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PHTY3140 > L26: Acute Neurological Injuries > Flashcards

L26: Acute Neurological Injuries Flashcards

1
Q

What are 9 cerebral areas of the brain?

A
  1. Middle cerebral artery
  2. Anterior cerebral artery
  3. Posterior cerebral artery
  4. Frontal lobe: Planning/organising, personality
  5. Temporal lobe: Smell and sound
    • R = visual memory
    • L = verbal memory
  6. Occipital lobe: Visual information
  7. Parietal lobe: Sensation, touch, pressure
    • R = visuo-spatial
    • L= language
  8. Brainstem: Cranial nerves, survival and arousal
  9. Cerebellum: Coordination
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2
Q

What is the purpose of the frontal lobe?

A

Planning/organising, personality

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3
Q

What is the purpose of the temporal lobe? What about right and left?

A

Smell and sound

  • R = visual memory
  • L = verbal memory
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4
Q

What is the purpose of the occipital lobe?

A

Visual information

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5
Q

What is the purpose of the parietal lobe? What is right and left?

A

Sensation, touch, pressure

  • R = visuo-spatial
  • L= language
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6
Q

What is the purpose of the brainstem?

A

Cranial nerves, survival and arousal

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7
Q

What is the purpose of the cerebellum?

A

Coordination

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8
Q

What are the 3 types of acquired brain injuries (ABI)?

A
  1. Malignancy: e.g. Tumour
  2. Mechanical injuries: e.g. Haemorrhage, embolus, aneurysm, arteriovenous malformation (cardiovascular)
    • Forward/backward deceleration/acceleration - injury of frontal, occipital lobe
    • Side impact - injury of temporal lobe
  3. Trauma (TBI): e.g. MVA, assault, sporting accident, falls
    • Associated with hypoxia, swelling and raised intercranial pressure, altered biochemistry, speed of impact if accident, multi -trauma or multi-diagnoses
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9
Q

What is a traumatic brain injury (TBI)?

A

an acute brain injury resulting from mechanical energy to the head from external physical forces.

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10
Q

TBI can occur in the context of penetrating cranio-cerebral injuries, but _______ deficits are generally more important than _____ elements.

A

focal neurological; diffuse

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11
Q

When assessing neurological disorders, you can match the symptoms with the _____ of each brain area and the ______ to that area.

A

functions; blood supply

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12
Q

What are the 4 operational criteria for clinical identification for TBI (≥1 of the following)?

A
  1. Loss of consciousness
  2. Post-traumatic amnesia
  3. Neurological abnormalities: Neurological signs, seizure, intracranial lesion
  4. Manifestations of TBI must not be due to drugs, alcohol, medications, other injuries, treatment for other injuries or other problems (e.g. psychological trauma, language barrier or co-existing conditions).
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13
Q

What are the 4 natures of traumatic brain injuries (TBI)?

A
  1. Increasing incidence
  2. Young males 18-35 yos due to lifestyles and behaviours
  3. Survival due to better, faster retrieval and improved ICU management
  4. Usually high speed impact > shearing force > diffuse axonal injury > global dysfunction
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14
Q

What are the 9 primary injuries for the brain?

A
  1. Skull fractures
    • Fracture of temporal bone - can tear middle meningeal artery - EDH
    • Fracture of base of Skull: CSF leak, raccoon eyes, Battle’s sign (bruising behind ear).
    • Depressed skull fractures - push on cortex causing contusion and laceration
  2. Contusion, laceration, haemorrhage
  3. Shearing/tearing of neural structures
  4. Loss of autoregulation
  5. Change in efficiency of BBB
  6. Damage to structures at foramens: Cranial nerves, pituitary, hypothalamus, blood vessels
  7. Cranial nerves contusion or tearing
    • Cranial nerves most often damaged: Olfactory, optic, facial, auditory.
  8. Blood vessels: e.g. Tearing of middle meningeal artery (EDH), tearing of internal carotid (carotico -cavernous fistula)
  9. Pituitary/hypothalamus malfunction
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15
Q

What are the 3 skull fractures as primary injuries for the brain?

A
  1. Fracture of temporal bone - can tear middle meningeal artery - EDH
  2. Fracture of base of Skull: CSF leak, raccoon eyes, Battle’s sign (bruising behind ear).
  3. Depressed skull fractures - push on cortex causing contusion and laceration
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16
Q

What are secondary injuries for the brain?

