Exam 2: CNS Pt2 Flashcards
What is the general term for bleeding that occurs within the skull?
intracranial hemorrhage
What are the 4 intracranial hemorrages we are covering?
- Primary Brain Parenchymal Hemorrhage
- Subarachnoid Hemorrhage (saccular aneurysm)
- Ruptured AVM
- Lacunar Infarct and Slit Hemorrhage
Causes of intracranial hemorrhage are widely variable. Name some of the possible causes:
- long-term hypertension
- trauma
- vascular malformations
- intracranial tumors
What is a spontaneous (nontraumatic) form of intracranial hemorrhage that is most likely to occur in older adults around age 60 who have a history of long-term hypertension?
Primary Brain Parenchymal Hemorrhage
Are Primary Brain Parenchymal Hemorrhage small or large?
small, and sometimes referred to as “micro bleeds”—> but could develop into massive bleeds
T/F. Primary Brain Parenchymal Hemorrhage features are variable, but smaller hemorrhage, less likely to cause clically sig. features, and larger the hemorrhage, more life-threatening or lethal it may be.
True
What is the MC cause of Primary Brain Parenchymal Hemorrhage?
hypertension
About how many inds. with long-term hypertension die following Primary Brain Parenchymal Hemorrhage?
15%
If someone comes into your office and says “this is the worst headache I’ve ever had”, what are you thinking?
Subarachnoid hemorrhage–> medical emergency!!!
What occurs when bleeding exists w/in the subarachnoid space?
subarachnoid hemorrhage
What are subarachnoid hemorrhages characteristically associated with? But what else could cause them?
ruptured saccular aneurysms
- ruptured intracranial vascular malformations or tissue distortion from benign or malignant intracranial tumor
What represents 90% of all intracranial aneurysms? Where are they most likely to develop?
Saccular aneurysms (AKA berry aneurysms)
–from anterior vessels of Circle of Willis, particularly at branched points
What percentage chance of rupturing each year do:
Saccular aneurysms smaller than 1 cm?
Larger than 1 cm?
smaller–> 1% chance
larger –> 50% chance
Are subarachnoid hemorrhages highly lethal?
yes! about 25-50% of all first-time bleeds results in death
What percentage of people that have one saccular aneurysm, have multiple?
about 30%
What are 6 of the most common risk factors someone may have that may be indicative of a subarachnoid hemorrhage?
- older than age 40
- “thunderclap” HA that peaks in intensity
- onset of HA with exertion
- loss of consciousness
- neck pain/stiffness (nuchal rigidity)
- limited neck flexion
What disease is ass. with intracranial saccular aneurysms on the Circle of Willis?
Polycystic Kidney Disease
What involves the bilateral formation of multiple cysts on the kidneys?
Polycystic Kidney Disease (PCKD or autosomal dominant polycystic kidney disease)
How do the cysts manifest in Polycystic Kidney Disease?
cysts expand as one ages and cause tissue ischemia, atrophy, and kidney failure
How common is Polycystic Kidney Disease? What is responsible for it?
1 in 500-1000 inds
90% have mutated PKD1 gene
other 10% have mutated PKD2 gene
What are common features of Polycystic Kidney Disease?
- flank pain
- a “dragging” or “heavy” sensation in area of kidneys
- HAs
- increased UTIs
When does Polycystic Kidney Disease manifest with clinically sig. features? When does end-stage kidney failure usually occur?
the 30s
the 50s
What other issues is Polycystic Kidney Disease associated with?
- saccular aneurysms on Circle of Willlis
- multiple hepatic cysts
Saccular aneurysms are present in about ___ individuals with Polycystic Kidney Disease
30%
What is a tangled mass of arteries and veins that may develop anywhere w/in brain that involve tortuous vessels that manifest with telangiectasia and frequently contain a fistula?
Ateriovenous malformation (AVM)
What is a fistula?
an abnormal connection b/w large artery and large vein
cause nutrient rich blood to bypass capillary network
What are the most dangerous form of intracranial vascular malformation? What does it increase the risk of?
