lecture 6: head trauma , seizures, headache and vertigo Flashcards
what is the primary external cause for a TBI
falls
TBI rates of death were highest for people ____ years of age
> 75
what is the leading cause of a TBI related death from a
>65
25-64
5-24
0-4
falls
intentional self harm
motor vetichle crashes
assaults
what scale is used for TBI screen and assess eyes opening , verbal response and best motor response
glasgow coma scale
what is the total scare for the glasgow coma scale ? and what is worse and what is better
3-15
3 is worse (dead basically)
15 is normla
75% of cases of TBI’s are ___
concussion/mild
if someone has a glasgow coma scale of 13-15 what does that indicate
mild tbi
how is a mild tbi/concussion defined
trauma that messes that brain up and is manifested by one of these things …
any LOC
loss of memory befor or after
change in mental status
focal neurologic deficits
if someone has a GCS score of 9-12 whst can we indicate
moderate TBI
what kind of TBI is Usually associated with prolonged LOC +/- neurologic deficit
moderate
if someone has a GCS of <8 what can we suspect
severe TBI
if a pateitns is obtunded or comatose , has significant neurologic injury , often structural brain lesions apparents on head trauma and needs airway protection , mechanical ventilation, or intracranial pressure monitoring what kind of TBI can we susapect
severe
how is the recovery for a severe TBI
prolonged and often incomplete
what is the difference between a penetrating and non penetrating head injury
penetrating is when the skull and meninges are breached and a non pent is the soft tissues are forced into the hard skull
ex: bullet going into head (pen) … getting hit with an elbow during a basketball game (non)
what is the difference between coup and counter coup
coup is where the injury takes place and counter coup is where the brain hits the skull and is usually worse then koo
ex: if u hit ur head on the table the coup is ur forehead but the counter coup is th back of ur head here the brain hit it
what is the first phase of a TBI
direct consequence of trauma
diffuse axonal injury
what is the second phase of a TBI
– Begins quickly after primary phase
– Hypoxia and hypoperfusion
– Inflammation
what is the neurological assessment for a head injury
glasgow coma sale
what is anisocoria
pupil size difference
what are the localizing signs for a head injury
• Anisocoria (pupil size differences)
• Diplopia due to CN palsies
• Absence of gag (glossopharyngeal -> vagal)
• Abnormal breathing patterns
if someone has a head injury and their pupils are dilated , fixed what is damages
CN 3 (uncal)
if someone has a brain injury are their pupils are large , “fixed”, hippus what is damaged
pretectal
if someone’s pupils are pinpoint after a head injury what is damaged
pons
if the pupils are in midposition and fixed after a brain injury what is damaged
midbrain
if someone has a brain injury and there pupils are small , reactive what is damaged
diencephalic
decerebrate posture results from damage to what ?and how will someone look in this position
upper brain stem and the position is extended
decorticate posture results from damage to what ?and how will someone look in this position
one or both corticospinal tracts
position is flexed
where is the bleeding happening for the following hemorrhages
intracerebral
subarachnoid
subdural
epidural
inside the brain
in the subarachnoid spaces
b/t arachnoid matter and dura matter
b/t dura matter and skull
what kind of hematoma usually follows a low velocity injury
subdural
epidural hematoma is bleeding from ____ ____ or ____ and is torn by a ____ or ____ fc
meningeal artery or vein
temporal or parietal fracture
what kind oat hematoma will someone have a “lucid interval”
epidural
which means they nay be good st first and talking then hours later they die
what is the shape of the clot for an epidural hematoma
lens shaped
what is the sequelae of head injury
• Hydrocephalus
• CSFleak
• Subarachnoidhemorrhage
• Vascularinjury
• Infection
what syndrome will someone have Headache, fatigue, dizziness, difficulty concentrating, disturbed sleep, anxiety, depression. May persist months to years.
