CVAs and Acquired brain injury Flashcards
CVA S&S:
o SUDDEN numbness or weakness of face, arm, or leg (especially on one side of the body)
o confusion, dizziness
o trouble speaking or understanding speech
o trouble seeing out of one or both eyes
o trouble walking
o loss of balance or coordination
o severe headache with no known cause
CVA Risk factors:
o non-modifiable: age (doubles after 55 yrs), M>F, family history, PREVIOUS STROKE OR TIA
o modifiable: HTN, cardiac disease, DM, hypercholesterolemia, smoking, high BMI, cocaine/meth use, oral contraceptives (?)
Types of CVA
Ischemic (80%)
Hemorrhagic (20%)
What causes an ischemic stroke??
caused by thrombosis, embolism, lacunar infarct
What is the response in the brain following an ischemic stroke
- death of tissue where there is no blood (core death)
- possible preservation of area surrounding core that is supplied by collaterals (ischemic penumbra) * cerebellum and hippocampus neurons ++ sensitive to ischemia
- release of glutamate, Ca2+, edema, O2 free radicals, degeneration occurs
What causes a Hemorrhagic stroke
caused by aneurysm and AV malformation
Where do the majority of hemorrhagic strokes occur?
Cerebral cortex & basal ganglia
Do ischemic or hemorrhagic strokes occur more frequently in young people
hemorrhagic
Ischemic stroke Rx:
- get to hospital right away, if ischemic they can get tissue plasminogen activator (TPA) which will dissolve the clots and restore blood flow (within 3 hours)* NOT APPROPRIATE FOR HEMORRAGIC STROKE!!
- Possible surgery to remove clot
Hemorrhagic stroke Rx
- surgery to stop bleed
* better long term prognosis for recovery of function (than ischemic)
What is the ABCD score used for
for prediction of progression and risk of recurrence
What is the acronym for ABCD
A= age B = blood pressure C = clinical features (hemiplegia, speech problems) D = Duration
4 steps to prevent the recurrence of a stroke
o anticoagulation therapy (aspirin)
o lipid lowering agent
o lifestyle change
o exercise
Is grey or white matter capable of functional reorganization
grey
What is a transient ischemic attack?
How long does it take to resolve?
Likely to reoccur?
transient blockage of circulation, mild S/S
resolves usually w/in 24 hours
huge recurrence (80% within a year)
can results in lasting damage
What is a traumatic brain injury
Change in brain function due to external force
What are some possible co-occurences to a TBI
Decrease or loss of consciousness - impaired cognition - physical function - emotion or behavior (may be temporary or permanent)
What are the two classifications for TBI
a) closed: no skull # or laceration of the brain, meninges not breached, does not require hitting head
b) open: meninges breached, exposed brain or laceration
What are 5 mechanisms for TBI
o coup (primary mechanical injury)
o contracoup (secondary mechanical injury) including: ischemia, edema
o DAI (diffuse axonal injury): sheering/tearing from rotational forces in areas of density change (grey to white matter)
o contusion
o anoxic injury forces
What is the primary injury in a TBI
direct damage from mechanical forces, focal or diffuse
What is the secondary brain injury in a TBI
circulation deficits (blood flow usually 50% less then pre-injury), edema, increased ICP, epilepsy/seizure, glutamate, contusions
What are 4 types of hematomas?
Epidural
Sub-dural
Subarachnoid
Intracranial
Where do epidurals hematomas occur?
90% are associate with what?
Which brain region do they occur in?
Arterial or venous bleed?
- outside the dura, 90% associated with skull fractures
- most often in temporal or temporoparietal region
- arterial bleed
Where do sub-dural hematomas occur?
What type of intervention do they often require?
Arterial or venous bleed>
- blood collects between arachnoid mater and dura
- often requires surgical intervention (burrholes or craniotomy
- venous bleed
Where do subarachnoid hematomas occur?
What is often their outcome?
- bleeding between arachnoid and pia mater of brain
* fatal
What is the most common type of hematoma?
intracranial
Where do intracranial hematomas occur?
under pia mater
What is normal intracranial pressure? What is a dangerous level?
0-20mmHg = normal
> 20mmHg for over 5 minutes
How do you monitor intracranial pressure?
