Section 4: Head Trauma, Intracranial Hemorrhage and Subarrachnoid Hemorrhage

Question 1

Diagnosis of choice for head trauma leading to loss of consciousness

Answer 1

CT scan without contrast

Question 2

True or False:

Do not use skull x-rays in head trauma.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7360-7361). . Kindle Edition.

Answer 2

True. If the head trauma is severe, then diagnosis requires a CT scan.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7360-7361). . Kindle Edition.

Question 3

1. Are there focal neurological deficits in concussion?
2. What is the CT scan result in concussion?

Answer 3

1. Never
2. Normal

Question 4

1. Are there focal neurological deficits in contusion?
2. What is the CT scan result in contusion

Answer 4

1. Rarely
2. Ecchymosis

Question 5

1. Are there focal neurological deficits in subdural hematoma?
2. What is the CT scan result in subdural hematoma?

Answer 5

1. Yes or no
2. Crescent-shaped collection

Question 6

1. Are there focal neurological deficits in epidural hematoma?
2. What is the CT scan result in epidural hematoma?

Answer 6

1. Yes or no
2. Lens-shaped collection

Question 7

Rx of head trauma

1. Concussion
2. Contusion
3. Subdural and epidural hematomas

Answer 7

1. No Rx
2. Admit, but vast majority get no treatment
3. Subdural and epidural: Large ones are drained; small ones are left alone to reabsorb on their own.
   
   • Large intracranial hemorrhage with mass effect:
   1. Intubation/ hyperventilation to decrease intracranial pressure. Decrease pCO2 to 25– 30, which will constrict cerebral blood vessels.
   2. Administer mannitol as an osmotic diuretic to decrease intracranial pressure.
4. Perform surgical evacuation.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7384-7391). . Kindle Edition.

Question 8

True or False:

Steroids have a place in intrcranial hemorrhage

Answer 8

False

Question 9

Indications for stress ulcer prophylaxis

Answer 9

• Head trauma
• Burns
• Endotracheal intubation with mechanical ventilation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 7395). . Kindle Edition.

Question 10

CF of SAH

Answer 10

• Sudden, severe headache
• Stiff neck
• Photophobia
• Loss of consciousness (LOC) in 50 percent of patients
• Focal neurological deficits in 30 percent of patients

SAH is like the sudden onset of meningitis with a LOC but without fever.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7398-7400). . Kindle Edition.

Question 11

Diagnosis of SAH

• Best initial test
• Most accurate test

Answer 11

• CT head without contrast
• LP (not necessary if CT is diagnostic)

Question 12

Normal WBC to RBC ration in CSF

Answer 12

1:500

Question 13

RX OF SAH

Answer 13

• Perform angiography to determine the site of bleeding
• Embolize the site of the bleeding. This is superior to surgical clipping.
• Insert a ventriculoperitoneal shunt if hydrocephalus develops
• Prescribe nimodipine orally; this is a calcium channel blocker that prevents stroke

When SAH occurs, an intense vasospasm can lead to a nonhemorrhagic stroke

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7409-7416). . Kindle Edition.

Question 14

1. What step should be taken before an SAH rebleeds
2. If a patient with SAH rebleeds, what are the chances that the patient will die?

Answer 14

1. Embolize or clip the source of bleeding
2. 50%

Question 15

Rx of large intracranial hemorrhage with mass effect

Answer 15

• Intubation/ hyperventilation to decrease intracranial pressure
  
  • Decrease pCO2 to 25– 30, which will constrict cerebral blood vessels
• Administer mannitol as an osmotic diuretic to decrease intracranial pressure
• Perform surgical evacuation