Lecture 9 Head Trauma, Seizures, Vertigo Flashcards
What is the most common cause of traumatic brain injury in the US?
Falls
The rate of death due to traumatic brain injury is highest above what age?
75
Most common cause of TBI per age group?
0-4
5-24
24-64
65+
assault
motor vehicle
intentional self harm
falls
What are the 3 categories of the glasgow coma scale?
How is it scored
Eye opening
verbal response
best motor response
3 (worst) - 15 (best
75% of TBIs are what?
Where does this rank on the glasgow coma scale?
concussion or mild TBI
13-15
Moderate TBI is what score on the glasgow coma scale?
9-12
usually associated w/ prolonged loss of conciousness and neurological deficit
Severe TBI is what glasgow coma score?
Under 8
Coup vs Contrecoup
Coup- the site of the original impact
contrecoup - where your brain bounces off of due to momentum from initial impact (opposite side of coup)
penetrating vs nonpenetrating head injury
penetrating usually causes mod-severe tbi
In an MRI you’ll see _____ on one side and _____ on the other side after a traumatic brain injury
bleeding - on side of original impact
swelling on side of contrecoup
TBI first and second phase
First phase- direct consequences of trauma
second phase - hypoxia and hypoperfusion + inflammation injury
What is the monroe kellie doctrine?
Only so much volume can fit inside the skull
brain + CSF + Blood …..
tumor? Extra fluids? swollen brain? = bad
What kind of herniation is E
tonsillar herniation
What kind of herniation is A??
Cingulate herniation
What kind of hernation is B
Uncal herniation
What kind of herniation is C?
Central herniation
What CN could be affected if you have an abscence of gag reflex?
9 or 10
What are pupil size differences called?
anisocoria
How will the pupils look if the pons is injured?
Both pinpoint (very small)
How will the pupils look if CN3 is injured?
One will be very dilated
How will the pupils look if the pretectal area is damaged?
large pupils that do not constrict w/ light
What kind of posturing is this?
What is damaged?
Decorticate posturing
Both or one corticospinal tracts
What kind of posturing is this?
What is damaged?
Decerebrate
Upper brainstem
What kind of imaging is best for showing blood in brain
GRE (its a kind of MRI)
bleeding inside the brain is called
intracerebral hemorrhage
bleeding into the subarachnoid space is called
subarachnoid hemorrhage
bleeding between the arachnoid and dura is called
sub dural hemorrage
bleeding between the skull and dura is called
epidural hemorrage
What kind of hemorrage is this?
subdural
usually blood across the whole hemisphere
What normally causes a subdural hematoma?
Low velocity injury
What kind of hematoma is this?
Epidural
usually a lens shape
What is an epidural hematoma usually from??
Bleeding from meningeal artery or vein torn by temporal or parietal fx
What kind of hematoma usually has a lucid interval where they seem ok before they are comatose
epidural hematoma
How does postconcussion syndrome present?
Headache, fatigue, dizziness, difficulty concentratng, disturbed sleep, anxiety, depression
lasts for months to years
What are the 2 hallmarks of a concussion?
Confusion and amnesia
How long can a concussion last?
1 month
anything over 1 month is post-concussion syndrome
Which gender has more risk of concussion for comparable sports?
Is concussion risk higher in competition or practice?
Female
competition
Highest risk sports for concussion in boys?
Highest risk in girls?
Football, hockey, lacrosse soccer wrestling basketball
Soccer, hockey, lacrosse, basketball field hockey, softball, gymnastics
why is history of prior concussion a major riskfactor for concussions
because subsequent concussions will be worse
How to handle a concussion in sports participants?
Standardized symptom checklist administered
if concussion is suspected- remove player from play
CT head scan should not be utilized unless we suspect more severe traumatic brain injury
What are 4 symptoms that will warrant a CT head scan in a player whos had a concussion
- glasgow coma scale < 15
- deteriorating mental status
- potential spinal injury
- progressive worsening symptoms or new neurological signs
Individuals supervising a player w/ a concussion should only allow return to sport (play or practice ) after….
LHCP has determined the concussion has resolved
additionally only after theyre asymptomatic and off any medication
What are the steps of the concussion return to play protocol
Baseline (no activity)
step 1: Light aerobic
step 2: sport specific aerobic
step 3: non contact training drills
step 4: practice w/ full contact
step 5: return to play
How does the return to play protocol progress?