• extraventricular drain (EVD, most common), subarachnoid or subdural bolt, intraparenchymal monitor, epidural sensor
What is an important consideration if using EVD to monitor intracranial pressure
have to close stopcock to avoid backflow of large amounts of fluid back into patient
ALWAYS CHECK PHYSICAIN ORDERS!
What are signs of a basal skull fracture
- signs are blood or CSF out of nose or ears, raccoon eyes, bruising over mastoid (battle sign)
What is a coma?
- altered state of consciousness so that no amount of stimulus or only pain will cause Pt to respond, patient in not aware of self or others, lasts for short length of time and either turns to death or vegetative state
What are the effects of a frontal lobe injury
- poor planning and judgment, disinhibition
- Broca’s aphasia (problem with language production)
- altered manners, moral, and emotions
What are the effects of a parietal lobe injury
- somatosensory function alterations in touch, pressure, temp, and position awareness
- some language comprehension (Wernicke’s)
- motor planning issues (apraxia)
What are the effects of a temporal lobe injury
- Comprehensive and receptive aphasia (Wernicke’s and Broca’s)
- memory impairment
- auditory processing
- integration and regulation of emotion, motivation, and behaviour
What are the effects of an occipital lobe injury
- more damaged in contra-coup injury then coup
- see visual problems and visual field deficits
What are the effects of having respiratory issues
decrease LOC,
compromised respiratory center
increased oral secretions
What is the Rx for respiratory issues related to TBI
manual techniques, suctioning etc. should be used with caution
suction: pre and post O2 should be 100% , only suction for 10 seconds
How do you modify TBI treatment for ICP control
maintain neutral head at all times, keep Rx short and combine Rx with other procedures
Abnormal posture contributes to…
handling and contracture formation
What does decerebrate posturing indicate
brain stem damage (lesions or compression in midbrain) and lesions in cerebellum
What does decerebrate posture look like
extension of UE and LE
What does decorticate posturing indicate
damage to areas including cerebral hemisphere, thalamus, cord, corticospinal tract
What does decorticate posturing look like
arms flexed
Legs extended
How do you prevent contractures post TBI
place muscles in lengthened position, 20 minutes to 12 hours/day, use of resting splints; splinting and casting and passive ROM
How do you manage confusion/agitation post TBI
- keep instructions short and simple, avoid over stimulation, be aware of mental and physical fatigue
- protect joints especially if have flaccidity, transfers take more people, have environment prepared
What is a concussion?
- complex pathological process affecting the brain, induced by traumatic biomechanical forces
- mild form of brain injury (most common TBI)
Concussion S&S
o loss of consciousness may or may not be present
o behavioral change (overly emotional, cannot control them)
o cognitive impairment (problems with thinking and planning ahead)
o sleep disturbance, dizziness, irritability, memory and visual changes
Baseline cognitive Ax for concussion
SCAT 5
What is second impact syndrome
o rare/fatal uncontrolled swelling of brain
o minor 2nd blow before initial symptoms are resolved
What is post-concussion syndrome?
What does it increase your risk of?
o persistent symptoms
o 3+ concussions = 5X greater risk Alzheimer’s, 3x memory deficits
Grades of concussion
- grade 1: does not lose consciousness, dazed
- grade 2: no LOC, period of confusion, does NOT recall event
- grade 3: loss of consciousness for short time, NO memory of event, requires eval asap, classic concussion
5 Outcome measures for TBI
- Glasgow coma scale
- Rancho levels of cognition
- Length of LOC
- Length of post traumatic amnesia
- Review of diagnostics imaging
Glasgow coma scale scoring + when is it use
3 categories: eye opening, verbal response, motor response,
total score out of 15
done usually in acute injury
Rancho levels of cognition good predictor of what?
High score good or bad
- good predictor of functional outcomes after injury (1-10 scale)
- want a higher score
When do most changes on diagnostic imaging occur
in first 6 months
What is the time limit for functional improvement follwoing a TBI
unlimited!
Why are outcome measures not totally predictive of function
preinjury health, social support, age, nature of injury (location and extent), patient motivation ALL PLAY FACTOR
