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Neuro > Head Injury + Brain Haemorrhage > Flashcards

Head Injury + Brain Haemorrhage Flashcards

1
Q

What are RF for brain injury and what type

A

Focal - contusion / haematoma
Diffuse - diffuse axonal injury

RF
Head injury
Hypertension
Aneurysm
Ischaemic stroke
Brain tumour
Anti-coagulate
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2
Q

How does basal skull fracture present

A

Panda eyes
Battle sign (bruised mastoid)
CSF leakage ears or nose

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3
Q

What does a 3rd CN palsy secondary to tentorial herniation present with

A

Unilateral dilated + fixed pupils or sluggish

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4
Q

What does bilateral suggest

A

Bilateral CN 3 palsy from herniation or poor CNS perfusion

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5
Q

What does optic nerve injury cause

A

Unilateral dilated pupil

May be equal and cross reactive

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6
Q

What causes bilateral constricted pupils

A

Opiates
Pontine lesion
Metabolic encephalopathy

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7
Q

What causes unilateral constricted but light responsive

A

Sympathetic pathway disruption

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8
Q

What gets immediate CT

A 
GCS <13 initial
GCS <15 2 hours post
Suspected open or depressed skull fracture
Basal skull
Post traumatic seizure
Focal neuro deficit
\+1 vomit
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9
Q

Who gets CT within 8 hours

A

Anyone on warfarin
If LOC / amnesia
>65
Hx bleeding / clotting issues
Dangerous mechanism
30 mins retrograde amnesia of immediately before
CT cervical spine if neck pain / reduced rotation

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10
Q

Who gets ICP monitoring

A

If GCS 3-8 even if CT normal as ICP may begin to rise

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11
Q

What do you want for ICP monitoring

A

Minimal CPP
70 in adults
40-70 in children

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12
Q

How do you treat

A 
ATLS principles
Stabilise cervical spine
ABCDE
FBC, clotting 
Intubate if GCS <8 - urgent airway 
IV mannitol if rising ICP
Immediate head CT 
Depression craniotomy may be needed
If depressed skull fracture =surgical reduction + debridement
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13
Q

Electroylyte complication of head injury

A

Hyponatraemia due to inappropriate ADH secretion

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14
Q

What is extradural haemorrhage

A

Blood between skull and dura as dura peeled off skull

Nothing normally present

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15
Q

What causes extradural

A

Head injury
Often low impact
90% associated skull fracture which damages middle meningeal artery splitting dura

Usually temporal region / temporal bone fracture
Pterion = area that encompasses
- Parietal bone
- Temporal bone
- Greater wing of sphenoid
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16
Q

What are the symptoms of extra-dural

A

Classic lucid interval
LOC, briefly regain then lost again due to expanding haematoma
Headache
Vomit
Confusion
Seizures
Hemiparesis / hyperreflexia / upgoing plantar

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17
Q

What cane extra-dural lead too

A

Uncal herniation
3 CN palsy - fixed/. dilated pupil
CUshing’s = late
Death by res arrest

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18
Q

How do you Dx extra-dural haemorrhage

A

CT / MRI
Shows biconvex shape limited by sutures as blood pushes on brain (skull can’t move)
Hyperdense

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19
Q

What is CI

A

LP

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20
Q

How do you Rx extra-dural

A 
Craniotomy
May do Burr hole if unable
Evacuation
Airway protection
Intubation, ventilation and mannitol
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21
Q

What are the layers of the SCALP

A 
Skin
Connective tissue
Aponeurosis
Loose connective tissue
Periosteum (skull)
Dura -> arachnoid -> pia
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22
Q

What is subdural haemorrhage

A

Blood between dura and arachnoid
Not in brain
Not normally anything there

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23
Q

When should you suspect subdural

A

Fluctuating consciousness

Evolving stroke + anti-coagulant

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24
Q

What causes acute subdural

A

High energy impact
Stretches subdural emissary veins which burst

Bridging veins connect brain to sinus
Transverse sinus > sigmoid > IJV

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25
Q

What causes chronic subdural

A

Rupture of bridging veins - which are friable in elderly
Elderly and alcoholic at risk and anti-coagulant
Shaken baby
Minor trauma

