Neurology #5 Flashcards
A subarachnoid hemorrhage is MC due to
A ruptured berry aneurysm at the anterior communicating artery
Risk factors for a subarachnoid hemorrhage
- Smoking
- Hypertension
- PKD, CAD, smoking, alcohol, marfan Syndrome, family history
Symptoms of a subarachnoid hemorrhage
- Sudden, intense thunderclap headache
- Worst headache of my life
- Nausea, vomiting, meningeal symptoms (neck stiffness, fever, photophobia)
- May have LOC initially
Diagnostics for a subarachnoid hemorrhage
- CT scan without contrast: initial
- LP: xanthrochromia (yellow-pink color of CSF due to breakdown of RBCs)
What diagnostic is done AFTER confirmed subarachnoid hemorrhage to identify source of bleeding and other aneurysms?
4-vessel angiography
Treatment for a subarachnoid hemorrhage
-Supportive: bed rest, stool softeners, lower intracranial pressure (Nimodipine)
How to prevent a rebreeding of a SAH
-Endovascular coiling or surgical clipping of aneurysm or AVM
Lowering the BP may reduce the risk of rebleeding in a SAH. What medications are preferred?
Labetolol, Nicardipine, Enalapril
What medications are given to reduce increased intracranial pressure, in an intracerebral hemorrhage?
IV mannitol
Physical exam signs of a basilar skull fracture
- Periorbital ecchymosis (Raccoon eyes)
- Mastoid ecchymosis (Battle Sign)
- Hemotympanum (blood behind TM)
- Rhinorrhea (CSF leak)
True or False: most basilar skull fractures are nonoperative without underlying brain injury?
True
What is a Jefferson (Burst) Fracture?
Fracture of the Atlas (C1)
-Bilateral fractures of both anterior and posterior arches of the atlas
Stability of the Burst/Jefferson Fracture is determined by what?
Involvement of the transverse ligament
Mechanism of injury for a Burst/Jefferson Fracture
-Axial load on the back of the head or hyperextension of the neck (diving)
What two views of XR are ordered with a Burst Fracture?
- Lateral radiographs: increase in predental space between C1 and odontoid (Dens)
- Odontoid views: step off of lateral masses of atlas
Management, both nonoperative and operative, for a Burst Fracture
- Nonoperative: external immobilization for 6-12 weeks for stable fractures
- Operative: C1-C2 fusion if unstable
An odontoid fracture (fracture of dens/odontoid process of the axis/C2) is from what?
Head placed in forced flexion or extension in anterior-posterior orientation (forward fall onto the forehead)
With a hangman’s fracture (C2/axis pedicle) fracture, what is one complication that can occur?
Spondylolisthesis between C2 and C3 (anterior dislocation of C2)
MOA of a Hangman’s Fracture
-Extreme hyperextension (MVA, chin hitting the steering wheel)
What is the difference between a nonoperative and an operative Hangman’s Fracture?
Nonoperative (Type I): < 3 mm horizontal displacement = right cervical collar for 4-6 weeks. (Type II) 3-5 mm displacement = closed reduction and immobilization 8-12 weeks
Operative (Type II): > 5 mm displacement with angulation
What is a Clay-Shoveler’s Fracture?
Spinous process avulsion fracture (C6-T3)
Where does a Clay Shoveler’s Fracture MC occur?
C7 MC
MOA of a Clay Shoveler’s Fracture
Forced neck flexion after sudden deceleration injuries (MVA)
-Usually a stable injury
Treatment for a Clay Shoveler’s Injury?
Nonoperative: NSAIDs, rest, immobilization for support
Surgical excision only needed if persistent pain or nonunion
What is subclavian steal syndrome?
Signs and symptoms due to retrograde blood flow from vertebral artery to ipsilateral arm as a result of decreased flow into the subclavian artery
MC etiology of subclavian steal syndrome
Atherosclerosis of subclavian artery
-Others: dissecting aortic aneurysm, thoracic outlet syndrome
Symptoms of subclavian steal syndrome
- Arm arterial insufficiency: arm claudication with exercise, paresthesias
- Vertebrobasilar insufficiency: syncope, neuro deficits, vertigo, weakness
What is seen on physical exam of a patient with subclavian steal syndrome?
Blood pressure difference between the arms ( > 15 mmHg) compared to unaffected arm
-Radial pulse diminishes with arm elevation or exercise
Treatment for subclavian steal syndrome
-Revascularization or percutaneous transluminal angioplasty
Deficits of an anterior cord injury
- Motor deficit: lower extremity > upper extremity
- Sensory deficit: pain, temperature, light touch
- May develop bladder dysfunction
-Preserved: vibration pressure, proprioception, light touch
Deficits of a central cord injury
- Motor: upper extremity > lower extremity
- Sensory: pain, temperature (in upper > lower) = shawl distribution
- Preserved: proprioception, vibration, pressure
Deficits of a posterior cord injury
- Motor: NONE
- Sensory: loss of proprioception and vibratory sense only
- Preserved: pain, light touch, no MOTOR DEFICITS
What is Brown-Sequard Syndrome?
- Ipsilateral deficits
- -Motor
- -Vibration and proprioception
- Contralateral Deficits
- -pain and temperature