A

Any neurological damage that increases morbidity or mortality that occurs after the primary injury

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17
Q

What are 9 secondary injuries for the brain?

A
  1. Delayed cerebral haemorrhage, cerebral oedema, hypercapnia, hypoxia, hypotension, sustained raised ICP, infections, respiratory complications
  2. Neurons are torn or ruptured, leaking out toxic neurotransmitters (glutamate, chloride, potassium & sodium)
  3. Loss of autoregulation > loss of arterioles tone > increased CBF > fluid moves into extracellular space (vasogenic)
  4. BBB inefficiency > large molecules leak into extracellular space drawing water with them > vasogenic oedema
  5. Decreased perfusion > failure of Na pump > Na & H2O accumulate in cell (cytotoxic)
  6. Hyperthermia: May be due to systemic infections or dysfunction of the hypothalamus as a result of the head injury
  7. Increased body temperature will increase the basal metabolic rate - oxygen and glucose consumption
    • To keep body O2 demand low (so more O2 for brain): Ice therapy for fever, preoxygenate before physio
  8. Secondary injury due to swelling in enclosed skull
  9. When skull moves, the structures (e.g. nerves, blood vessels) going through foramens will be injured
    • Foramen magnum is where brainstem is. Any pressure going down here is life-threatening.
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18
Q

What is cerebrospinal fluid (CSF)?

A

clear colourless fluid circulating between the space between the arachnoid and pia mater and into the spinal canal.

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19
Q

What are 5 purposes of cerebrospinal fluid (CSF)?

A
  1. Fluid pathway for the delivery of substances to the brain cells
  2. Elimination of by-products of brain metabolism
  3. Transport hormones from their origin to peripheral sites of action
  4. Cushioning of brain tissue within skull
  5. Ability to respond to pressure changes
  6. pH of CSF influences pulmonary drive
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20
Q

Where and how much cerebrospinal fluid (CSF) is produced?

A

Produced in the choroid plexus ~500 mL/day

21
Q

What are 4 characteristics of CO2 and cerebrospinal fluid (CSF) is produced?

A
  1. Chemoreceptors within the floor of 4th ventricle detect changes in pH of CSF
  2. pH of CSF becomes more acidic with increasing CO2
  3. Hyperventilation to maintain homeostasis
  4. pH of CSF influences pulmonary drive and cerebral blood flow
22
Q

What are 5 causes of hydrocephalus?

A
  1. Excessive accumulation of CSF In the ventricular system
  2. Obstruction within the ventricular system
  3. Faulty absorption of CSF
  4. Over-production of CSF
  5. Impaired venous absorption
23
Q

What are the 2 relative displacements of the brain?

A
  1. The skull is filled with non-compressible components. If any component increases in volume, then another component must decrease to maintain constant volume.
  2. Brain (80%), blood (10%), CSF (10%)
24
Q

What is the intracranial pressure (ICP)? What is the nromal ICP?

A

Pressure that CSF exerts within ventricles

  • Normal ICP 0-15 mmHg, or 80-180 mm of water
25
Q

What is the cerebral perfusion pressure (CPP)? What is the normal CPP? What is the equation for CPP?

A

Blood pressure gradient across the brain that estimates the adequacy of cerebral circulation

  • Normal CPP 80-100 mmHg
  • CPP = Mean SAP (blood pressure) - ICP
26
Q

What are 4 ways to maintain cerebral perfusion pressure (CPP)?

A
  1. If BP too low, then give BP support to increase it
  2. If ICP too high, then release CSF to decrease ICP
  3. If both ineffective, then surgery takes a piece of skull away to maintain CPP
  4. Beware of physio treatment that may change BP, CPP
27
Q

What is the management of hypotension?

A

Cerebral oxygenation is threatened by systemic hypotension

  1. Inotropic support: Dopamine, phenylephrine, norepinephrine, epinephrine, dobutamine
  2. Fluid resuscitation - consider effects on other systems
28
Q

What are 4 features of Diffuse Axonal Injury (DAI)?

A
  1. Shearing injury
  2. Immediate loss of consciousness without any focal lesion seen.
  3. Maybe widespread neurological dysfunction, diffuse white matter degeneration and diffuse cerebral swelling.
    • Lots of little areas injured
  4. Grade 1-4
29
Q

What are 4 types of haemorrhage?

