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NEUROMUSCULAR > lecture 6: head trauma , seizures, headache and vertigo > Flashcards

lecture 6: head trauma , seizures, headache and vertigo Flashcards

1
Q

what is the primary external cause for a TBI

A

falls

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2
Q

TBI rates of death were highest for people ____ years of age

A

> 75

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3
Q

what is the leading cause of a TBI related death from a
>65
25-64
5-24
0-4

A

falls
intentional self harm
motor vetichle crashes
assaults

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4
Q

what scale is used for TBI screen and assess eyes opening , verbal response and best motor response

A

glasgow coma scale

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5
Q

what is the total scare for the glasgow coma scale ? and what is worse and what is better

A

3-15
3 is worse (dead basically)
15 is normla

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6
Q

75% of cases of TBI’s are ___

A

concussion/mild

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7
Q

if someone has a glasgow coma scale of 13-15 what does that indicate

A

mild tbi

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8
Q

how is a mild tbi/concussion defined

A

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

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9
Q

if someone has a GCS score of 9-12 whst can we indicate

A

moderate TBI

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10
Q

what kind of TBI is Usually associated with prolonged LOC +/- neurologic deficit

A

moderate

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11
Q

if someone has a GCS of <8 what can we suspect

A

severe TBI

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12
Q

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

A

severe

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13
Q

how is the recovery for a severe TBI

A

prolonged and often incomplete

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14
Q

what is the difference between a penetrating and non penetrating head injury

A

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)

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15
Q

what is the difference between coup and counter coup

A

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

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16
Q

what is the first phase of a TBI

A

direct consequence of trauma
diffuse axonal injury

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17
Q

what is the second phase of a TBI

A

– Begins quickly after primary phase
– Hypoxia and hypoperfusion
– Inflammation

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18
Q

what is the neurological assessment for a head injury

A

glasgow coma sale

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19
Q

what is anisocoria

A

pupil size difference

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20
Q

what are the localizing signs for a head injury

A

• Anisocoria (pupil size differences)
• Diplopia due to CN palsies
• Absence of gag (glossopharyngeal -> vagal)
• Abnormal breathing patterns

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21
Q

if someone has a head injury and their pupils are dilated , fixed what is damages

A

CN 3 (uncal)

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22
Q

if someone has a brain injury are their pupils are large , “fixed”, hippus what is damaged

A

pretectal

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23
Q

if someone’s pupils are pinpoint after a head injury what is damaged

A

pons

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24
Q

if the pupils are in midposition and fixed after a brain injury what is damaged

A

midbrain

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25
Q

if someone has a brain injury and there pupils are small , reactive what is damaged

A

diencephalic

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26
Q

decerebrate posture results from damage to what ?and how will someone look in this position

A

upper brain stem and the position is extended

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27
Q

decorticate posture results from damage to what ?and how will someone look in this position

A

one or both corticospinal tracts
position is flexed

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28
Q

where is the bleeding happening for the following hemorrhages

intracerebral
subarachnoid
subdural
epidural

A

inside the brain
in the subarachnoid spaces
b/t arachnoid matter and dura matter
b/t dura matter and skull

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29
Q

what kind of hematoma usually follows a low velocity injury

A

subdural

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30
Q

epidural hematoma is bleeding from ____ ____ or ____ and is torn by a ____ or ____ fc

A

meningeal artery or vein
temporal or parietal fracture

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31
Q

what kind oat hematoma will someone have a “lucid interval”

A

epidural

which means they nay be good st first and talking then hours later they die

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32
Q

what is the shape of the clot for an epidural hematoma

A

lens shaped

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33
Q

what is the sequelae of head injury

A

• Hydrocephalus
• CSFleak
• Subarachnoidhemorrhage
• Vascularinjury
• Infection

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34
Q

what syndrome will someone have Headache, fatigue, dizziness, difficulty concentrating, disturbed sleep, anxiety, depression. May persist months to years.

A

post concussion syndrome

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35
Q

what is – Trauma induced alteration in mental status that may or may not involve loss of consciousness

A

concussion (mild TBI)

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36
Q

what is the hallmark of concussions

A

confusion and amnesia

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37
Q

how long does a concussion last and when do the symptoms start

A

lasts up to 1 month and symptoms can start early or later

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38
Q
  • 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

A

concussion

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39
Q

– Inattention
– Slowed thinking
– Confusion
– Amnesia
– Disorientation
– Vacant stare
– Loss of Consciousness

these are all mental symptoms of what

A

concussion

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40
Q

– Emotional lability
– Depression – Anxiety
– Mania

these are all affective symptoms of what

A

concussion

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41
Q

– Increased sleep latency
– Frequent waking
– Increased or decreased sleep time

these are all sleep symptoms of what

A

concussion

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42
Q

what sports related concussion are highest in boys

A

football, ice hockey, lacrosse > soccer, wrestling, basketball

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43
Q

what sports related conccusion are highest in girls

A

-soccer
-ice hockey
-lacrosse
-basketball

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44
Q

are female or males higher for sports concussion injury

A

female

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45
Q

a CT head should not be utilized to diagnosis a sports related concussion but rather what..

