Neuro Flashcards
You are the ED intern on duty. You are asked to see a 20 year-old who was struck on the left side of his head by a cricket ball. Initially he was drowsy and a bit confused, then he appeared to recover completely. He is now mildly confused, he has a severe headache and has vomited four times. His pulse is 60 bpm and regular, and his BP is 170/110 mmHg. During the examination his GCS drops rapidly to 8/15. What is your differential diagnosis and what investigations would you like?
DDx is an extradural haematoma. Bradycardia, HTN and irregular breathing is the Cushing triad associated with herniated brainstem.
Caused by a bleed from the MMA
Urgent non-contrast CT head. Intubate patient beforehand due to rapid deterioration
potential surgical decompression through burr hole/craniectomy. Ligation/diathermy of MMA is used to stop bleeding.
You are the ED intern on duty. You are asked to see a 20 year-old who was struck on the left side of his head by a cricket ball. Initially he was drowsy and a bit confused, then he appeared to recover completely. He is now mildly confused, he has a severe headache and has vomited four times. His pulse is 60 bpm and regular, and his BP is 170/110 mmHg. During the examination his GCS drops rapidly to 8/15. What is your differential diagnosis and what has happened to cause this problem?
DDx includes extradural haematoma, subdural, intracerebral haemorrhage, base of skull fracture, C-spine fracture.
The cause is tonsillar herniation of the brainstem through the foramen magnum causing the Cushing syndrome of Bradycardia, HTN and irregular breathing.
A 56 year-old woman is brought to the ED by her partner. She had complained of a sudden onset, severe headache immediately before collapsing, unconscious on the floor. She has regained consciousness after a few minutes, and now complains of neck stiffness. PMH is completely unremarkable, other than being a long term smoker. What is the likely diagnosis and what are the causes?
The most likely diagnosis is a subarachnoid haemorrhage.
Mostly cause through aneurysm (~85%), AV malformation (~15) and cocaine use
A 56 year-old woman is brought to the ED by her partner. She had complained of a sudden onset, severe headache immediately before collapsing, unconscious on the floor. She has regained consciousness after a few minutes, and now complains of neck stiffness. PMH is completely unremarkable, other than being a long term smoker. What is the likely diagnosis, and how would the patient’s neurological condition best be monitored clinically during initial assessment?
The most likely diagnosis is a subarachnoid haemorrhage.
The neurological condition is best monitored by serial GCS
A 56 year-old woman is brought to the ED by her partner. She had complained of a sudden onset, severe headache immediately before collapsing, unconscious on the floor. She has regained consciousness after a few minutes, and now complains of neck stiffness. PMH is completely unremarkable, other than being a long term smoker. What is the likely diagnosis and how would the diagnosis be confirmed?
Likely diagnosis is a subarachnoid haemorrhage. Confirm diagnosis with a CT head and a lumbar puncture
A 56 year-old woman is brought to the ED by her partner. She had complained of a sudden onset, severe headache immediately before collapsing, unconscious on the floor. She has regained consciousness after a few minutes, and now complains of neck stiffness. PMH is completely unremarkable, other than being a long term smoker. What is the likely diagnosis, and what is the usual treatment if this diagnosis is confirmed? - coil or clip
Subarachnoid haemorrhage with the key features of severe headache and neck stiffness.
Clipping of artery requires open surgery and involves clipping the responsible artery to prevent further bleeding
Coiling is an endovascular technique where coil, glue or mesh is placed to prevent bleeding
You are the ED intern on duty. You are asked to see a 75 year-old man who has been brought into the hospital from home where he has been becoming increasingly confused and clumsy. He was previously well and independent. He had a fall about three weeks ago, when he cut his forehead. He has little medical history of note, he used to smoke and still drinks about 30 standard units of alcohol per week. On direct questioning he is confused in time and place. Physical and neurological examination are normal. What is your differential diagnosis?
What investigations would you like?
DDx is a subdural haemorrhage.
Investigations include CT head, FBC, coags, LFT, UEC, urinalysis, blood glucose, blood alcohol
Cortical bridging veins are damaged in a subdural. These veins drain into the superior sagittal sinus.
You are the ED intern on duty. You are asked to see a 75 year-old man who has been brought into the hospital from home where he has been becoming increasingly confused and clumsy. He was previously well and independent. He had a fall about three weeks ago, when he cut his forehead. He has little medical history of note, he used to smoke and still drinks about 30 standard units of alcohol per week. On direct questioning he is confused in time and place. Physical and neurological examination are normal. A CT head shows a subdural haematoma. What has happened inside this man’s head?
What treatment is required?
Subdural haematoma is due to a break in the cortical bridging veins. The initial break in the veins came three weeks ago, and blood has slowly pooled out and increased ICP to the point where he is now experiencing symptoms. Bridging veins bridge the cortical veins and superior sagittal sinus.
Treatment required is a surgical decompression through a burr hole or a craniectomy. No clipping or ligation is required.
The length of time for presentation in elderly is also increased due to age related atrophy increasing the potential space for the haematoma.
What is the importance of the primary and secondary brain injuries when managing an acute head injury?
Identification is important to improve outcomes and reduce morbidity. Primary brain injuries occur at the time of injury, whereas secondary brain injuries occur as a result of the primary trauma.
Primary injury include base of skull fracture, brain contusion, haemorrhage or diffuse axonal injury.
Secondary injury includes increased ICP, cerebral oedema, ischaemia, hypoxia, hypotension, metabolic imbalance, cytotoxicity, infection
What are the methods most commonly used for clinical assessment of a head injury?
Clinical assessment includes GCS scoring, vital signs, CN exam and mental state exam.
Short history and examination can be performed.
CT head
