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CM 4 GERI & NEURO > HA, and Concussions > Flashcards

HA, and Concussions Flashcards

1
Q

location of concussion direckt correlated w/ si/sx

Frontal-

Parietal-

Occipital-

Top of the head impacts-

A

Frontal- irritability, inappropriate tearfulness

Parietal- headache, nausea

Occipital- dizziness, disequilibrium, visual symptoms

Top of the head impacts- more likely to cause LOC than front or side impacts

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2
Q

pathophys of concussions

A
  • Hyper-acute ionic flux (K+, Ca+)
  • release of excitatory NT
  • Acute hyperglycolysis
  • Sub-acute metabolic depression
  • Inflammation
  • ↓cerebral blood flow for days-weeks

Combination of these metabolic alterations has been proposed to cause the transient and prolonged neurologic deficits that characterize concussions

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3
Q

dx of concussion

A
  • SCAT-5
  • Balance error scoring system (BESS)
  • Non-healthcare concussions recognition tools 5 (CRT5)
  • Concussion assessment & response (CARE)
  • Sideline assessment of concussion (SAC)
  • Graded Sx checklist (GSC)
  • Glasgow coma scale (GCS)
  • +/- CT (LOC!)
  • fMRI (BOLD contrast)
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4
Q

tx of concusisons

A

Retest neuro function q30 min

Observe x4 hours

Sx management (ex. analgesics, antiemetics)

  • No opioids

Brain rest x24-48 hours

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5
Q

define Post-concussive syndrome

A

Si/Sx last beyond the usual recovery period (7-10 days)

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6
Q

tx of Post-concussive syndrome

A

Amitriptyline

Antiemetics (dihydroergotamine & metoclopramide)

Occipital blocks

Propranolol

Indomethacin

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7
Q

define second impact syndrome

A

Death or devastating neurological injury attributed to massive brain swelling in athletes who sustain a second head injury before full recovery from the first

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8
Q

define imPACT testing and its use

A

imPACT TESTING - Most widely used and scientifically validated computerized concussion evaluation system

  • Not a tool to diagnose concussion
  • Not a substitute for medical evaluation and treatment
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9
Q

define CTE

accumulation of??

A

Repeated concussions

An accumulation of abnormal hyperphosphorylated tau (p-tau) in neurons and astroglia distributed around small blood vessels at the depths of cortical sulci

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10
Q

•Most common type of traumatic intracranial mass lesion

A

Subdural hematoma

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11
Q

define subdural hematoma & etiology

acute

subacute

chronic

A

Form between the dura and the arachnoid membranes–> T_earing of bridging veins_

Acute (1-2 days)

Subacute (3-14 days)

Chronic (>15 days)

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12
Q

si/sx of subdural hematoma vs epidural hematoma

A

SDH- Gradually increasing LOC

  • HA
  • Dizziness
  • Cognitive impairment
  • Seizures

EDH - Lucidity –> rapid deterioration

  • Severe HA
  • Vomiting
  • Seizures
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13
Q

define EDH and causes

A

Arise in space between the dura and the skull

  • Due to shearing and rotational forces and blows to the side of the head
  • Adolescents and young adults affected most

Shearing of meningeal arteries

  • Trauma (ex. skull fx)
  • Epidural abscess
  • Infection
  • Cancer
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14
Q

SDH is due to tearing of ___

EDH is due to tearing of ___

A

SDH is due to tearing of bridging veins

EDH is due to tearing of meningeal arteries

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15
Q

comapre/conrast head CT for SDH vs EDH

A

Head CT

SDH - crescent shaped)

EDH - biconvex

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16
Q

Surgical evacuation (ex. craniotomy, burr) is always indicated in what cases of EDH / SDH

A
  • >30 cm or mls
  • acute EDH with a GCS < 9 and pupillary abnormalities
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17
Q

compare contrast SDH vs EDH

location

arterial vs venous

LOC ??