Player must be asymptomatic for 24 hours before moving onto the next step
if they have symptoms they go back 1 step
post concussive syndrome is when symptoms persist more than
1 month
What are the symptoms of post concussion syndrome
persistent low grade headache and light headedness
poor attention/memory/concentration
depression anxiety irritability
intolerance of noise and lights
sleep disturbances
What is Chronic Traumatic Encephalopathy
Spectrum of disorders associated w/ long term consequences of single or repetitive TBI
seen in contact sports
years of play increase risk
What are the symptoms of CTE
Behavioral changes are the earliest manifestation
- agression
- agitation
cognitive impairment develops overtime
- can progress to dementia
motor involvement
- dysarthria
- spasticity
- looks like parkinsons disease
- ataxia
If a patient is having a seizure what should you do
put him in bed, lying on side, rails up, protect patient from injury
dont put anything in their mouth
someone must stay w/ them
be ready to describe the seizure to nurse or doctor
Why should we time a seizure?
Should resolve in 1-2 minutes
more than 5 they might need medication or 911
What are the most common causes of seizure?
Brain Tumor, subarachnoid hemorrage, severe TBI
Seizure vs Epilepsy
Seizure - single unprovoked or provoked episode
Epilepsy - two or more unprovoked seizured separated by more than 24h
Episode of transient behavioral/sensory/motor/visual symptoms associated w/ abnormal excessive cortical activity in the brain
seizure
note: 8-10% of the population will have a seizure
Focal vs generalized seizure
focal- starts in one area of the body, easy to localize in brain
generalized - not easy to localize
Seizure etiology
Genetic:
Structural:
Genetic: gene mutations
structural: any lesion that disrupts neural networks
How can the metabolic system cause a seizure?
hypo or hyperglycemia
hypocalcemia
hyponatremia
uremia
drugs
What is the most common etiology of a seizure world wide
Infectious
HIV, Malaria, Congenial Zika, Congential CMV, Neurocysticercosis
Seizure that begins on one side of the body
Does not impair conciousness
Motor involvement, clonic or tonic
Sensory: Paresthesias, visual hallucinations
EEG with contralateral focal discharge
“Focal Onset seizure without loss of conciousness”
AKA
Simple Partial Seizure
How can simple partial seizures present?
Visual- seeing flashes
Auditory: hearing ringing or hissing
Focal motor: tonic clonic movements of upper or lower limbs
facial- grimancing
autonomic- sweating/flushing/epigastric sensations
What is a Complex partial seizure also called
focal onset seizure with loss of awareness
Seizure w/o loss of awareness lasting seconds
OR
with loss of awareness usually more than 1 min
sensory aura- olfactory, auditory hallucinations, epigastric rising
experiental aura- psychic feeling, de ja vu
autonomic aura- flushing nausea pallor
aphasia if dominant side is affected
typically followed by confusion, fatigue, gradual recovery
temporal lobe seizure
just think that temporal lobe processes sensory so a temporal lobe seizure has a lot to do with sensory
Seizure that occurs in clusters at night
brief in duration
may have aura
early posturing or clonic activity
may have large amplitude, irregular, complex movements
autonomic features
brief post-ictal phase (recover)
Frontal lobe seizure
Sudden onset of unresponsiveness lasting seconds with interruption of ongoing activity but no loss of muscle tone (patient can stay standing)
patient returns to normal activity (no post-ictal state)
EEG with generalized 3Hz spike and wave
abscence seizure
What kind of seizure is common in children
absence seizure
can explain why some children may appear to underpreform in school/lose concentration, this kind of seizure is hard to spot
Sudden onset of loss of conciousness with onset of rigid muscle tone (tonic phase) followed by rhythmic convulsive movements lasting up to several minutes (clonic phase)
post-ical somnolences lasts minutes to hours (confusion afterwards)
Ictal EEG shows bilateral discharges
Generalized tonic-clonic seizure
Tonic vs Clonic phase of a seizure
Tonic - generalized stiffness of limbs w/ back arched
Clonic - jerks of limbs, body, and head
What is a myoclonic seizure?
Single brief jerk
may involved any or all limbs or the torso
typically occur with other generalized seizures
NOT ALL MYOCLONUS IS A SEIZURE
What is a seizure called where the person collapses/falls foward/their head drops
atonic seizure
Seizure that occurs in 2-5% of children, occurs when they have a FEVER
most occur between 6 months to 3 years
33% will have atleast one recurrence 10% will have 3 or more
febrile seizure
What is the prognosis like for febrile seizures?
excellent
no antiepileptic drugs needed, diastat can be taken as needed
Is it possible to have bilateral seizure symptoms and remain concious
No
What is NOT a seizure?
Prolonged duration
gradual onset
thrashing, struggling, crying, pelvic thrusting
motor activity that starts and stops
arrhythmic jerking
retaining conciousness despite bilateral jerking
Preceded by lightheadedness, dizziness, sweating
whitening/graying out of vision
sweating/pallor
more rapid recovery
may have urinary incontinence
syncope
During clinical evaluation after a seizure most will need a….