A

to exclude more severe traumatic brain injury

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46
Q

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

A

step 3 : non contact training drills

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47
Q

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

A

24 hours

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48
Q

how long are symptoms persist for post concussive syndrome

A

> 1 month

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49
Q

what is a chronic traumatic encephalopathy

A

spectrum of disorders aosscited with long term consequences of a single or repetitive TBI

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50
Q

what are some of the behavioral changed seen with chronic. traumatic encephalopathy

A

• Aggression
• Agitation
• Impulsivity
• Depression
• Suicidality

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51
Q

what motor involvement is invovled with chronic traumatic encephalopathy

A

• Dysarthria
• Spasticity
• Motor neuron disease
• Parkinsonism, tremors
• Ataxia

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52
Q

• 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 ?

A

get him to bed and lying on side with rails up
do not put anything in his mouth
push the nurse call button

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53
Q

what is the leading causes for epilepsy

A

brian tumor

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54
Q

 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

A

seizure

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55
Q

what is Two or more unprovoked seizures separated in time by greater than 24 hours or single seizure with heightened risk of future seizures

A

epilepsy

56
Q

what are 2 examples of genetic syndromes of epilepsy

A

Juvenile myoclonic epilepsy, Lennox-Gastaut

57
Q

any lesion to disrupt neuronal network: stroke, hemorrhage, tumor, encephalitis, meningitis, gliosis from trauma or severe hypertension.. this is what kind of epilepsy

A

structural

58
Q

hypo-/hyperglycemia; hypocalcemia, hyponatremia, uremia, drugs or illicit substances… these are what type of epilepsy etiology

A

metabolic

59
Q

what is Lennox-Gastaut

A

multiple different sezuire types

60
Q

what is the most common causes of epilepsy world wide

A

infections

61
Q

– GAD65
– Rasmussen syndrome

these are what kind of etiology for epilepsy

A

immune

62
Q

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

A

focal onset seizure without loss of awareness (AKA: simple partial seizures

63
Q

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

A

focal onset seizure with loss of awareness (complex partial seizures)

64
Q

• 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

A

temporal lobe

65
Q

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

A

frontal lobe

66
Q

what sezuire is Sudden onset of unresponsiveness lasting seconds, with interruption of ongoing activity but no loss of muscle tone.

A

absence

67
Q

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

A

absence seizures

68
Q

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

A

generalized tonic clonic seizures

69
Q

what are myoclonic seizures

A
  • SINGLE brief jerks
  • many involve any limbs or all
  • occur with other seizures
    -Ictal EEG shows generalized spike and wave
70
Q

is all myoclonus a seizure ?

A

no

71
Q

what is a atonic seizure

A

-head drop
-falls forward

VERY HARD TO CONTROL

72
Q

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

A

FEBRILE SEZIURE

73
Q

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 ???

A

no epileptic event

74
Q

is someone is experiencing syncope what may happe??

A

-lightheaded , dizzy , sweating
-change of vison
-sweating and pallor
-urinary incontinence

75
Q

after a seizure what will most people need

A

EEG and contrast MRI of brain to see if high risk for reoccurrence

40% of epilepsy patients will have normal initial EEG

76
Q

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

A

status epilepticus

77
Q

who is most likely to be diagnosed with epilepsy syndrome

A

children

78
Q

what is the recommendation for treating seizures in children

A

treat after 1st seizure when risk of 2nd seizure outweighs risk of drug side effects

79
Q

___ ideation is black box warning on many AEDs on current market

A

Suicidal

80
Q

what are the general side effects of AEDs

A

-somnolence (excessive sleepiness)
-nausea
-ataxia
-nystagmus
-confusion
-rash

81
Q

what is the side effects of Valproic acid medications for epilepsy

A

weight gain
tremor

82
Q

what is the side effects of phenytoin medications for epilepsy

A

gum hyperplasia , cerebellar ataxia, rash

83
Q

what is the side effects of topiramate medications for epilepsy

A

kidney stones
cognitive
weight loss

84
Q

what is the side effects of carbamazepine medications for epilepsy

A

dizzy , N/V , rash

85
Q

what is the side effects of levetriaceatam medications for epilepsy

A

behavioral changes , psychosis

86
Q

• 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

A

epilepsy

87
Q

Migraine (with or without aura), tension HA, cluster HA… these are all what kind of headache disorders

A

primary

88
Q

brain tumor, increased intracranial pressure, meningitis, encephalitis, aneurysm, hypertension… these are all examples of what kind of HA disorder

A

secondary

89
Q

what are one of the most common reasons patients visit. a primary care physician or ER

A

HA

90
Q

are most headaches primary or secondary

A

primary

91
Q

what are the red flags for headaches

A

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

92
Q

– 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

A

secondary

93
Q

• 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 ??