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26
Q

What is the brain damage in subdural

A

More severe than extra-dural

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27
Q

How does acute subdural present

A 
Range of presentations
Fluctuating consciousness
Headache
Personality change
Raised ICP
Seizure 
Focal neuro 
Coma due to coning
No meningitic Sx
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28
Q

How does chronic present

A

Progressive history of confusion, reduced consciousness or neurological deficit after head injury
Headache

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29
Q

Who is at risk

A

On anti-coagulant

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30
Q

How do you Dx

Differences between acute / chronic

A 
CT = 1st line
MRI
Diffuse concave shape not limited by sutures - blood tricked around brain as no dura to stop 
Hyperdense if acute
Hypodense if chronic
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31
Q

How do you manage

A

Usually conservative but contact neuro-surgery
Monitor ICP
Craniotomy
Burr hole surgery

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32
Q

DDX

A

Stroke
Dementia
CNS
Weirnecke’s

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33
Q

What is SAH

A

Blood between arachnid and pia were CSF is located

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34
Q

What causes SAH

A 
Trauma = most common 
Traumatic / spontaneous rupture of berry aneurysm = most common
AV malformation = most common in the young 
Tumours
Infectious - encephalitis
Mycotic aneurysm
Spasm
Venous sinus thrombosis
Vasculitis
35
Q

How does SAH present

A 
Sudden onset thunderclap headache
Worse ever
Occipital / hit on back of head
N+V
Menigism - stiff neck / photophobia / phonophobia 
Seizures 
Reduced GCS due to sudden rise in ICP 
Papilloeema due to raise ICP 
Visual disturbance 
FOcal neuro
Hypertension 
May have sentinel headache due to warning leak
36
Q

What might you see on ECG

A

ST elevation due to vagal stimulation but no infarction

37
Q

What are RF for SAH

A 
Previous SAH 
Trauma 
High BP
Smoking
Alcohol
Age
Cocaine use 
Female
FH
Polycystic kindey
Sickle cell 
Coarctation Aorta
Ehler's Danlos
38
Q

How do you Dx

A 
General + neuron exam
Routine bloods
FUndoscopy
Non-contrast CT = 1st line
Angiography once SAH confirmed to locate the source of bleeding
39
Q

What does CT show

A

All grooves flooded
Hypertense
Can’t see gyro

40
Q

What do you do if CT -ve

A

LP post 12 hours
Look for xanthochromia (breakdown of RBC)
Stays +ve for 12 days

41
Q

What can you do after 2 weeks

A

Angiogrphy

42
Q

If patient presents within 6 hours of headache onset and CT normal

A

Discharge

43
Q

How do you treat

A

Refer neurosurgery
CT intracranial angio to identify lesion for surgery
Coil for aneurysm = 1st line as endovascular
Surgical clipping but more invasive as involves craniotomy

44
Q

What do you do whilst awaiting Rx

A

Strict bed rest
Control BP
Nimidopine (CCB) = evidence that reduces reflex vasoconstriction / spasm after SAH as well as lowering BP (given for 21 days)
- Only give if aneurysmal SAH
Don’t want to lower BP acutely as might be needed to perfuse brain
Re-examine CNS - BP / pupils / GCS
Repeat CT if deteriorating

45
Q

What are complications of SAH

A 
Vasospasm
- Due to release of inflammatory cytokines
- Often new onset focal neurology 
- Peak incidence = 6-8 days 
Hyponatramia due to ADH
Seizures
Hydrocephalus requiring stent 
Cardiac dysfunction
Cerebral ischaemia
Stroke
Infection 
Re-bleed
46
Q

What determines prognosis

A

LOC
Age
Amount of blood on CT

47
Q

What causes hyponatraemia after SAH

A

Cerebral salt wasting

  • Fluid depletion due to urinary loss of Na and H20 follows
  • Patient will appear dehydrated
  • Rx = IV saline

