Neuropsychiatry

Question 1

what are the most commonest causes of traumatic brain injury?

Answer 1

MVA
Falls
Assaults

Question 2

what are the 2 mechanisms of pathophysiology for traumatic brain injury

Answer 2

Focal pathology- lesions of scalp/skull/dura; contusions, haematomas

Diffuse axonal injury

Question 3

Tell me about diffuse axonal injury?

Answer 3

acceleration/deceleration causes traumatic shearing of white matter in brain

• often not seen on first presentation/delayed presentation
• may be difficult to see radiologically as well
• need MRI to find it, but even then it can miss it

Question 4

what are some ways we can assess the severity of traumatic brain injury?

Answer 4

1. duration of loss of consciousness/coma
2. Measure initial GCS and compare
3. duration of post traumatic amnesia

Question 5

how might we monitor post traumatic amnesia?

Answer 5

Westmead PTA scale
Daily measurement

• can be unhelpful in severe PTA, and also presents logistical issues

Question 6

what is post traumatic amnesia?

Answer 6

-period from time of TBI to return of continuous memory and orientation

Question 7

what are some features of post traumatic amnesia?

Answer 7

Includes LOC, amnesia + disorientation, no continuous day to day memory, dream-like state

Poor attention/concentration
altered sleep/wake cycle
Fatigue
Irritable/agitation

Question 8

how might we manage post traumatic amnesia?

Answer 8

no curative treatment, self limiting usually.

Management is supportive and aims to minimise complications such as malnutrition, prevent contractures etc

Question 9

how might we manage an agitated PTA patient?

Answer 9

first line- modify the environment. Calm safe environment, structured, little external stimuli, non-threatening environment for patient

second line- Propranolol or mood stabilisers like carbamazepine

Question 10

tell me about the westmead PTA scale?

Answer 10

a series of 9 questions and 3 pictures, patient needs to answer all questions and identify all pictures correctly. if one is incorrect, there is cognitive impairment.

When patient achieves 12/12 on three consecutive days, then the PTA period is said to have ended

Question 11

how do we manage patients who have come out of PTA?

Answer 11

Through an individualised, goal oriented, interdisciplinary approach- i.e. cognitive rehabilitation.

Get a neuropsych assessment to assess cognitive state + competency!!

Cognitive rehab includes both cognitive remediation (ADL based) and behavioural management (identify behaviour and triggers)

Educate family/carers/patients about PTA.
No alcohol for 12 months.

Think about ‘graduated rehabilitation’. Gradually getting the patient back to driving, back to work/study, back to premorbid function

Refer to appropriate community services for support, and they may require an OT driving assessment and medical clearance before going back to driving.

Ensure follow up is made

Question 12

what allied health staff do you want to get involved with traumatic brain injuries?

Answer 12

Neuropsychologists!! Physiotherapists/occupational therapy etc if required

Question 13

what comprises of a neuropsychological assessment?

Answer 13

Looking at the strength and weaknesses in 6 areas of cognition:

1. attention
2. memory
3. language
4. visual spatial
5. executive functions
6. personality

Question 14

what are some factors that you have consider before conducting a neuropsychological assessment?

Answer 14

premorbid intellectual status
substance abuse
fatigue

Question 15

a young patient comes in to see GP with tiredness, headache and difficulty concentrating a few months post concussion. what are your steps with management?

Answer 15

1. assess whether the patient has mild PTA- look at past medical records for GCS at time of insult or hospital progress
2. if none available- can order ix like CTb or MRIbrain
3. Get neuropsychology assessment
4. neuro and depression screen examination
5. organise family meeting, patient education: explain assessment, talk about management of behaviours, explain seizure risk, recommend cutting out alcohol/recreational drug use
6. arrange follow up

Question 16

what is the most common symptom of mild traumatic brain injury?

Answer 16

headache

Question 17

what does BPSD stand for? how might we manage it?

Answer 17

behavioural and psychological symptoms of dementia

1. non-pharmacological approaches first including supporting carers
2. risperidone/olanzapine

Question 18

what are symptoms of PTA may persist in the post PTA period?

Answer 18

Memory impairment
Reduced attention
Reduced speed of processing
Change in behaviour and or personality

Question 19

what determines the age of onset for HD?

Answer 19

no of cag repeats. the greater the number, the earlier the onset of disease

Question 20

what are the main features of huntington disease?

Answer 20

chorea, dementia, psychiatric comorbidities including personality change/irritability/disinhibition

Question 21

what are some medical complications from TBI?

Answer 21

spasticity
heterotropic ossification
hydrocephalus
SIADH and DI
depression

Question 22

describe post concussion syndrome?

Answer 22

headaches, dizziness, fatigue, difficulty with short term memory persisting for greater than 3 months post concussion

Question 23

what length of PTA is associated with permanent disability?

Answer 23

generally the longer the PTA period, the more severe the injury and the worse the outcome.

So generally PTA greater than 4 weeks may result in permanent disability

Question 24

what are some social issues that may occur post traumatic injury?

Answer 24

difficulty returning to work (employment)
difficulty with relationships with others
inability to return to premorbid activity/function

Question 25

what are some rehab goals for spinal cord injury and how might we achieve them?

Answer 25

1. Prevent complications such as contractures + respiratory infections- daily neurological exams; management of spasticity including stretching and baclofen
   - ensure annual influenza vaccination, aid expectoration and cough
2. psychosocial management- social worker, psychiatry input
3. equipment and home modification- OT home review; wheelchair etc
4. bladder mx- initially IDC/SPC and if possible, begin to encourage reflex emptying and intermittent self catheterisation–> urodynamic study may be required; prevention of UTI or mx of UTI if relevant
5. Adequate bowel care
6. Pain management- psychological and pharmacological therapies (pregabalin/gabapentin)

Question 26

what is Pick’s disease?

Answer 26

a rare type of frontotemporal dementia that presents early (middle aged individual), is familial, and is associated with acute functional decline/poor prognosis. Often involves personality/behaviour changes and language difficulties including aphasia

Question 27

what are some neurological complications of TBI?

Answer 27

visual changes, particularly diplopia (usually VIth nerve palsy), altered accommodation and hemianopia.
• anosmia (up to 40%)
• high level balance/co-ordination -difficulties/vertigo/dizziness
• high level word finding difficulties, language difficulties
• focal neurological deficits such as hemiparesis/dyspraxia/dysphasia are less common and related to focal trauma in many cases (eg assault with a blunt instrument causing local damage only)