Neurotrauma Flashcards

1
Q
  1. A 21 years old male presents to the emergency department after being involved in a gunfight. His GCS is 15 with a non – focal examination but several bullet holes are noted in his scalp with protruding cerebral tissue. His CT Scan of the head is shown in the figure. What is the BEST definitive management strategy for this injury :
    A. 14 – day course of antibiotics
    B. Bedside laceration repair
    C. Surgical removal of all bullet fragments
    D. Cranioplasty and removal of accessible fragments
    E. Surgical durotomy repair
A

D. Cranioplasty and removal of accessible fragments

Given the easily accessible, non – eloquent confused brain and large elevated fracture, surgical removal of the accessible bullet fragments is the procedure of choice. There are reports of their superficial only (local irrigation and wound closure) or aggressive approaches (craniotomy and thorough debridement of injured brain and the gun shot tract for removal of deep fragments) to treatment. However, the best evidence supports an intermediate approach in the majority of cases, in which readily accessible bone and missile fragments are removed in addition to non – viable brain. In the above case a there is a large elevated fragment of frontal bone in addition to numerous entrance/exit wounds seen on the patient’s scalp.

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2
Q
  1. A 24 years old patient with gunshot wound to C3 is resuscitated after a PEA code and found to have fixed and dilated pupils, absent corneal reflexes, and absent cough and gag reflexes. A head CT reveals diffuse cerebral edema with loss of grey – white differentiation. He is normothermic and normotensive and his urine toxicology screen and electrolyte panels are within normal limits. Which component of the brain death examination cannot be used in this patient to evaluate for brain death?
    A. Cold caloric testing
    B. Nuclear cerebral blood flow study
    C. EEG
    D. Apnea testing
    E. Transcranial Doppler Ultrasonography
A

D. Apnea testing

An apnea test in apatient with a C3 level spinal cord injury will be confounded by his spinal cord injury and will not be a reliable way to assess for brain death.
In a patient who is normothermic and normothensive and whose urine toxicology screen and electrolyte panels are within normal limits. The absence of brain stem reflexes (including cold caloric testing) are consistent with a clinical diagnosis of brain death. In the absence of confounding factors (such as that seen in this case), a confirmatory apnea test would be sufficient to diagnose brain death. However, in light of this confound, other confirmatory tests are required to either (1) confirm the absence of cerebral blood flow (e.g. transcranial Doppler Ultrasonography or nuclear cerebral blood flow studies, or angiography)

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3
Q
  1. A 25 years old male is thorought to the emergency department after a motor vehicle crash. His blood pressure is low, requiring pressors. His GCS score is 5. A ventriculostomy is inserted and his intracranial pressure is found to be 35 mmHg. What is the most appropriate immediate treatment for lowering his ICP?
    A. CSF drainage
    B. Mannitol
    C. Barbiturate Coma
    D. Calcium channel Blocker
    E. Hyperventilation
A

A. CSF drainage

The most appropriate treatment for this patient’s intracranial hypertension is drainage of CSF. This is the only option listed that will not also have the undesirable effect of compromising cerebral perfusion and thereby potentially aggravating cerebral ischemia.
Barbiturate coma may be effective for lowering ICP in many patients through its suppression of cerebral metabolism with a consequent decrease in cerebral blood flow and blood volume. However, its major adverse effect is hypotension. As a general rule, barbiturates should not be used in patients in whom it is already difficult to maintain a normal blood pressure. Additionally, several other measures to lower ICP are generally employed prior to the use of this intervention. Calcium channel blocker are not used clinically to

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4
Q
  1. A 30 year old male is brought to the emergency department after a motor vehicle crash. His GCS score is 13. He begins to have seizure activity in the emergency department and the seizure is continuing after several minutes. What is the pharmacologic treatment of choice for the seizure?
    A. Phenobarbital
    B. Pancuronium
    C. Phenytoin
    D. Lorazepam
    E. Paraldehyde
A

D. Lorazepam

The answer is lorazepam. The recommended initial pharmacologic treatment of persistent seizures consists of lorazepam (Ativan), 0.1 mg/kg up to 4 mg given over two minutes. Benzodiazepines are preferred as initial treatment because of their high efficacy and rapidity of action. Lorazepam is preferred over diazepam (Valium) because of the greater duration of its anti seizure effect (12 – 24 hours vs 15 – 30 mins).
Anticonvulsants such as phenytoin or Phenobarbital can be started in addition to the forst line treatment for prevention of subsequent seizures. Pancuronium is a skeletal muscle relaxant. Because they have no antiepileptic effects. These type of drugs are not indicated as a primary treatment for seizures, and in fact they make the clinical detection of ongoing seizures more difficult. Their only role in these patients is to

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5
Q
  1. A 40 year old male develops left facial droop and left hemiparesis 48 hours after a motor vehicle accident despite initially being neurologically intact after the accident. A non – contrast head CT at the time of detoriation is negative. The most appropriate net diagnostic evaluation is :
    A. Cerebral perfusion study
    B. CT of the cervical spine
    C. MRI of the cervical spine
    D. CT angiogram of the cervical spine
    E. ICP monitoring
A

D. CT angiogram of the cervical spine

This patient’s clinical course (delayed neurological deficit post – trauma in the setting of a negative head CT) is most consistent with a vascular dissection in the neck or at the skull base. For carotid injury, this may become evident within hours of the injury. Vertebrobasilar dissections typically present 2 – 3 days after the injury. The most sensitive and specific study would be a digital subtraction angiogram (not an option). Followed by a CT angiogram. This study allows evaluation of both the carotid and vertebral systems from their origin through the skull base, and is sensitive to both dissection and external compression from fracture – dislocations or hematoma. Carotid duplex study is not sensitive for injury to the vertebral system, nor will it demonstrate vascular injury at the skull base. Other anatomic imaging of the neck(CT/MRI) may demonstrate a traumatic cause for the vascular injury, but will not specifically demonstrate the vascular abnormality. A cerebral perfusion study may demonstrate the areas at risk due to embolic events, but will not demonstrate the underlying cause. ICP measurements is superficious since the patient is awake anda alert.