post concussion syndrome
what is – Trauma induced alteration in mental status that may or may not involve loss of consciousness
concussion (mild TBI)
what is the hallmark of concussions
confusion and amnesia
how long does a concussion last and when do the symptoms start
lasts up to 1 month and symptoms can start early or later
- Physical
– Headache
– Nausea/Vomiting
– Photophobia (sensitvie to light)
– Phonophobia (sensitive to loud noise)
– Dizziness
– Slurred speech
– Blurred vision
– Incoordination
these are all physcial symptoms of what
concussion
– Inattention
– Slowed thinking
– Confusion
– Amnesia
– Disorientation
– Vacant stare
– Loss of Consciousness
these are all mental symptoms of what
concussion
– Emotional lability
– Depression – Anxiety
– Mania
these are all affective symptoms of what
concussion
– Increased sleep latency
– Frequent waking
– Increased or decreased sleep time
these are all sleep symptoms of what
concussion
what sports related concussion are highest in boys
football, ice hockey, lacrosse > soccer, wrestling, basketball
what sports related conccusion are highest in girls
-soccer
-ice hockey
-lacrosse
-basketball
are female or males higher for sports concussion injury
female
a CT head should not be utilized to diagnosis a sports related concussion but rather what..
to exclude more severe traumatic brain injury
what retunr to plat protocol is this
goal: more intense but non contact n
time: close to typical routine
activities: running , high intensity stationary biking , the players regular weight lifting routine , non contact sports specific drills
step 3 : non contact training drills
for each step of the retunr to play protocol for concussion the player must be asymptomatic for how long before going to the next steps
24 hours
how long are symptoms persist for post concussive syndrome
> 1 month
what is a chronic traumatic encephalopathy
spectrum of disorders aosscited with long term consequences of a single or repetitive TBI
what are some of the behavioral changed seen with chronic. traumatic encephalopathy
• Aggression
• Agitation
• Impulsivity
• Depression
• Suicidality
what motor involvement is invovled with chronic traumatic encephalopathy
• Dysarthria
• Spasticity
• Motor neuron disease
• Parkinsonism, tremors
• Ataxia
• You are the PT working with a patient who has had a stroke when he suddenly starts having an apparent seizure..
what do u do for safety?
what do you NOT do?
what do u push ?
get him to bed and lying on side with rails up
do not put anything in his mouth
push the nurse call button
what is the leading causes for epilepsy
brian tumor
Single provoked/unprovoked episode
Episode of transient behavioral, sensory, motor, visual symptom, associated with abnormal excessive cortical activity in the brain.
May be provoked or occur spontaneously
what does this describe
seizure
what is Two or more unprovoked seizures separated in time by greater than 24 hours or single seizure with heightened risk of future seizures
epilepsy
what are 2 examples of genetic syndromes of epilepsy
Juvenile myoclonic epilepsy, Lennox-Gastaut
any lesion to disrupt neuronal network: stroke, hemorrhage, tumor, encephalitis, meningitis, gliosis from trauma or severe hypertension.. this is what kind of epilepsy
structural
hypo-/hyperglycemia; hypocalcemia, hyponatremia, uremia, drugs or illicit substances… these are what type of epilepsy etiology
metabolic
what is Lennox-Gastaut
multiple different sezuire types
what is the most common causes of epilepsy world wide
infections
– GAD65
– Rasmussen syndrome
these are what kind of etiology for epilepsy
immune
what seizure
- begins on ONE SIDE OF THE BODY
- does NOT IMPAI CONSCUOUSNESS
-motor : clonic or tonic
-sensory: parenthesis, visual hallucination
-EEG with CONTRLATERAL focal discharge
focal onset seizure without loss of awareness (AKA: simple partial seizures
what seizure has
-impairment of consciousness , cognitive , affective symptoms
- auditory hallicucinations
- formed visual hallucinations
-olfactory hallucinations
-psychomotor phenomenon, chewing movements , wetting lips
-dysphasia
-when they seize they shake and then turn and seize and then they are fine
-EEG shoes left temporal lobe seizure
focal onset seizure with loss of awareness (complex partial seizures)
• Withoutlossofawareness:oftenlastseconds
• With loss of awareness: usually>1min
• May have had febrile seizures in childhood
• Sensory aura–olfactory,gustatory,epigastricrising, auditory hallucinations
• Experiential aura–psychic feeling,déjà vu, depersonalization, fear, panic
• Autonomic aura–flushing, nausea, pallor
• Aphasia if dominant temporal lob onset
• Typically followed by post-ictal confusion,fatigue ,with gradual recovery
what seizure is this
temporal lobe
what seizure may have
-aura “jacksonian march”
-early posturing or clonic activity
-may have large amplitude , irregular, complex movements ,
-clusters of seizures AT NIGHT
- BRIEF in duration but can quickly secondarily generalize
-AUTONOMIC FEAUTURES
- brief post-ictal phase
frontal lobe
what sezuire is Sudden onset of unresponsiveness lasting seconds, with interruption of ongoing activity but no loss of muscle tone.