Ateriovenous malformation (AVM)
increased risk of intracranial hemorrhage
What is telangiectasia?
a cluster of widened vessels; superficial ones are referred to as “spider veins”
At what age and in what sex are Ateriovenous malformation (AVM) most likely to be discovered?
males b/w ages 10-30
What is present in about half of all cases of Ateriovenous malformation (AVM)? What else could AVMs cause?
headaches
Also:
- subarachnoid hemorrhage
- seizures
What percentage of Ateriovenous malformation (AVM) will rupture and cause a subarachnoid hemorrhage?
~4%
What may children develop that are born with large Ateriovenous malformation (AVM)?
high-output heart failure b/c of nutrient rich blood bypassing capillaries via presence of large fistula or mult.
What occurs when diastolic blood pressure is maintained at a level that is above 130 mm Hg?
Hypertensive encephalopathy (AKA acute hypertensive encephalopathy)
What does Hypertensive encephalopathy cause?
disrupts BBB and produces widespread vasogenic edema–> which will increase ICP and glocal cerebral dysfunction
What are some early indications of Hypertensive encephalopathy? If PB is NOT reduced, what can occur?
- HA
- confusion
- vomiting
NOT reduced:
- convulsions
- coma
- death
T/F. Hypertensive encephalopathy is not a medical emergency.
FALSE– it is, and reducing BP is essential for survival
What will individuals who end up dying from Hypertensive encephalopathy manifest with?
- widespread cerebral edema
- cerebral herniations
- cerebral petechiae
- fibroid necrossi in walls of cerebrum
When it comes to CNS trauma, are males or females MC to get it?
males are 2x MC (violence, fights, MVA)
What is a neurodegenerative pathology that develops from repetitive CNS trauma and manifest in a gradual onset?
Chronic Traumatic Encephalopathy (CTE, dementia pugilistica, or being “punch drunk”)
What inds. is Chronic Traumatic Encephalopathy (CTE) MC reported in?
- boxers
- American Football players
- inds with military history and have exposure to blast injuries
What are some symptoms of Chronic Traumatic Encephalopathy (CTE)?
- memory loss
- aggressive changes in behavior/mood
- increased impulsivity
- depression
- apathy
- substance abuse
- motor dysfunction
How do we Dx Chronic Traumatic Encephalopathy (CTE)?
Dx is done post-mortem via detection of tau proteins in the brain (specifically p-tau proteins)
What do we are clinicians need to keep in mind for a CNS trauma?
ABCDs: A- Airway B- Breathing C- Circulation D- disability
What is a Cerebral Contusion?
a contusion (blood vessels rupture and blood accumulates) develops in brain following trauma to brain and involves hemorrhagic CNS injury localized edema at the site
What structure is the most susceptible to injury from Cerebral contusion? How does it manifest? What lobes are MC?
gyri
“wedge-shaped” with widest area near area of impact near skull
frontal lobe and temporal lobe
What is a coup injury vs and contrecoup injury?
coup injury = contusion at side of injury
contrecoup injury = contusion occurs opposite side of brain as the impact
What will occur when the brain suffers a penetrating wound, such as occurs with bullet wound or skull fragment entering the brain?
Cerebral laceration
laceration = wound that develops following tearing of a tissue following a trauma
What will Cerebral lacerations injury? What will they cause?
neurons and glial cells and will cause hemorrhage via vascular disruption
hemorrhage–> could be epidural, subdural, or subarachnoid
What describes widespread injury to the white matter of the deep brain tissues due to severe head trauma involving angular acceleration?
Diffuse axonal injury (DAI)
- widespread axonal injury and edema
T/F. Diffuse axonal injury (DAI) is rarely lethal.
FALSE–it is highly-lethal and involves severe neurological impairment
What is responsible for half of all post-traumatic concussions?
Diffuse axonal injury (DAI)
What is Shaken Baby Syndrome?
result of child abuse involving the forceful shaking of a child
(=non-accidental head injury or abusive head trauma)
What do most cases of Shaken baby syndrome involve? Who else can experience it?
infants = MC
but children up to 5 years could experience it
What are the three criteria for Shaken Baby Syndrome?