CT features

A
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18
Q

list examples of primary vs secondar headache

A

Primary

  • Migraine
  • tension-type
  • cluster headache

Secondary

  • sinus headache
  • SAH
  • tumor
  • hydrocephalus
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19
Q

HA red flags

A

RED FLAGS ...SNOOP 5

  • S: Systemic symptoms (fever, weight loss) or Secondary risk Factors (HIV, cancer)
  • N: Neurologic symptoms or abnormal signs
  • O: Onset - abrupt, peak < 1 minute (thunderclap, SAH, CVST, dissection)
  • O: Older - age > 50 years (GCA, glaucoma, cardiac cephalalgia)
  • P: Previous headache history, pattern change, progressive
  • P: Postural (CSF leak/low pressure headache; IIH)
  • P: Precipitated by valsalva, exertion (Chiari malformation, space occupying lesion-tumor/mass)
  • P: Pulsatile tinnitus (diplopia, transient visual changes- IIH)
  • P: Pregnancy or postpartum (pre-eclampsia, eclampsia, apoplexy, etc.)
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20
Q

HA RED FLAGS …on exam

A
  • Abnormal vital signs - increased BP/HR or temperature
  • AMS
  • Alteration in LOC
  • meningeal irritation (Brudzinski’s/Kernig’s signs)
  • Papilledema - swelling of optic nerve indicating elevated ICP
  • P_resence of focal neuro signs_ - hemiparesis, hemisensory loss, ataxia, aphasia, dysarthria, signs of brainstem dysfunction, pathological reflexes
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21
Q

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) is a primary vs secondsayr HA

22
Q

define IIH

A

A disorder of the of CSF mechanics

  • disease process mimics a space occupying lesion, with none being found

More common in obese women

23
Q

CSF is produced –>

CSF is resorbed –>

A

CSF is produced –> choroid plexus; also

CSF is resorbed –> arachnoid granulation

24
Q

si/sx of IIH

A

Progressive headache- wks to months

Diffuse pain, holocephalic - can be lateralized

postural changes:

