Lec 68 Traumatic Brain Injury Flashcards
How do you diagnose traumatic brain injury?
- physical examination of orientation, level of consciousness, motor response, reaction of pupils to light, ability to talk, respiration
CT is gold standard
What is the glasgow coma scale [GCS]?
assesses degree of consciousness on 15 point scale based on:
- eye opening response
- verbal response
- motor response
lower score on admission = worse outcome
What are the different types of eye opening response as measured by the glasgow coma scale?
4 = spontaneous 3 = speech 2 = pain 1 = no response
What are the different types of verbal response as measured by the glasgow coma scale?
5 = oriented to time place and person 4 = confused 3 = inappropriate words 2 = incomprehensible sounds 1 = no response
What are the different types of motor response as measured by the glasgow coma scale?
6 = obeys commands 5 = moves to localized pain 4 = flexion withdrawal from pain 3 = abnormal flexion [decorticate] 2 = abnormal extension [decerebrate] 1 = no response
What is a closed head injury vs penetratin?
closed = dura remains intact penetrating = object pierces skull and breaches dura
What is a skull fracture?
break in one or more of 8 bones of cranial portion of skull
usually due to blunt force trauma
likely associated with concussion
What is etiology/signs of epidural hematoma?
blood between dura and skull
etiology: trauma leading to laceration of meningeal arteries
classic lucid interval before symptoms being; later –> blood increases ICP –> causes herniation, coma
have a convex lens shaped hematoma
pupil is localizing factor
What are signs of subdural hematoma?
blood between dura and arachnoid
esp in older, alcoholic
acute: high ICP, life-threatening; better prognosis if chronic
may be acute, subacute [1-2 wks], or chronic {> 2 wks]
image = concave, crescent shaped hematoma widespread = limited by flax not sutures
What is most at risk for subdural hematoma?
elderly, alcoholic
What is etiology of subarachnoid hemorrhage?
aneurysm rupture, head trauma
What is etiology of subdural hematoma?
etiology: trauma causing sheering of bridging veins that cross subdural space
What are differences in epidemiology and outcome of epidural vs subdural hematoma?
subdural = more brain damage + more common + life threatening epidural = less common + coma
What are signs of subarachnoid hemorrhage [SAH]?
bleeding into subarachnoid space [between arachnoid and pia]
rapid onset “thunderclap” headache, N/V, confusion or lower consciousness, sometimes seizure, reactive vasospasm –> further hypoxic injury
Volume of SAH = most powerful predictor of 30 day mortality
What is cerebral contusion? what parts of brain most at risk
cell death accompanied by leakage of blood = intraparenchymal injury
frontal and temporal lobes = most at risk because of ridges in skull base
can be hemorrhagic or not
How does diffuse cerebral injury manifest?
concussion or diffuse axonal injury
What is concussion? signs?
transient alteration of consciousness due to impact to head; due to temporary alteration of ion channels and energy balance
can have normal head CT
diagnosis is purely clinical
What are acute clinical signs of concussion?
confusion, retrograde and anterograde amnesia, seeing stars or white/black out visually
What are signs of post concussion syndrome?
days to months
headache, N/V, dizziness, visual complaints, fatigue depression, difficulty concentrating, reading, memory, sleep disturbance
What is second impact syndrome?
rare syndome where reinjury occurs before resolution of previous concussion
diffuse cerebral dysregulation with massive cerebral edema and herniation occurs
almost always younger than 20
What is diffuse axonal injury?
shearing of axons from neurons that occurs with head injury
longer period of unconsciousness, coma
normal CT or can have evidence punctate hemorrhages in grey/white junctions or with deep hemorrhages [corpus callosum or ventricle]
clinical exam may be much worse than radiographic appearance
What is chronic traumatic encephalopathy [CTE]?
occurs due to repetitive brain injury/concussions;
mech = possible repetitive axonal stretching and deformation
especially in unresolved concussions
What is gross pathology of chronic traumatic encephalopathy?
similar to alzheimers
- cortical + medial temporal lobe + mamillary body atrophy
- separation of septum pellucidum
- tau protein immunoreactivity [neurofibrillary tangles]
- SN, locus ceruleus pallor
What are early clinical features of chronic traumatic encephalopathy? late?
short term memory impairment, cognitive dysfunction, depression/apathy, emotional instability, impulse control issue, suicide
late = dementia, parkinsonism
What is genetic risk factor for chronic traumatic encephalopathy?
apolipoprotein e4 allele [ApoE4]
What is goal of severe head injury management?
prevent secondary injury = usually ischemic injury; due to hypoperfusion, hypoxia, hypotension
in ER: maintain BP > 90, attend scalp laceration, maintain O2 saturation > 90
OR: evacuation of mass lesions
ICU: monitor ICP, normovolemia