absence
what seizure is
-Sudden onset of unresponsiveness lasting seconds, with interruption of ongoing activity but no loss of muscle tone.
- patient returns to normla activity with NO POSTICITAL STATE
- EEG with 3 Hz spike and wave
-MOST COMMON IN CHILDERN
absence seizures
what seizure is this ..
• Sudden onset of loss of consciousness with onset of rigid muscle tone (tonic phase) followed by rhythmic convulsive movements lasting up to several minutes (clonic phase)
• Postictal somnolence minutes to hours
• Ictal EEG shows BITLATEAL DISCHANRGES
generalized tonic clonic seizures
what are myoclonic seizures
- SINGLE brief jerks
- many involve any limbs or all
- occur with other seizures
-Ictal EEG shows generalized spike and wave
is all myoclonus a seizure ?
no
what is a atonic seizure
-head drop
-falls forward
VERY HARD TO CONTROL
what seiuzre is this ..
• Occur in 2-5% of children
• Most occur between 6 months-3 years (upto6yo)
• GTC seizure lasting a few minutes
• 33% will have at least one recurrence ,<10% will have 3 or more.
• Prognosis excellent
- NO NEED FOR ANTIEPILEPTIC DRUG
FEBRILE SEZIURE
if someone is having a gradual onset of a seizure , PROLONGED duration , thrashing , struggling , crying , pelvi thrusting , motor activity that STARTS AND STOPS , arrhythmic jerking and RETAINED consciousness despite BILATERAL jerking what do we think ???
no epileptic event
is someone is experiencing syncope what may happe??
-lightheaded , dizzy , sweating
-change of vison
-sweating and pallor
-urinary incontinence
after a seizure what will most people need
EEG and contrast MRI of brain to see if high risk for reoccurrence
40% of epilepsy patients will have normal initial EEG
what conditions is this
• Generalized seizure activity lasting >5 min or recurrent seizures without return of consciousness for > 5 min
• Generalized tonic-clonic seizures
• Morbidity and mortality risk increases with
duration
• Rapid diagnosis and treatment necessary
status epilepticus
who is most likely to be diagnosed with epilepsy syndrome
children
what is the recommendation for treating seizures in children
treat after 1st seizure when risk of 2nd seizure outweighs risk of drug side effects
___ ideation is black box warning on many AEDs on current market
Suicidal
what are the general side effects of AEDs
-somnolence (excessive sleepiness)
-nausea
-ataxia
-nystagmus
-confusion
-rash
what is the side effects of Valproic acid medications for epilepsy
weight gain
tremor
what is the side effects of phenytoin medications for epilepsy
gum hyperplasia , cerebellar ataxia, rash
what is the side effects of topiramate medications for epilepsy
kidney stones
cognitive
weight loss
what is the side effects of carbamazepine medications for epilepsy
dizzy , N/V , rash
what is the side effects of levetriaceatam medications for epilepsy
behavioral changes , psychosis
• Cognitive impairment
• Symptoms of depression, anxiety, or other
changes in mood or behavior
• Problems sleeping
• Unexplained injuries, falls, or other illnesses
• Thinning of the bones or osteoporosis (due to AEDs)
• risk of death
these are all impacts of what
epilepsy
Migraine (with or without aura), tension HA, cluster HA… these are all what kind of headache disorders
primary
brain tumor, increased intracranial pressure, meningitis, encephalitis, aneurysm, hypertension… these are all examples of what kind of HA disorder
secondary
what are one of the most common reasons patients visit. a primary care physician or ER
HA
are most headaches primary or secondary
primary
what are the red flags for headaches
SSNOOP4
* Systemic Symptoms–fever or weightloss
* Secondary Disease–HIV,cancer,immunosupression
* Neurologic Symptoms–confusion,impaired alertness, focal weakness
* Onset–sudden,abrupt,orsplitsecond