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6
Q
  1. A 52 year old restrained driver presented after a motor vehicle accident with an L2 sensory level, 4/5 strength in his proximal and 4-/5 strength in his distal lower extremities and a severe L2 fracture. What is this patient’s ASIA impairment Scale score (modified Frankel score) :
    A. B
    B. D
    C. C
    D. E
    E. A
A

B. D

The patient here has sustained an ASIA D injury, where motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle strength of at least grade 3. An ASIA A injury is complete, an ASIA B injury is incomplete where sensory function is spared without motor function except for preservation of the sacral segments. An ASIA C injury has a motor function preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle strength less than grade 3. ASIA E is normal strength

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7
Q
  1. Comminution of the occipital condyle is most often associated with which cranial nerve palsy?
    A. X
    B. IX
    C. VII
    D. XI
    E. XII
A

E. XII

The cranial nerve most comon affected by occipital condyle fracture is the CN XII due to the close relationship of the hypoglossal canal to the occipital condyles. Cranial nerves X, IX, and XI (in order) are the net most common cranial nerves affected because they course through the jugular foramen.

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8
Q
  1. The GCS score for the patient shown in the video is :
    A. 3
    B. 6T
    C. 5T
    D. 10T
    E. 7T
A

E. 7T

The patient in this example is intubated orally and therefore receives a 1T for verbal response. The patient does not open his eyes to verbal or painful stimuli (1) but does localize briskly with his right upper extremity (5). The total GCS score is 7T.
The GCS is the most widely used scoring system for quantifying the level of consciousness after traumatic brain injury (TBI). It is used primarily because it is simple, has a high degree of interobserver reliability, and correlates with outcome after seere brain injury. The GCS is shown in Figure 1. The examiner determines the patient’s best eye opening response, best verbal response, and best motor response. The total score (range 3 – 15) re[resents the sum of the numeric scores of each of the categories. Use of the GCS has limitations. If apatients has an ETT in place, verbal scores cannot be assessed. For this reason, many prefer to document the score by its individual components, so a non – intubated patient with a GCS score of 15 might be documented as a follows : E4 V5 M6. An intubated

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9
Q
  1. The neurological examination of a34 year old patient who suffered an MCA stroke 20 hours ago declines acutely from alert but hemiplegic to GCS 4 (E1, M3) despite maximal medical management. A head CT reveals a large right MCA infarct with 2 cm of midline shift and cisternal effacement. The most appropriate management of this patient is :
    A. Endovasculae clot retrieval
    B. Endovascular TPA administration
    C. Heparin bolus and infusion
    D. Ventriculostomy
    E. Decompressive hemicraniectomy
A

E. Decompressive hemicraniectomy

In a young person with non – dominant MCA infarct less than 24 hours old who is rapidly deteriorating due to herniation who fails conservative measures, decompressive craniectomy is the only intervention that can acutely reverse the subfalcine herniation. Recent studies suggest decompressive craniectomies in the setting of stroke may be beneficial even in patients beyond 50 year of age. Ventriculostomy is the only other intervention that may alleviate some of the intracranial hypertension. However, in the setting of significant neurologis deficit and osternal effacement, it is unlikely to provide adequate relief and long term improvement in neurologic function.

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10
Q
  1. What is the definition of a concussion?
    A. A loss of consciousness resulting from head trauma with significant parenchymal disruption or abnormalities
    B. A loss of consciousness resulting from head trauma without significant parenchymal disruption or abnormalities
    C. A transient alteration of consciosness resulting from head trauma without significant parenchymal disruption or abnormalities
    D. A transient alteration of consciosness resulting from head trauma with significant parenchymal disruption or abnormalities
A

C. A transient alteration of consciosness resulting from head trauma without significant parenchymal disruption or abnormalities

A concussion is defined as a transient alteration of consciousness resulting from head trauma, without significant parenchymal disruption or abnormalities. The diagnosis has been used interchangeably with the diagnosis of Mild Traumatic Brain Injury. A period of loss of consciousness is not required for the diagnosis.

Any loss of consciousness generally connotes a moderate to severe concussion although grading varies. Although loss of consciousness is widely used to determine grade, post concussive amnesia may have a stronger correlation with degree of persistent cerebral dysfunction.

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11
Q
  1. What is the indication for repair of anterior wall frontal sinus fractures?
    A. Acute and or chronic sinusitis
    B. Formation of mucocele
    C. CSF leak and resulting meningitis
    D. Repair of cosmetic deformity
    E. All of the above
A

D. Repair of cosmetic deformity

If there is a question of cosmetic deformity in the future, the fracture may be explored for possible reduction and function. The anterior wall of the frontal sinus is the stronger of the two tables. The anterior wall is very rarel associated with CSF leak or injury to the drainage system. The key issues in the management of these fractures are to determine the extent of injuries. Specifically, to determine whether the posterior wall is involved and if there are associated injuries to the drainage system. If the injuries are isolated to the anterior wall. The issues of infection, mucocele formation, and sinusitis are less relevant to the management of these fractures.

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