A

no things migraine

94
Q

when is the peak onset for migraine

A

20-24 for women and 15-19 for male

95
Q

what is the highest indecenc for migraines

A

between 20-35

96
Q

what is the criteria for a migraine

A
  • > 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 )

97
Q

this decribes what aura .. positive scintillating scotomata with fortification spectra (like bright flashing lights with blindness)

A

classic

98
Q

what is a stereotypes prodromal symptoms for migraine with aura

A

aura … can be visual , motor , sensory or cognitive

99
Q

are migraine with aura or without aura more common

A

without

100
Q

what are the 3 pronged treatment or HA

A

lifestyle changes
acute abortive >3 days
prophylaxis > 5

101
Q

what is the medication that is taken everyday with HA

A

prophylaxis

102
Q

when should u consider to take prophylaxis for HA

A

-when they interfere with patients life
- HA are frequent or prolonged
- atypical migraines

103
Q

if someone has a HA lasting longer then 5 days what shoudl they take

A

prophylaxis

104
Q

what could possibly works on inhibition of the peripheral and central sensitization of the trigeminovascular neurons

A

botulinum toxin (botox)

105
Q

how many injections would someone get for botulinum toxin for chronic migraines

A

31

106
Q

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
A

analgesic rebound/withdrawal headache

107
Q

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

A

cluster

108
Q

• 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

A

secondary

109
Q

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
A

tension

110
Q

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

A

tension type

111
Q

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

A

facial pain (trigeminal neuralgia)

112
Q

• 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

A

trigeminal neuralgia (tic douloreux)

113
Q

what is the medical treatment from trigeminal neuralgia

A

carbamazepine, oxcarbamazepine

114
Q

what is the sx treatment for trigeminal neuralgia

A

microvascular decompression of trigeminal ganglia

115
Q

what is defined as the sensation that u are moving

A

vertigo

116
Q

what is defined as the sensation that the world is moving

A

opscillopsia

117
Q

u want to figure out if the vertigo is cerebellar or vestibular related what would u do

A

finger to nose for cerebellar and balance for vestibular

118
Q

if vertigo has to do with the vestibular portion of CN VIII , vestibular nuclei with brainstem and center connection what is the localization

A

central

119
Q

if there is dysfucntion of the semicircular canals , utricle and saccule what locatiation of vertigo is it

A

peripheral

120
Q

– Peripheral vestibulopathy
– Benign paroxysmal positional vertigo (BPPV) – Ménière’s disease
– Vertebrobasilar ischemia
– Migraine (rare)
– Seizures (rare

these are DD of attacks of what

A

vertigo

121
Q

– Peripheral vestibulopathy – Cerebellopontine tumor – Multiple sclerosis
– Brainstem infarct
– Ototoxic drugs

these are DD of what

A

chronic vertigo

122
Q
  • Most common cause of recurrent vertigo
  • Most episodes last a few weeks,but maybe
    recurrent, can persist for years

what vertigo is this

A

Benign Paroxysmal Positional Vertigo
(BPPV)

123
Q

Benign Paroxysmal Positional Vertigo is an episodic vertigo lasting how long and what is it triggered by

A

10-30 seconds
-tilting the head
-rolling over
-straightening after bending

124
Q

in Benign Paroxysmal Positional Vertigo 85% is due to involvement of what canal

A

posterior semicircular

125
Q

what test is used for Benign Paroxysmal Positional Vertigo

A

dix hallpike (vertigo)

126
Q

• 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

A

Peripheral Vestibulopathy: “Viral Labyrinthitis” and Vestibular Neuritis

127
Q
  • 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

A

ménière’s disease

128
Q

Vertigo Due to Posterior Fossa Mass or Infarction
is describes as what

A

-acute , severe vertigo (infarction ) or slow (mass)
- limb ataxia IPSILATERAL to lesion
- +/- BS signs
- +/- intractable nausea/ vomit

129
Q

what are the accompanying BS signs with vertigo due to BS ischemia

A

– Diplopia
– Cortical blindness
– Dysarthria/Dysphagia – Quadriparesis
– Tinnitus
– Hearing loss

130
Q

what does provoactive maneuvers show

A

nystagmus of long duration not fatigable

131
Q

vestibular migraine has at lease ___ episodes & current or post history plof miagrane

A

5

132
Q

At least 50% of viestibualr migraine episodes associated with at least one of the following migrainous features:

A

– Migraine headache
– Photo/phono
– Visual aura

133
Q

what is the most common chronic vestibular condition

A

persistent postural perceptual dizziness

134
Q

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

A

Persistent Postural-Perceptual Dizziness

135
Q

what is the best treatment option for vertigo

A

vestibular rehabilitation

NEUROMUSCULAR (15 decks)

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