A
  1. Extradural haemorrhage (EDH)
  2. Subdural haemorrhage (SDH)
  3. Subarchnoid haemorrhage (SAH)
  4. Intercerebral haemorrhage (ICH)
30
Q

What are 3 features of Extradural haemorrhage (EDH)?

A
  1. Usually arterial in origin, but can be venous
  2. Most associated with fractures of temporal or parietal bone, causing injury to middle meningeal artery
  3. If arterial, it can rapidly develop space-occupying lesions (SOL), leading to herniation and death.
31
Q

What are 3 features of CT scans of Extradural haemorrhage (EDH)?

A
  1. Midline shift
  2. Lost ventricles
  3. Large volume of blood
32
Q

What are 2 features of subdural haemorrhage (SDH)?

A

Acute SDH occurs within 72 hours of injury

Associated with large brain damage from the injury and worst prognosis

Chronic SDH occurs ≤3 weeks after injury

33
Q

What are 3 features of CT scans of subdural haemorrhage (SDH)?

A
  1. Midline shift
  2. Lost ventricles
  3. Blood around brain
34
Q

What are 6 features of subarchnoid haemorrhage (SAH)?

A
  1. Bleed into the subarachnoid space and spread around
  2. Often accompanies other types of traumatic haemorrhage
  3. Associated with poorer outcome
  4. Associated with hydrocephalus
  5. Traumatic or spontaneous (resulting from aneurysmal or arteriovenous malformation leakage or rupture)
    • Atrioventricular malformation (AVM): Web of capillaries become knotted into an aneurysm. can be asymptomatic or rupture
  6. Symptoms: Headache, photophobia
35
Q

What are 4 features of CT scans of subarchnoid haemorrhage (SAH)?

A
  1. Midline shift
  2. Blood in brain
  3. Some loss of ventricles
  4. Angiogram (R) shows aneurysm
36
Q

What are 2 features of intercerebral haemorrhage (ICH)?

A

Most traumatic ICH are small multiple petechial haemorrhages or contusions

Associated with diffuse axonal injury

37
Q

What are features of CT scans of intercerebral haemorrhage (ICH)?

A
38
Q

What is the World Federation of Neurological Surgeons (WFNS) scale for?

A

grades subarachnoid haemorrhages

39
Q

What is the World Federation of Neurological Surgeons (WFNS) scale (Grade 1-5)? What are the features?

A
40
Q

What is the Fischer Scale: CT scan appearance? What are the features?

A
41
Q

What are the 5 characteristics of Dysautomia (ANS “fight” mode occurs in response to small stimulus (e.g. voice))?

A
  1. Occurs in patients without obvious structural lesions of the central ANS (hypothalamus) or raised intracranial pressure.
  2. Associated with DAI, pre-admission hypoxia, younger age and brainstem injury
    • Occurs in 10-30% DAI
  3. Associated with a poorer neurological recovery
  4. Increased energy expenditure ≤250%,
  5. Increased catecholamines
42
Q

What are 7 other names for Dysautonomia?

A
  1. Diencephalic storm or seizure
  2. Paroxysmal sympathetic storm
  3. Autonomic dysfunction syndrome
  4. Sympathetic storming
  5. Neurostorming
  6. Acute midbrain syndrome
  7. Central dysregulation
43
Q

What are the 3 phases of dysautonomia? What are the features of each?

A
44
Q

What are 2 causes of dysautonomia?

A
  1. Release of diencephalon and brainstem from cortical control
  2. Due to impaired autonomic function with abnormal reflex responses to muscle mechanoreceptors or chemoreceptors during hypertonia
45
Q

What are 3 symptoms of dysautonomia?

A
  1. Increased HR, BP, temperature
  2. Rigidity and posturing
  3. Diaphoresis
46
Q

What are 4 outcomes of dysautonomia?

A
  1. Longer rehab and length of stay
  2. ICU admission no longer than for patients without dysautonomia
  3. Longer duration of PTA
  4. Worse outcome at discharge
47
Q

What is the aim in the management of dysautonomia?

A

Aims to minimize secondary cerebral injury due to dysautonomia

48
Q

What are the 7 managements of dysautonomia?

A
  1. Morphine: Narcotic analgesic
  2. Bromocriptine: Pituitary hormone
  3. Dantrolene sodium: Muscle relaxant
  4. Propranolol: Beta adrenergic blocking agent
  5. Diazepam: Antianxiety agent
  6. Clonazepam: Anticonvulsant
  7. Cholorpromazine: Antipsychotic

PHTY3140 (28 decks)

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