* Older–new onset and progressive >50 year old
* Previous Headache History–first headache or different (change in attack frequency, different features)
* Positional
* Papilledema (swelling of the optic nerve)
* Precipitants–cough,Valsalva
– Subarachnoid hemorrhage (Ruptured aneurysm)
“worst headache of my life”
– Intracerebral hemorrhage
– Carotid or vertebral artery dissection
– Carotid cavernous fistula (arteriorvenous connection)
– Cerebral venous sinus thrombosis
– Subdural/Epidural hematoma
– Hydrocephalus
– Bacterial meningitis
– Idiopathic intracranial hypertension
– Brain tumor
these are causes of ___ HA
secondary
• 24yearoldpresentswithsevere throbbing unilateral headaches which have been occurring since she was a teenager. She gets them once a week and needs to lie down in a dark room. She as associated nausea and vomiting as well as sensitivity to light and sound. She takes Ibuprofen which helps a little. They have not changed in frequency or character since they started but they are interfering with her life. Normal exam.
any red flags ??
no things migraine
when is the peak onset for migraine
20-24 for women and 15-19 for male
what is the highest indecenc for migraines
between 20-35
what is the criteria for a migraine
- > 5 HA
- 4-72 hours
- 2 out of the 4
throbbing
unilateral
mod to sever
worse w activity
-1 out of 2
nause/vomit
photophobia (bright light) or phonophobia (loud noise )
this decribes what aura .. positive scintillating scotomata with fortification spectra (like bright flashing lights with blindness)
classic
what is a stereotypes prodromal symptoms for migraine with aura
aura … can be visual , motor , sensory or cognitive
are migraine with aura or without aura more common
without
what are the 3 pronged treatment or HA
lifestyle changes
acute abortive >3 days
prophylaxis > 5
what is the medication that is taken everyday with HA
prophylaxis
when should u consider to take prophylaxis for HA
-when they interfere with patients life
- HA are frequent or prolonged
- atypical migraines
if someone has a HA lasting longer then 5 days what shoudl they take
prophylaxis
what could possibly works on inhibition of the peripheral and central sensitization of the trigeminovascular neurons
botulinum toxin (botox)
how many injections would someone get for botulinum toxin for chronic migraines
31
what HA does this describes
- Very common and underdiagnosed
- Worse in the AM – after not having medicine in system overnight
- Patient takes ever increasing doses of OTC medicine but slight drop in blood levels leads to rebound headache
- Particularly drugs with caffeine
analgesic rebound/withdrawal headache
what HA does this describe
Severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 min
- Either or both of the following:
–
1 of the following ipsilateral symptoms or signs: a) conjunctival injection / lacrimation; b) nasal congestion c) eyelid edema; d) forehead and facial sweating; e) forehead and facial flushing;
f) sensation of ear; g) miosis / ptosis a sense of restlessness or agitation
-Frequency from 1/2 d to 8/d for > half the time when active
cluster
• 30 year old man presents with altered mental status, headache, and vomiting. He has had headaches in his 20s episodically but for the past 3 months has had a constant headache that is more occipital and associated with much more nausea and vomiting
primary or secondary
secondary
what type of HA would u think with this patient
- 27yearoldfemalelawyercomes to your office complaining of:
– Bioccipital non-throbbing moderate intensity squeezing pain.
– Radiates like a band around the head.
– Started 3 years ago, remains unchanged
– No other associated symptoms
– Resolves somewhat with ibuprofen
tension
what HA is this
• May not be due to muscle tension!