SIADH

  • Kidney retain water which dilutes Na
  • Concentrated urine
  • Rx = fluid restriction
48
Q

What is intracerebral haemorrhage

A

Collection of blood within substance of brain

Form of stroke

49
Q

What are natural causes

A 
Hypertension
AV anomaly
Aneurysm
Amyloid angiopathy
Vascular tumours
50
Q

What causes traumatic

A

Diffuse axonal injury after big decelaration in rotational force
Shearing of long fibres
Often = brain dead / coma
May not pick up on CT / MRI

51
Q

How does it present

A

Ischaemic stroke so always do CT before thrombosis as might haemorrhage
More focal signs than SAH

52
Q

How do you Dx

A

CT = hyperdense everywhere

APP shows hypoxic ischaemic damage present in DAI after 3 hours

53
Q

How do you Rx

A

Stroke team
Conservative
Surgical evacuation if large / decompressive craniotomy to prevent ICP rising
Skull put into abdominal to keep safe

54
Q

Bone on CT =

A

HYPERDENSE

WHITE

55
Q

Fluid / CSF on CT

A

HYPODENSE

BLACK

56
Q

What is isodense

A

Grey

57
Q

What causes inter ventricular haemorrhage

A

Premature ventricles (IVH)
SAH
Vascular
Tumour

58
Q

How do you Dx

A

CT

Hyperdense in ventricle space

59
Q

How do you Rx

A

Urgent surgical diversion

60
Q

What are complications

A

Obstruting hydrocephalus requiring drain

61
Q

What is contusion

A

Bruising of brain

62
Q

What causes contousin

A

Depressed fracture

63
Q

What is COUP and COUNTRECOUP

A 
Coup = contusion at blow
Contrecoup = opposite to force
64
Q

What causes laceration

A

Blunt force

65
Q

What causes incision

A

Sharp force

66
Q

What causes a brain aneurysm

A

Weakening of blood vessels

67
Q

Where do most occur

A

Branch points of circle of Willis where arteries connect as most turbulent flow
Berry or micro = most common

68
Q

What are RF for developing aneurysm

A 
Smoking 
High BP
Age
Women
FH
PCKD
Ehlor danlos
Certain connective tissue / vasculitis
69
Q

What are symptoms

A 
Only notice if burst causing SAH
Sudden severe headache
Decreased consciosness
N+V
Neck stiffness
Photophobia
Coma
70
Q

How do you Dx

A

CT
LP 12 hours after
Angio 2 weeks after

71
Q

How do you Rx

A

Monitor aneurysm

Coil or clip

72
Q

Complications

A 
Hydrocephalus
Vasospasm
Ischaemia
SAH
Stroke
73
Q

How common is SAH

A

1 in 10 people with thunderclap headache

74
Q

What is important to do if GCS drops

A 
ABCDE
Urgent airway if GCS <8
Blood sugar 
Pupils - PEARL
Urgent CT - radiology
Bleep anaesthetist
75
Q

How doy ou detect diffuse axonal injury

A

MRI

76
Q

Who needs urgent neurosurgical review

A

GCS <8

77
Q

How do you investigate cervical spine

A

CT

78
Q

What is immediate with diffuse axonal injury

A

Coma

Takes weeks to recover

79
Q

How may cervical spine injury present

A

Pain
Reduced movement
Neuro soins e.g. can’t feel legs

80
Q

How do you check CSF is CSF

A

Glucose

81
Q

Differences in stroke

A 
Ischaemi = no headache
Haemorrhagic = headache
82
Q

Young adult presents with menigism and headache what are DDX

A 
Ruptured AV malformation
Ruptured aneurysm
Menngitis 
Rupture mycotic aneurysm 
Migraine 
Trauma
83
Q

What are the sutures in the skull

A

Coronal at front

Saggital down middle

Neuro (19 decks)

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