CT scans (head)

Question 1

17y, struck by a cricket ball at the side of his head, lucid interval, CT head scan shows skull fracture + convex lens shaped mass that does not crosses the suture lines

Answer 1

Epidural/Extradural Haematoma -> bleed from the middle meningeal artery

Question 2

70y, fell from stairs, CT head scan shows a crescent-shaped (half-moon) white mass that follow the shape of the brain and crosses suture lines

Answer 2

Subdural Haematoma -> bleed from bridging veins being lacerated (venous blood) -> white mass indicates it it an acute bleed

Question 3

Indications of URGENT CT scan head (MUST be looked at + interpreted WITHIN 1hour)

Answer 3

GCS < 13 on initial assessment; GCS <15 at 2h assessment; suspected open/depressed skull fracture; any sign of skull fracture; post-traumatic seizure; focal neurological deficit; >1 episode of vomiting

Question 4

GCS score

Answer 4

Best eye response (4: spontaneous, verbal opening, pain opening, no opening), Best verbal response (5: oriented, confused, inappropriate words, incomprehensible, non verbal), Best motor response (6: obeys commands, localises pain, withdrawn from pain, flexion to pain, extension to pain, do not move) – 13-15: Mild traumatic brain injury (mTBI). Also known as a concussion / 9-12: Moderate TBI / 3-8: Severe TBI.

Question 5

Ischaemia, air, fat, tumour

Answer 5

dark

Question 6

Blood, calcification, IV contrast

Answer 6

white

Question 7

Epidural/Extradural Haematoma: Management

Answer 7

True neurological emergency = Get the neurosurgical team involved IMMEDIATELY (burr hole followed by craniotomy and evacuation of haematoma) while maintain the patient stable

Question 8

“Lemon/Lentiform sign”

Answer 8

Epidural/Extradural Haematoma

Question 9

50y, alcoholic, on warfarin, no history of head injury, CT head scan shows a crescent-shaped (half-moon) grey mass that follow the shape of the brain and crosses suture lines

Answer 9

Subdural Haematoma -> grey mass indicates it it a chronic bleed

Question 10

“Banana sign”

Answer 10

Subdural Haematoma

Question 11

Management of serious head injury

Answer 11

ABCD: Airway (chin lift/jaw thrust to open airways, provide oxygen, protect cervical spine), Breathing (hyperventilate to keep PCO2 around 4.5kPa), Circulation (correct hypovolaemia), Disability (if <8 GCS: urgent airway protection) + Urgent CT scan head + Neurological referral (if appropriate)

Question 12

Indications for Neurological referral

Answer 12

Depressed skull fracture/suspected penetrating injury/CSF leak, CT shows intracranial lesion, persistent coma, deterioration of CGS after admission, progressive focal neurological signs, seizure without recovery, confusion for >4h

Question 13

Severe headache (“the worst headache of my life”), photophobia, vomiting, nuchal rigidity/neck stiffness, CT scan head shows a “star sign”, white lesion with a spider shape

Answer 13

SAH (Subarachnoid Haemorrhage) -> bleed into the basal cisterns, between brain sutures (mostly from rupture of Berry aneurisms in the Circle of Willis, but can also be due to trauma/tumour)

Question 14

Bleed within ventricles on CT scan head

Answer 14

Intraventricular haemorrhage

Question 15

Intraventricular haemorrhage: main causes

Answer 15

Secondary to SAH or intraparenchimal haemorrhage (primary are rare: vascular malformation, aneurysms, intraventricular tumour)

Question 16

Bleed within brain parenchyma

Answer 16

Intraparenchimal haemorrhage/Haemorrhagic stroke (10% of all strokes)

Question 17

intraparenchimal haemorrhage: main cause

Answer 17

Hypertension

Question 18

Intraparenchimal haemorrhage: management

Answer 18

IMMEDIATE referral to neurosurgical team for surgical coiling + IV hypertonic saline if raised ICP (headache, papilloedema, nausea/vomiting) + admit to ICU for intubation and ventilation + consider carotid endarectomy if stenosis >50%