  • Worse with lying down
  • better when upright

Pulsatile tenderness

Worsens or triggered by cough, valsalva maneuver

25
Hallmark PE finding in IIH
papellidema
26
eye exam fts in IIH
**Papilledema** **Peripheral visual field loss** --\> occurs before visual acuity loss **6th nerve palsy (Abducens)** --\> D/t ↑ ICP on 6th nerve It is possible to
27
imaging/ dx of IIH
**MRI** (most likely w/ contrast) * Flattening of posterior globe * Optic sheath fenestration * Empty sella **MRV (w/ contrast)** -\> No venous obstruction **LP** --\> Lateral decubitus \*\*Legs extended * _Opening pressure_ \*\* (↑250, 200-250 if other sx present ) * Closing pressure * CSF studies (cell count and diff, glucose, and protein) – Normal
28
tx of IIH first line papilledema
**FIRST LINE**: Acetazolamide (_Diamox_) * Carbonic anhydrase inhibitor * ↓ CSF production **Weight loss** Other meds used: * Methazolamide * Topiramate * Furosemide * Spironolactone * Steroids (but not first line) * Triamterene **Optic nerve sheath fenestration** * Only if papilledema; can lead to visual loss
29
normal vs pathologic pressures
Normal pressure ≤ 15 mmHg (200 mmH2O) Pathologic ≥ 20 mmHg
30
meds assoc w/ IIH
* Tetracyclines * Vitamin A and retinoids * Nalidixic acid, leuprorelin acetate * Withdrawal of corticosteroids
31
IIH asssoc conditions
* Obstructive Sleep Apnea (OSA) * PCOS * Antiphospholipid antibody syndrome * HIV infection * Cerebral venous thrombosis/stenosis
32
differentiate b/w longer vs shorter duration HA and give examples
**Longer Duration: \> 4 hours** * Migraine * Tension-type headache (generally) * New Daily Persistent Headache * Hemicrania Continua **Shorter Duration: \< 4 hours** * Cluster headache * Paroxysmal Hemicranias * Hypnic Headache * Idiopathic stabbing headache
33
types of cluster HA
**Episodic (most common)** * At least 2 cluster periods lasting from 7 days to 1 year (when untreated) and * separated by pain-free remission periods of ≥3 months. * Cluster periods usually last between 2 weeks and 3 months. **Chronic** * without a remission period * or with remissions lasting \<3 mo for at least 1 yr
34
si/sx of cluster HA
_Occur in cycles;_ know the exact time of year that headaches start; often seasonal * 1-8 per day, lasting 15 to 180min Unilateral, _periorbital/retro-orbital pain_ Stabbing and unbearable - _the worst pain you will ever experience in your life;_ * “Hot poker into the eye” Nicknamed the “_suicide headache”_
35
cluster HA behavior and autonmic fts
**HEADACHE BEHAVIOR:** * pacing, irritated, pounding fists, head against objects or walls **Autonomic features:** * Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, lid ptosis - A_ll ipsilateral (same side as pain)_
36
when is neuroimaging apprioriate for cluster HA
if this is the first time they are being worked up or if this is an initial event. * Exclude a cranial lesion - has been found on occasion MRI with and w/o contrast (preferred) CT non- contrast
37
tx of cluster HA acute preventitive
**Acute Treatment** * High Flow O2 non-rebreather * Sumatriptan injection –subcut * Other triptans - zolmitriptan nasal spray * Prednisone taper * Occipital nerve blocks * Neuromodulation devices - vagal nerve stimulator **Preventive Treatment:** CCB - Verapamil - mainstay * Long QT assess ECGs
38
Dull, steady ache; _band-like_ in distribution around head bilateral, mild to moderate intensity Pressing or tightening in quality _Physical activity does not worsen pain_ * Nausea, photo/phonophobia are not usually present * Vomiting never present
tension HA
39
Most common abnormal finding in tension HA
**pericranial tenderness**
40
tx of tension HA acute chronic pphx
**Acute**: Acetaminophen, NSAIDs, Aspirin **Chronic**: NSAIDs, biofeedback, * may use prophylaxis if \>15 days per month **Prophylactic** : tricyclics (i.e. - amitriptyline at low dose,
41
smoking is greatest RF in what type of HA
cluster
42
Calcitonin Gene Related Peptide (CGRP) is assoc w/ what type of HA
migriane
43
Headache is Severe, unilateral throbbing * Worse w/ activity * Nausea * Photophobia
migraine
44
Physical activity does not worsen pain of ____ HA Physical activity worsens pain of ___ HA
Physical activity _does not_ worsen pain of _tension_ HA Physical activity _worsens_ pain of _migraine_ HA
45
HA described as the worst pain you will ever experience in your life "hot poker in eye"
cluster - retrobulbar pain
46
HA in ; band-like in distribution around head
tension
47
Acute Tx of migraine specific nonspecific
**Nonspecific Treatments**: ↓ pain through general pain pathways * Acetaminophen, NSAIDs * Anti-emetics (dopamine blockers) * Opioid/barbiturates * Muscle relaxants **Specific Treatments**: ↓ pain through direct actions on the trigeminovascular system, including 5HT1B/D/F receptors: * Triptans - * Dihydroergotamine (DHE) * Ergotamines
48
migraine tx alt to triptans
**Selective Serotonin 1F agonists** * Reyvow (lasmitidan) * Non-vasoconstrictive **Small molecule CGRP antagonists (-gepants)** * Ubrelvy (ubrogepant) * Nurtec (rimegepant)
49
Acute Treatment of migraine in the ED Setting
* _Diphenhydramine IV_ * _Anti-emetic IV_ (Zofran, Reglan, or Compazine) * _Ketorolac IV_ * Can consider i_njectable sumatriptan_ * _Magnesium sulfate_ * Solu-medrol/_dexamethasone/steroids_ IV * Consider DHE IV * _Valproate_ IV * Last resort – _opioids_
50
Preventive Treatment of migraine
_Divalproex (Depakote)_ - CAUTION in women of childbearing age _Propranolol, timolol_ _Metoprolol_ is also used _Topiramate (Topamax)_ _Amitriptyline_

CM 4 GERI & NEURO (4 decks)

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