- Subdural hematoma
- Widespread cerebral edema
- Bilateral retinal hemorrhage
Victims of Shaken Baby Syndrome may also have what ass.?
up to 95% have skull Fx ass.–> MC in occipital or parietal bones
What percentage of Shaken Baby syndrome cases are lethal? What about the other 75%?
25%
75% survival will involve permanent neurological disability–> blindness, motor impairment (ataxia or cerebral palsy), and reduced cognitive functioning
What is a concussion defined as?
form of brain injury involving temporary neurologic dysfunction following trauma
(mild traumatic brain injury, mTBI)
We don’t know for sure what causes a concussion, but what is there preliminary evidence of? (4)
- reduced metabolic state
- dysregulated neurotransmission
- calcium and potassium ion imbalances
- reduced CSF flow rates
What are common signs and symptoms of concussions?
- HAs
- neck pain
- reduced cognition
- disorientation
- “in a fog”
- loss of consciousness
- nausea/vomiting
- dizziness/ balance problems
- ringing in ears (tinnitus)
- photophobia and phonophobia
- depression
- fatigue
- diplopia
- difficulty sleeping
- nervousness
How do we Dx concussions?
cannot be objectively Dx
- Neurocognitive Testing –> SCATs or computerized ImPACT tests
What is the term used to describe when inds experience persitent features of a concussion after a period of time where it reasonably should have been resolved (wk or months)?
Post-concussive syndrome
How common is Post-concussive syndrome?
about 15% of all cases of concussion
What is Second-impact syndrome?
develops when an ind. experiences a second concussion, BEFORE symptoms of earlier one were resolved
The mechanisms of Second-impact syndrome are not understood, but what is it thought to cause it?
thought that the 2nd concussion causes dysregulation of intracranial arterioles–> thus causing widespread intracranial edema
T/F. Second-impact syndrome is often lethal, but is rare.
True
What does Second-impact syndrome cause? And what can that lead to?
Involves rapid brain swelling, increased ICP, cerebral herniation —> which causes disability, coma, or death
Brain bleeds aren’t always ass. with concussions, but when they are what is indicative of it?
Progressively worsening neurological abnormalities
–medical emergency!!!
What are some examples of Progressively worsening neurological abnormalities?
- repeated vomiting
- worsening HA
- sustained or worsening vision
- dysphagia
- ataxia
How would one rule out a intracranial hemorrhage that could occur with a concussion?
CT scan
What forms of intracranial hemorrhage are more likely to occur following a trauma?
- Epidural hematoma
2. Subdural hematoma
What develops following the traumatic disruption of dural ARTERIES?
Epidural hematoma
What is the MC disrupted artery of an Epidural hematoma?
middle meningeal artery
How do Epidural hematomas manifest? How lethal are they?
due to it being an artery–> accumulate very rapidly
could be lethal within hours (medical emergency!)
T/F. Epidural hematomas are MC than subdural hematomas, and are ass. with a skull fracture.
False– epidural hematomas are LESS common (2%) than subdural hematomes; but YES, epidural hematomas do commonly cause skull fx
What develops following the traumatic disruption of the bridging subdural veins extending from cerebral hemispheres to the dural sinuses?
Subdural hematomas (involves veins)
How do Subdural hematomas manifest? How lethal are they?
slowly manifest (due to veins involved) and may clot and self-resolve w/o Tx
if large enough may be lethal w/in couple
T/F. Since subdural hematomas involve a vein, they are not a medical emergency
False– an immediate neurosurfical referral is necessary
What percentage of severe head injuries are subdural hematomas suspected to develop in?
25%–> therefore MC than epidural hematomas
Are Subdural or Epidural hematomas most likely to affect infants and geriatics?
subdural hematomas are
If an infant develops a subdural hematoma, what is most likely the cause?
What are if a geriatric ind. develops one?
infant–> MC victim of child abuse
Geriatric –> following cerebral atrophy making subdural veins taught and vulnerable to disruption–> and minor fall or trip could cause minor amount of head trauma and cause this
