Stroke/TBI Flashcards
What is the greatest risk factor for late post-traumatic seizures in patients with a traumatic brain injury?
(a) Multiple subcortical contusions
(b) Subdural hematoma with evacuation
(c) Midline shift greater than 5mm
(d) Bilateral parietal contusions
Answer: D
In a 4-site Model System Center observational study, the highest risk factors for late post-traumatic seizures were found to be bilateral parietal contusion (66%), penetration of the dura (62.5%), and multiple intracranial operations (36.5%), multiple subcortical contusions (33.4%), subdural hematoma with evacuation (27.8%), and midline shift greater than 5mm (25.8%).
A 25-year-old man with a history of a traumatic brain injury is noted to have a marked functional decline from his normal level of functioning. You order a computed tomography (CT) scan, which reveals large ventricles with flattening of the sulci and periventricular lucency. You tell the family that a ventriculoperitoneal shunt
(a) is emergently needed, and immediate referral to neurosurgery is indicated.
(b) will not be helpful, because the findings on the CT scan are due to irreversible atrophy of
brain tissue (hydrocephalus ex vacuo).
(c) is not indicated, because he does not have the triad of incontinence, gait disorder, and dementia.
(d) may be helpful, because about 50% of patients with post-traumatic brain injury hydrocephalus experience significant improvement.
Answer: D
A series reported by Tribl and Oder found that of 48 patients who underwent ventriculoperitoneal shunting for post-traumatic hydrocephalus slightly more than half experienced significant benefit.
Your 5-year-old patient with spastic tetraplegic cerebral palsy needs a wheelchair prescription. He is dependent for transfers, but cognitively normal. He is able to feed himself and uses a communication device. His family transports him in their car in an adapted car seat. On examination, he is unable to sit unsupported, but sits well with minimal support; he has no scoliosis, and his passive range of motion is full. Which elements would be best to include in his wheelchair prescription?
(a) Folding frame, sling seating
(b) Adaptive stroller, linear seating
(c) Tilt in space frame, custom seating
(d) Rigid frame, contoured seating
Answer: D
While this child is totally dependent for transfers, he only requires minimal support to sit upright and has no fixed deformities. Custom seating should be used for those with fixed deformities. A tilt-in-space frame should be used when children need to have their position in space changed frequently because of deformities or medical problems. While it is tempting to prescribe a wheelchair with a folding frame for a family who transports a child in a car rather than a van, the child will be better positioned using contoured seating and a rigid frame. At age 5 years, the size of frame needed will be able to be transported in a car even without folding. Adaptive strollers usually position the child in a reclined position and should be used as a backup to a wheelchair, which is not easily transported in an automobile, or for a child who can walk but periodically needs dependent mobility for fatigue or following seizures or for similar reasons.
The largest change in bone mineral density in a hemiplegic patient 1 year after a stroke occurs in the
(a) humerus on the paretic side. (b) proximal femur on the paretic side. (c) distal radius on the paretic side. (d) lumbar spine.
Answer: A
In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density (BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine
A 23-year-old woman who is unresponsive after an acute traumatic brain injury can visually track. She periodically pushes the nurse’s hand away when the nurse administers a subcutaneous heparin injection. The patient is exhibiting
(a) a coma state.
(b) a minimally conscious state.
(c) a vegetative state.
(d) a sleep/wake cycle.
Answer: B
A minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self, or environmental awareness, is demonstrated by any or all these actions: simple gestures, purposeful behavior, appropriate smile/cry or vocalization to stimulation, reach for object, purposeful visual tracking. The vegetative state is associated with preserved hypothalamic and brainstem autonomic function and the patient exhibits a sleep/wake cycle, but there is an absence of cortical activity, judged behaviorally. The patient may exhibit visual pursuit but not in relation to meaningful behavior. The term persistent vegetative state is confusing and it is suggested that the term be abandoned, since it combines diagnosis (vegetative) with prognosis (persistent). Coma is a transient state after a traumatic brain injury (TBI) of being not awake and not aware of surroundings, and is seen in patients with a severe TBI and a Glasgow coma scale (GCS) of 8 or lower.