Question 19

If suspicion of SAH and no lesion on CT scan head: management

Answer 19

Perform lumbar puncture after 12h (look for xanthochromia)

Question 20

SAH (Subarachnoid Haemorrhage): management

Answer 20

Referral to neurosurgical team + nimodipine (prevent and treat ischaemic neurological deficits secondary to vasospasm) + mannitol (if raised ICP)

Question 21

Cisterns: “clown”

Answer 21

Eyes: Sylvian, Nose: Suprasellar, Moustache: Ambient (circumcephalic), Mouth: Quadrigeminal

Question 22

Ring enhancing lesion with mass effect on CT scan head (black circle)

Answer 22

Cerebral abscess

Question 23

Cerebral abscess: 1st line imaging

Answer 23

CT scan head

Question 24

Cerebral abscess: definitive diagnosis

Answer 24

Needle aspiration

Question 25

Cerebral abscess: management

Answer 25

IV Ceftriaxone for 4-8wks, followed by craniotomy and debridement

Question 26

Most common type of malignant primary brain tumour in adults

Answer 26

Glioblastoma Multiforme

Question 27

Most common type of malignant primary brain tumour in children

Answer 27

Medulloblastoma

Question 28

Most common type of primary brain tumour

Answer 28

Meningioma (typically slow growing)

Question 29

“Butterfly appearance” tumour on CT scan head

Answer 29

Glioblastoma Multiforme (very aggressive)

Question 30

Meningioma is associated with:

Answer 30

Neurofibromatosis / Multiple Endocrine Neoplasia

Question 31

Most common type of brain cyst

Answer 31

Arachnoid cyst (non-cancerous fluid-filled sac, often asymptomatic)

Question 32

Medulloblastoma starts in the…

Answer 32

cerebellum

Question 33

Medulloblastoma: S/S (mnemonic)

Answer 33

DANISH: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia/Heel-shin test

Question 34

Ischaemic stroke: management

Answer 34

1st line: non-contrast CT head to exclude haemorrhage stroke (black); thrombolysis within 4.5h of symptom onset; aspirin (after rule out haemorrhage); thrombectomy; consider long-term management with multi-disciplinary team

Question 35

Sudden numbness or weakness in the face, arm, or leg, on one side of the body + Sudden confusion, trouble speaking, or difficulty understanding speech + Sudden trouble seeing in one or both eyes + Sudden trouble walking, dizziness, loss of balance, or lack of coordination + CT scan head shows Hypodensity (cytotoxic edema), loss of gray-white differentiation, cortical swelling, and loss of sulcation (effacement of brain sulcus from tissue swelling)

Answer 35

Ischaemic stroke

Question 36

60y, memory problems, unsteady, staggered walking, loss of bladder control, CT scan head shows dilated lateral ventricles, no signs of raised ICP

Answer 36

Normal-pressure Hydrocephalus “wacky, wet, wobbly” (reversible dementia, gait ataxia, urinary incontinence) -> DD: Alzheimer’s and Parkinson´s diseases

Question 37

Normal-pressure Hydrocephalus: management

Answer 37

1st line: CT scan head; Lumbar puncture (contraindicated in obstructed hydrocephalus due to blockage); surgical insertion of ventriculoperitoneal shunt (DEFINITIVE treatment)

Question 38

Normal-pressure Hydrocephalus: risk factors

Answer 38

idiopathic, elderly, SAH, trauma, meningitis

Question 39

Headache (worst in the morning), papilloedema, nausea/vomiting, coma + CT scan head shows dilated lateral ventricles

Answer 39

Hydrocephalus

Question 40

Hydrocephalus: management

Answer 40

External ventricular drain, ventriculoperitoneal shunt, surgery (if obstructive cause)

Question 41

Hydrocephalus: risk factors

Answer 41

Obstructive (tumour/SAH/IVH), Non-obstructive (meningitis, Arnold-Chiari malformation), Congenital (pre-eclampsia/alcohol abuse in pregnancy)