Exam I Flashcards
coronal suture joins
frontal and parietal
sagittal suture joins
two parietal bones
lambdoid suture joins
occipital and parietal
squamous suture joins
parietal and temporal
CN II examination
- pupillary reflex
- VF
- VA
CN V examination
- cotton wisp
- corneal reflex
- mastication
CN VII examination
- facial expression
- taste ant 2/3 of tongue
CN IX (glossopharyngeal) exam
- gag reflex
- swallow
- posterior 1/3 taste
major switchboard for brain
thalamus
controls motor function/initiation of actions
basal ganglia
essential for memory and learning facts
hippocampus
maintains homeostasis, circadian rhythm, autonomic control
hypothalamus
main brain artery that comes off of vertebral arteries
basilar
things to consider for a physical exam on a neurp pt?
- GCS is comatose
- perform a full system PE on ICU pts
eyes opening response
4-opens sponataneously
3-to speech
2-to pain
1-none
verbal response
5-oriented to time, place, person 4-confused, disoriented 3-inappropriate words 2-incomprehensible sounds 1-none
motor response
6-obeys command 5-moves toward pain 4-moves away from pain 3-abnormal flexion 2-abnormal extension 1-none
pt presents with rhino/otorhhea after trauama, think
CSF leak
when should you perform imaging on a neuro emergency pt?
ALWAYS, regardless of injury severity
best initial imaging modality in acute setting
CT
most sensitive test
MRI, technically the best but takes too long
-use this for cauda equina first line though
Monroe-Kelly doctrine
3 things in brain that can elevate intracranial pressure
- blood
- brain
- CSF
HA and vomiting favors which type of stroke?
- SAH
- ICH
Arterial bleed between skull & dura
epidural hemorrhage, MCC skull fx impacting the middle meningeal artery
clinical course of epidural hemorrhage
injury—-brief LOC—-lucid state—coma
what will an epidural hemorrhage show on CT?
- lens/convex shape, does not cross suture line
- temporal bone fx
- midline shift
how to manage epidural hemorrhage
- craniotomy w/evacuation of hemorrhage If clot thickness is greater than 10mm or if midline shift is greater than 5mm
- change in pupil size
- GCS <9
- observation if small (Q1 neuro checks for 24-72 hrs)
Venous bleed MC* between dura & arachnoid (tearing of bridging veins. MC seen in elderly
subdural hematoma, MC blunt trauma often causes bleeding on other side of injury “contre-coup”.
what will a subdural hemorrhage show on CT?
- CONCAVE (Crescent-shaped) MAY cross suture line
- midline shift
Arterial bleed between arachnoid & pia mater
subarachnoid hemorrhage, MC from berry aneurysm or AVM
clinical signs of SAH?
- thunderclap HA, worst of life
- meningeal signs (photophobia, neck pain, NV)
how to dx SAH?
- CT first
- if negative, do a LP (xanthochromia (RBC’s), ↑CSF pressure & no focal neuro sx)
how to manage SAH?
- bed rest
- stool softener
- phenytoin seizure prophylaxis
- anti anxiety
- possible lower BP
how do people get intraparenchymal hemorrhages
- HTN
- AVM
when should you not perform a LP?
intracerebral hemorrhage, may cause herniation
how to manage intracerebral hemmorhage
supportive
- anticonvulsants
- steroids for edema
clinical manifestation of basilar fx
Battle sign
Racoon Eyes
Hemotympanum
Rhinorrhea/
Otorrhea (CSF)
normal ICP?
15mmHg
>20 needs tx
idiopathic intracranial HTN
aka pseudotumor cerebri
- increased ICP with no other cause of increased ICP found on CT/MRI
- MC in obese women
clinical signs of pseudotumor cerebri
- HA worse with straining
- N/V, tinnitus, photophobia
- can lead to blindness (increased cup:disk)
how to dx pseudotumor cerebri
- papilledema on slit lamp
- CT to r/o mass then do a LP
- LP would show increased opening pressure
how to manage pseudotumor cerebri
-acetazolamide
MOA: carbonic anhydrase inhibitor
dead cells lyse and release intracellular contents resulting in edema. BBB remains intact
Seen in strokes
cytotoxic cerebral edema
BBB compromised due to release of VEGF from neoplastic cells allowing new vessels to grow
Seen in brain tumors
vasogenic cerebral edema
Decadron is effective treatment to stop secretion of VEGF
this type of cerebral edema is from HTN, capillary leakage
hydrostatic
this type of cerebral edema results from serum hyponatremia resulting in pulling of sodium from brain and resultant edema
osmotic
this type of cerebral edema is seen in hydrocephalus
interstitial,brain saturated with CSF
clinical signs of elevated ICP
- HA, NV
- cushing’s triad:bradycardiam, dyspnea, HTN
- herniation
- blown pupil on ipsilateral side of herniation
- decerebrate posture
medulla herniation will result in
- irregular or no breathing
- midposition, fixed pupils
- absent vestibulocular reflex
- absent motor reponse
midbrain/ upper pons herniation will result in
- hyperventilatin of Cheyne-stokes
- midposition, fixed pupils
- absent or abduction of vestibuloocular reflex
- decerebrate or no movement
most sensitive way to assess ICP
invasive ICP monitor, ventricle
can treat as well
20% risk of infection
when are invasive ICP monitors contraindicated?