You are seeing a 56-year-old male patient in consultation 3 days after a severe stroke. He is medically stable and has flaccid hemiplegia with poor sitting balance. He is sitting up in a chair for 2 hours twice daily and has just started bedside physical therapy (PT) and occupational therapy (OT). You recommend
(a) continued bedside therapy with OT and PT, focusing on sitting balance, followed by transfer to your inpatient rehabilitation unit when he can sit and stand with minimum assistance.
(b) transfer to your inpatient rehabilitation unit to start aggressive PT and OT.
(c) transfer to a subacute rehabilitation center to allow the patient time to improve with less
intensive therapy.
(d) that his OT start functional electrical stimulation to the flaccid arm to enhance neurologic recovery.
Answer: B
Early and aggressive therapy addressing the higher level skills of gait, higher order functional skills, and problem solving were associated with better outcomes in a multi-center observational study.
It is recommended that a patient with a first ischemic stroke who is positive for an antiphospholipid antibody be treated with:
(a) aspirin, 325mg orally daily. (b) warfarin, with an INR goal of 3.0–3.5. (c) clopidogrel (Plavix), 75mg orally daily. (d) ticlopidine (Ticlid), 250mg orally twice daily.
Answer: A
Patients with a first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325mg/day) or moderate-intensity warfarin (INR 1.4–2.8).
Which of the following is NOT a feature of central autonomic dysfunction in traumatic brain injury in children?
(a) Hypertension (b) Tachypnea (c) Rigidity (d) Hypothermia
Answer: D
Central autonomic dysfunction occurs in some children following severe brain injury. It is characterized by hypertension, hyperpyrexia, rigidity, tachypnea, tachycardia, and diaphoresis. Various medications are used to treat this dysfunction, but no studies prove the value of one medication over another.
Which statement describes the chronic-pain concept of “central sensitization”?
(a) The evoked response of A-delta fibers to subsequent input is amplified. (b) The influx of sodium is fundamental to electrical signaling and subsequent generation of action potentials and excitatory postsynaptic potentials. (c) A complex set of activation-dependent post-translational changes occurs at the dorsal horn, brainstem, and higher cerebral sites. (d) The so-called “inflammatory soup,” rich in algesic substances, causes a lowering of threshold for activation and subsequent evoked pain.
Answer: C
Central sensitization is a complex set of activation dependent post-translational changes occurring at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at the level of the dorsal horn.
- The most common benign brain tumor in adults is
(a) astrocytoma.
(b) oligoblastoma.
(c) medulloblastoma.
(d) meningioma.
Answer: C
Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain tumors.
When an individual is exposed to a stimulus that causes tissue damage, an immediate response occurs that involves withdrawal and/or attempts to escape the stimulus. This reaction is an example of
(a) respondent learning.
(b) operant learning.
(c) cognitive behavioral theory.
(d) trial and error.
Answer: B
By successfully avoiding pain (ie, “punishment”), the individual achieves a reduction in pain, thus rewarding the avoidance behavior. The acquisition of pain behaviors may be determined initially by the history of learned avoidance behaviors, called operant learning. Respondent learning is when an aversive stimulus is paired with a neutral stimulus and with repeated exposures over time the neutral stimulus will come to elicit an aversive response (ie, fear).
In patients with a traumatic brain injury, which factor suggests a poor prognosis for emergence from unresponsiveness?
(a) Decorticate posturing (b) Flaccid muscle tone (c) Conjugate eye movement (d) Reactive pupils
Answer: B
After a traumatic brain injury, the following factors are associated with a better prognosis: younger age, reactive pupils, conjugate eye movement, decorticate posturing, early spontaneous eye opening, absence of ventilatory support, and higher Disability Rating Score on admission. Factors associated with poor prognosis include decerebrate posturing and flaccid muscle tone.
