Pre morbid
Cognitive status
Psychiatric illness
Personality disorder
Substance use

Post injury
Care/support
Neuro rehabilitation
Complicating effects of legal proceedings

28
Q

How does personality change progress?

A

Seen in 30-60% of moderate- severe brain injury survivors

Fluctuates but persists over time

May need to be moved to specialist care

29
Q

What are the pharmacological considerations in brain injury?

A

Start low go slow

Titrate cautiously and monitor for adverse effects

Sedating drugs may compromise cognitive/physical gains over time

Wean down meds over time and liaise with other services

30
Q

What are early pharmacological interventions?

A

Reduction of agitation
Propranolol, amantadine, valproate, carbamazepine, antipsychotics

Don’t use: benzodiazepines, opiates, phenytoin, psychostimulants

31
Q

What are longer term pharmacological interventions for brain injury?

A

Valproate and carbamazepine
Propranolol
Antidepressants may have use even outside of mood disorder
(Antipsychotics only for those with psychosis)

32
Q

What non-pharmacological treatment is used post BI?

A

Physiotherapy
Psychology
Occupational therapy
Speech and language therapy
Social care and placement

33
Q

What would be the work of a psychologist post brain injury?

A

Neuropsychological assessment
CBT
Cognitive training
Relaxation
Mindfulness
Anger management
Social skills training

34
Q

What would be the work of OT post brain injury?

A

Real world skills
Task oriented
Shopping, cooking, household
Managing demands of life

35
Q

What would be the work of a SaLT post brain injury?

A

Dysphasia
Dysphagia
Dysarthria
Communication problems, including style

36
Q

What is the most extreme form of apathy?

A

Rare
Akinetic mutism
Associated with damage to ACC

37
Q

How common is apathy in BI survivors?

A

10%

38
Q

What treatments are used for apathy post BI?

A

Dopamine agonists (amantadine)
Psychostimulants (methylphenidate)
Some use of antidepressants but for depressed patients

39
Q

What is cognition?

A

Mental process of knowing, including perception awareness reasoning and judgement

40
Q

How do frontal lobe syndromes present?

A

Personality change
Orbitofrontal:
Disinhibition
Euphoria
Emotional lability
Poor judgement

Dorsolateral:
Loss of initiative, apathy
Slowing of thought and action
Inattention
Distractibility
Poor planning and judgement
Reduced verbal fluency
Brocas

41
Q

How might parietal lobe syndromes present?

A

Cortical sensory loss
Astereognosis (recognition by touch)
Disorders of body schema
Anosognosia
Gerstmann syndrome

42
Q

What are the features of Gerstmann syndrome?

A

Dyscalculia
Dysgraphia
Finger agnosia
R-L disorientation

43
Q

How might temporal lobe syndromes present?

A

Auditory deficits
Sensory dysphasia (Wernicke’s)
Visual impairments (prosopagnosia)
Memory impairments
Personality change/psychosis (superstition/schizotypal)

44
Q

How might occipital lobe syndromes present?

A

Cortical blindness
Homonymous hemianopia
Scotomata
Visual agnosia
Alexia without agraphia

45
Q

What is the underlying mechanism of cerebellar cognitive affective syndrome?

A

Reciprocal connections between the cerebellum and cortical regions are disturbed by cerebellar damage

Management of neuropsychiatric disorders (22 decks)

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