• Can begin at any age
• Generally bitemporal, bioccipital, or bifrontal
• “tight band” around head with sense of “pressure” or “bursting”
• May be perceived as continuous for months or even years
tension type
what do u think with this pateint
• 48 year old man without significant PMH comes to your office with:
– 1 month history of momentary jabs of severe pain over right cheek
– Occurs at least once per day
– Triggered by brushing his teeth, drinking liquids,
cold wind touching affected area
– No significant Family History
facial pain (trigeminal neuralgia)
• Develops in mid to late life
• Sharp lightninglike momentary jabs of severe
pain in V2 and V3 distribution – V1 involved in < 5% of cases
• Pain may be spontaneous or may be triggered by sensory stimulation
• DDx: in young patients consider MS and brainstem mass
what is this
trigeminal neuralgia (tic douloreux)
what is the medical treatment from trigeminal neuralgia
carbamazepine, oxcarbamazepine
what is the sx treatment for trigeminal neuralgia
microvascular decompression of trigeminal ganglia
what is defined as the sensation that u are moving
vertigo
what is defined as the sensation that the world is moving
opscillopsia
u want to figure out if the vertigo is cerebellar or vestibular related what would u do
finger to nose for cerebellar and balance for vestibular
if vertigo has to do with the vestibular portion of CN VIII , vestibular nuclei with brainstem and center connection what is the localization
central
if there is dysfucntion of the semicircular canals , utricle and saccule what locatiation of vertigo is it
peripheral
– Peripheral vestibulopathy
– Benign paroxysmal positional vertigo (BPPV) – Ménière’s disease
– Vertebrobasilar ischemia
– Migraine (rare)
– Seizures (rare
these are DD of attacks of what
vertigo
– Peripheral vestibulopathy – Cerebellopontine tumor – Multiple sclerosis
– Brainstem infarct
– Ototoxic drugs
these are DD of what
chronic vertigo
- Most common cause of recurrent vertigo
- Most episodes last a few weeks,but maybe
recurrent, can persist for years
what vertigo is this
Benign Paroxysmal Positional Vertigo
(BPPV)
Benign Paroxysmal Positional Vertigo is an episodic vertigo lasting how long and what is it triggered by
10-30 seconds
-tilting the head
-rolling over
-straightening after bending
in Benign Paroxysmal Positional Vertigo 85% is due to involvement of what canal
posterior semicircular
what test is used for Benign Paroxysmal Positional Vertigo
dix hallpike (vertigo)
• Most cases probably viral
• Sudden onset of prolonged vertigo that is
constant, lasting days (worst in the first couple)
• Hearing loss
• Nausea/vomiting common
• ±Tinnitus
• No focal neurologic signs
• Often affects young people
what vertigo is this
Peripheral Vestibulopathy: “Viral Labyrinthitis” and Vestibular Neuritis
- Episodic severe vertigo and vomiting, lasting minutes to an hour.
- Feeling of fullness in ear and tinnitus
- Hearing loss,often progressive
what disease is this
ménière’s disease
Vertigo Due to Posterior Fossa Mass or Infarction
is describes as what
-acute , severe vertigo (infarction ) or slow (mass)
- limb ataxia IPSILATERAL to lesion
- +/- BS signs
- +/- intractable nausea/ vomit
what are the accompanying BS signs with vertigo due to BS ischemia
– Diplopia
– Cortical blindness
– Dysarthria/Dysphagia – Quadriparesis
– Tinnitus
– Hearing loss
what does provoactive maneuvers show
nystagmus of long duration not fatigable
vestibular migraine has at lease ___ episodes & current or post history plof miagrane
5
At least 50% of viestibualr migraine episodes associated with at least one of the following migrainous features:
– Migraine headache
– Photo/phono
– Visual aura
what is the most common chronic vestibular condition
persistent postural perceptual dizziness
Diagnostic criteria:
– Non-room-spinning, unsteadiness, and difficulties with a balance must be present for most of the days over a 90 period lasting for hours.
– Symptoms cannot be provoked but can be exacerbated by changes in position and exposure to certain stimuli.
– Must be **preceded by a condition **with acute, episodic, or chronic vestibular symptoms.
– Causes impairment.
– Cannot be explained by another medical condition or disorder
this is the criteria for what
Persistent Postural-Perceptual Dizziness
what is the best treatment option for vertigo
vestibular rehabilitation