Which statement is TRUE regarding post-stroke central pain?
(a) Damage to the thalamus plays a central role in the pathogenesis of central pain.
(b) Amitriptyline is the drug of first choice to treat central pain.
(c) 80% of stroke patients with central pain develop the pain within a month of their stroke.
(d) The pain usually resolves spontaneously and does not require medication.
Answer: B
The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to 60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief for some patients who do not respond to amitriptyline.
A patient with a recent stroke and hemiplegia presents to your clinic and is noted to have a genu recurvatum gait pattern. An aggressive stretching program has improved ankle range-of-motion, but not her spasticity and gait. The most appropriate treatment is
(a) an ankle foot orthosis with 5o of plantarflexion. (b) Achilles tendon lengthening. (c) phenol motor point injection to the hamstrings. (d) botulinum toxin injection to the gastrocsoleus muscle group.
Answer: D
Genu recurvatum is a common atypical gait pattern in patients with upper motor neuron pathology. It may be caused by ankle plantarflexor spasticity, heel cord contracture, quadriceps weakness, or spasticity and a combination of the above impairments. In this case an ankle foot orthosis with 5o of plantarflexion would worsen the gait. A tendon lengthening would be aggressive and more conservative management should be attempted first. A phenol motor point injection to the hamstrings would make knee control more problematic. Botulinim toxin can be very helpful for focal spasticity and can decrease ankle plantarflexor spasticity and decrease the backward force at the knee.
- Effects of prolonged bed rest include
(a) increased maximum oxygen consumption.
(b) increase of plasma volume.
(c) decreased resting heart rate.
(d) decreased cardiac stroke volume.
Answer: D
Prolonged bed rest has detrimental effects, which include an increased resting heart rate, loss of plasma volume, decreased cardiac stroke volume, and decreased maximum oxygen consumption.
Your co-resident presents an article in journal club on a new medication and its impact on outcomes following traumatic brain injury. On which point would you NOT need assurance before you decide to use this medication in your clinical practice?
(a) That the research study results are clinically significant
(b) That bias was eliminated from the study
(c) That the research study results are statistically significant
(d) That research investigators used valid outcome measures
Answer: B
When critically evaluating the medical literature, it is important to consider if the results of the study are both clinically and statistically significant. It is also important to consider whether the outcome assessment tools have been validated for both accuracy and reliability. While biases that may impact the outcome of the study also must be considered, it is often impossible to completely eliminate bias from the study.
Which statement is TRUE about the relative responses of the brain and the spinal cord after concussive trauma?
(a) The brain is more sensitive to trauma than the spinal cord. (b) The spinal cord is more sensitive to trauma than the brain. (c) The brain and the spinal cord are equally sensitive to trauma. (d) The brain’s neurologic recovery is less predictable than the spinal cord’s in its response to a given amount of trauma.
Answer: B
Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain. Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe concussive trauma to the brain results in a more severe neurologic dysfunction.
- Electromyographic biofeedback for stroke patients is most beneficial when
(a) proprioception is preserved.
(b) used in the upper limb.
(c) the patient is young.
(d) the patient has flaccid paralysis.
Answer: A
Hemiplegic stroke patients engaged in electromyography biofeedback training have a better functional outcome with lower extremity training than with upper extremity training. Further, their age and the duration of their hemiplegia have no effect on training outcome. Proprioceptive loss of the upper limb decreases the probability of making functional gains. Motivation by the patient is a necessity and is most beneficial when some voluntary activity is present.
An exclusion criterion for resistance training in patients with stable cardiac disease is:
(a) peak exercise capacity at 7 metabolic equivalents (METs).
(b) prior history of a stroke.
(c) controlled hypertension.
(d) severe valvular disease
Answer: D
Exclusion criteria for resistance training in stable cardiac patients include congestive heart failure, severe valvular disease, poor left ventricular function, uncontrolled dysrhythmias, and peak exercise capacity under 5 METs.
