Neurology: Head injury Flashcards by Hannah Falconer

What are the two types of insult in head injury?

Primary insult

Secondary insult

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What is a primary insult in head injury?

Focal and/or diffuse brain trauma

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What is a secondary insult in head injury?

Hypotension - low arterial BP
Hypoxia - low blood oxygen
Infection
Haematoma - bleeding/in around brain

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How is conscious level assessed?

Glasgow Coma Scale (GCS)

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What is a mild injury on the GCS?

13-15

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What is a moderate injury on the GCS?

9-12

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What is a severe injury on the GCS?

3-8

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What are the three components of the GCS?

Eye opening
Verbal response
Motor response

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What is the scale for rating eye opening in the GCS?

Spontaneous
To loud voice
To pain
None

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What is the scale for rating verbal response in the GCS?

Orientated
Confused, disorientated
Inappropriate words
Incomprehensible sounds
None

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What is the scale for rating motor response in the GCS?

Obeys
Localises
Withdraws (flexion)
Abnormal flexion posturing
Extension posturing
None

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What are some of the complications of head injury?

Permanent physical disability
Post traumatic epilepsy
Intracranial infection
Psychiatric illness
Chronic subdural haemorrhage
'Punch-drunk' dementia
Fatal

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What is the mnemonic for remembering parts of the scalp and what are they?

SCALP
S = skin
C = connective tissue
A = aponeurotic fascia
L = loose CT
P = pericranium

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What is the bone composition of the skull?

Outer and inner compact bone separated by spongy bone

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What are the brainstem and cerebellum called together?

Hindbrain

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Where in the hindbrain positioned?

Posterior cranial fossa

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What are the two elements of the skull?

Skull vault (upper part)
Skull base (upon which the brain rests)

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What does the skull vault include?

Includes frontal bone, squamous temporal bones and occipital bone, separated by sutures

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What does the skull base include?

Anterior, middle and posterior cranial fossae

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What is a linear skull fracture?

Commonly temporo-parietal from blow or fall onto side or top of the head and may continue onto the skull base

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What is a depressed skull fracture?

Focal impact which may push fragments inwards to damage the meninges, blood vessels and the brain

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What is there a risk of with a depressed skull fracture?

Meningitis and post-traumatic epilepsy

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What is a comminuted (mosaic) skull fracture?

Fragmented skull

What is a ring skull fracture?

Fracture line encircling the foramen magnum caused by a fall from height

How does a fall from height cause a ring skull fracture?

Fall from height, usually lands on feet, sometimes head, skull base and cervical spine are forced together

What is a 'contre-coup' skull fracture?

Fracturing of the orbital plates (anterior fossa) caused by a fall onto the back of the head

What is an intracranial haemorrhage?

Accumulation of blood within the rigid skull causes an increase in ICP and results in compression of the brain

What will happen if ICP continues to increase in an intracranial haemorrhage?

Death by compression of the brainstem due to herniation of the cerebellar tonsils into the foramen magnum

What does intracranial haemorrhage cause along with symptoms?

Reduction in conscious level

What is an extradural haemorrhage?

Bleeding occuring between the dura and the skull; accumulating blood strips the dura off the inner surface of the skull

How do the vast majority of extradural haemorrhages occur?

Damage to an artery in association with a skull fracture

Which artery classically causes extradural haemorrhages?

Middle meningeal artery

How do neurological symptoms develop with an extradural haemorrhage?

Accumulation of blood (haematoma) can cause raised intracranial pressure

What is a lucid interval?

Victim of injury seems to be okay without neurological symptoms but can deteriorate later

What is a subdural haemorrhage?

Bleeding occurring beneath the dura (and above the arachnoid)

What is a subdural haemorrhage usually caused by anatomically?

Bleeding from bridging veins which pass from the surface of the brain to drain into large venous channels within the dura

How can a subdural haemorrhage be caused?

Any motion which causes rotational or 'shearing' forces can cause the veins to be stretched and torn

Who is at an increased risk of subdural haemorrhage?

Those with atrophic (small) brains because the smaller brain has greater capacity for movement and the veins may be already stretched to some degree

Can lucid intervals be seen with subdural haemorrhage?

Yes

Which type of haemorrhage can often be mistaken for dementia?

Chronic subdural haemorrhage which causes chronic confusion

What is a subarachnoid haemorrhage?

Bleeding beneath the arachnoid membrane and above the brain

What is the most common cause of SAH?

Rupture of a cerebral artery (berry) aneurysm

What is SAH frequency seen in associated with?

Cerebral contusions (bruising to the brain)

What does TBSAH stand for?

Traumatic basal SAH

What is TBSAH?

Forceful impact to the upper part of the side of the neck causing abrupt rotational movement of the head leading to rupture of the vertebro-basiliar circulation and a concentration of SAH on the base of the brain

What are complications of intrinsic brain injury?

Cerebral oedema Cerebral contusion and laceration Coup contusion

What can cerebral oedema lead to?

Massive brain swelling with raised ICP and 'coning'

What is cerebral contusion and laceration?

Direct mechanical damage to the brain substance

What is a coup contusion?

Head is stuck with heavy blow and contusion is found directly under site of impact

What is a counter-coup?

Caused by moving head striking fixed object or unyielding surface, contusions are found diametrically opposite the site of head impact

What does tDAI stand for?

Traumatic diffuse axonal injury

How can a diagnosis of tDAI be made?

Microscopy of the brain tissue

What might raise suspicion of tDAI?

Concomitant damage to small blood vessels within the brain

What are usual scenarios associated with tDAI?

Vehicle collisions | Falls from heights

What is tDAI?

Serious rotational forces applied to brain tissue causing shearing of axons

Which areas of the brain are particularly susceptible to displaying tDAI?

``` Corpus callosum Para-sagittal white mater Posterior internal capsule Dorsolateral aspects of the rostral brainstem Cerebellar peduncles ```

What are victims clinically when tDAI is fully developed?

Comatose