EEG and contrast brain MRI
note: 40% of epilepsy patients will have normal EEG
generalized seizure activity lasting 5+ minutes or multiple seizures without return to conciousness of 5+ minutes
morbidity and mortality risk increases w/ duration
rapid diagnosis and treatment necessary
status epilepticus
Risk of second seizure after first is ________
risk of third seizure after second?
33%
76%
note: treatment in adults after 1st seizure reduces risk of second by 35% over 2 years
______ are more likely to be diagnosed with epilepsy syndrome
children
note: recommendation is to consider treating children after first seizure when risk of second outweighs risk of pharmacological side effects
What is a common side effect of seizure medication?
suicidal ideation
note: also somnolence, nausea, ataxia, nystagmus, confusion, RASH
Primary vs secondary headache disorders:
Primary- Migrane, tension HA, Cluster HA
Secondary- Brain tumor, increased intracranial pressure, meningitis, encephaliits, aneurysm, hypertension
note: more than 90% of headaches are primary
How to differentiate primary from secondary headaches
neuro red flags and atypical features
What are redflags of headaches?
SSNOOPPPP
- Systemic Symptoms
- Secondary Disease
- Neurologic symptoms
- Onset - sudden abrupt
- Older - new onset and progressive in person over 50
- Previous headache history- first headache or difference
- Positional
- Papilledema
- Precipitants - cough, valsalva
Migranes affect what sex more?
18% of women and only 6% of men
What is the IHS criteria for migranes?
5 or more headaches lasting 4-72 hours
2 out of 4 of these symptoms:
- throbbing
- unilateral
- moderate to severe
- worse w/ activity
1 out of these 2:
- nausea and/or vomiting
- photophobia and phonophobia
What is a migraine with an aura?
10% of all migranes
aura is a stereotyped prodromal symptoms
fortification spectra - visual illusion where you see things that look like layers of walls surrounding a castle
What are the two types of migranes?
Migrane w/ an aura
migrane w/o aura
When should a patient use prophylaxis to treat migranes
when the migranes significantly interfere w/ patients life
last 2-3 days 1-2 per week
patient cant use or overuses acute treatments
atypical migranes
4 medication w/ A level evidence for migrane
Topirmate
Betablockers
CGRP antagonist
Valproic acid
What is botulinum toxin
(botox)
31 injections to the head neck and shoulders
indicated for chronic migranes
inhibits central and peripheral nervous system
Analgesic/withdrawal headache symptoms
Very common / underdiagnosed
worse in AM after not having medicine in system overnight
due to drop in blood levels
Cluster headaches usually affects who at what age?
- usual onset is in 20s
- more commonly affects men
- no association with migranes
- 50x less common than migranes
____________ are a major symptoms in 30% of patient’s w/ brain tumors
headaches
note: only 1% of brain tumor present w/ ONLY a headache, most will have neurological symptoms
Headache w/ a tight band around head, sense of pressure, bursting
May be perceived as continuous for months or even years
Tension type headache
Vertigo vs Opscillopsia
Vertigo- sensation that you’re spinning
Opscillopsia - sensation that the world is moving
What is the goal when examining someone w/ vertigo
distinguish between central and peripheral
What does a positive head impulse test mean?
Peripheral vertigo
Most common reoccurent cause of vertigo?
BPPV
What canal is most commonly affected by BPPV
85% in posterior semicircular canal
how do you treat bppv?
dix hallpike
How to distinguish vestibular neuritis from other problems?
- (+) tinnitus
- hearing loss
Veritgo is CONSTANT
How does Ménière’s disease present
- feeling of fullness of ear
- tinnitus
- hearing loss, often progressive
What are the signs of vertigo due to posterior fossa mass or infarction?
- (+) Brainstem signs
- (+) intractable nausea/ vomiting
- decreased level of conciousness
- Acute severe vertigo (infarction) OR Progressive slow vertigo (mass)
What are the accompanying signs for Vertigo d/t Brainstem Ischemia?
- Diplopia
- Cortical blindness
- Dysarthria/Dysphagia
- Quadriparesis
- Tinnitus
- Hearing Loss
Provacative maneuver shows nystagmus of long duration, NOT FATIGUABLE
to remember: 2 eyes, 2 mouth, 4 limb, 2 ear issues
Chronic vestibular condition where patient has dizziness (not vertigo)
They do not fall
persistent postural perceptual dizziness
how do PTs treat vertigo?
Vestibular rehabiliation ( balance gaze stabilization)