- awake and responsive
- GCS >9
- DIC
- uncorrected coagulopathy
bolt monitor
goes into subarachnoid space, dura must be punctured
thin fiber optic cable is placed into the
intraparenchymal area, 3 mmHg variation
how to manage increased ICP?
- sedation/paralysis
- control BP
- hyperventilate to reduce CO2 to reduce cerebral blood flow to reduce ICP (from vasoconstriction)
- mannitol (expands plasma volume to draw fluid out of brain tissue)
- hypertonic saline
meds to avoid in neurosx
- anti platelet
- anti coag
- PCN (Decrease seizure threshold)
good anti-seizure med
-valproic acid, divalproex sodium
MOA-↑ GABA effects (↑CNS inhibition), inhibits glutamate/NMDA receptor-mediated neuronal excitation
SE-pancreatitis, hepatotoxicity
another good anti-seizure med
-phenytoin
MOA: Stabilizes neuronal membranes (limits firing of action potentials by blocking Na-dependent channels) causing CNS depression (related to barbiturates)
-used for seizure prophylaxis and after benzos for status epilepticus
S/E: rash (erythema mutliforme/SJS), gingival hyperplasia,hypotension, arrhythmias
best benzo for seizures
lorazepam
MOA: potentiates GABA-mediated CNS inhibition
1st line for status epilepticus
flumenazil is the reversal agent, monitor BP
phenobarbitol
MOA: binds to GABA receptor potentiating GABA-mediated CNS inhibition
Ind: Status epilepticus p phenytoin if status epilepticus persistent, febrile sz in children
SE: Depression, osteoporosis, irritability
anti coag reversal agents
Fresh frozen plasma, Prothrombin
Vitamin K
Protamine Sulfate
start if INR is 5
anti platelet reversal agents
Platelet infusion
DDAVP
important points when considering brain death
- make sure cause is irreversible
- assess brain stem reflexes (calorics, gag, pupils)
- Apnea test (brain will cause a reflex breath when CO2 levels rise too high) CO2 >60
calorics interpretation
eye looks towards cold water
away from warm water
positive apnea test
pCO2 > 60 or increase of 20 over a normal baseline with no respiratory effort
MC SEEN AFTER BURST FRACTURES OF VERTEBRAL BODIES ESP WITH FLEXION INJURIES*
Motor deficits: Lower extremity
Sensory deficits: temp and pain in LE
anterior cord syndrome
MC SEEN WITH HYPEREXTENSION INJURIES*
Motor deficits: upper extremity* esp distal extremities
(HANDS)*
Sensory deficits: Loss of Temp and pain* classically in a
shawl distribution*(in upper extremities)
central cord syndrome
MC SEEN AFTER PENETRATION INJURIES*
ipsilateral deficits:
Motor, vibration and proprioception*
contralateral deficits:
Loss of Temp and pain*
(usually 2 levels below injury)
Brown Sequard syndrome
how to manage the various cord syndromes
Removal of structures that are increasing the pressure on that specific portion of the spine. +/- Laminectomy
burst fracture-Jefferson
C1, can cause anterior cord syndrome
Hangman’s fx (pedicle)
C2- Axis- Hyperextension injury
odontoid fxs occure from
falling on face
type 2 unstable is the MC
Fx due to forced flexion of cervical spine
anterior wedge fx
Due to severe flexion injuries leading to the collision of the above vertebral body with the one below it.
flexion teardrop fx
- may present w/anterior cord syndrome
- Anterior displacement of a Wedge shaped fragment
Due to extension injuries of the neck, classically seen with diving accidents
extension teardrop fx
- may present w/central cord syndrome
- triangular shaped fragment
Spinous process fracture- due to neck flexion in MVA
clay shoveler’s fx
how to manage unstable cervical fxs
halo-vest immobilization
