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PM&R Recap > TBI > Flashcards

TBI Flashcards

1
Q

Most common cause of TBIs?
Civilians vs. veterans?

A

Civilians:
Falls (59%), MVC (29%), assaults (8%)….
Elderly - falls most common
Pediatric - MVC most common

Veterans: blast injury most common (33.1%), object hitting head (31.7%), falls (13.5%)

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2
Q

Diffuse axonal injury grading?

A

DAI = shearing of axons 2/2 acceleration/deceleration, rotational forces

Graded on MRI by location w/ associated petichial hemorrhages:
Grade 1 = cortical/subcortical
Grade 2 = corpus callosum
Grade 3 = Midbrain worst prognosis

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3
Q

Mechanism of injury typically seen for cerebral contusion injuries?

A

Coup-contrecoup injury involving rapid acceleration/deceleration

typically resolve over months - may impair executive function, behavior regulation, mood, and communication

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4
Q

Common brain locations for cerebral contusions?

A

orbital/inferior frontal lobe
anterior temporal lobe

due to sharp inner skull ridges (“horns” of the brain for PM&R recap)

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5
Q

What is the difference b/t primary and secondary injury in TBI?

A

Primary injury = immediate concussive force of impact causing disruptive shear forces, cerebral contusions, DAI, etc

Secondary injury = all the detrimental biochemical cascades that happen after the primary injury (inflammatory changes, ischemia, hypoxia, anoxia, vasogenic and cytotoxic edema)

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6
Q

Which neurotransmitter is responsible for excitatory toxicity in TBI/consussion?

A

Glutamate

Glutamate concentrations released into extracellular space d/t cellular lysis –> Ca++ activates second messenger pathways, exacerbated oxidative stress and initiates programmed cell death

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7
Q

Receptors implicated in excitatory toxicity enhancement?

A

NMDA receptors
GABA

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8
Q

Imaging to best appreciate DAI?

A

Diffusion-weighted MRI

Central white-matter damage (cortical/subcortial, corpus callosum, brainstem)

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9
Q

How is cerebral perfusion pressure (CPP) calculated?

A

CPP = mean arterial pressure (MAP) - intracranial pressure (ICP)

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10
Q

What is the rationale for monitoring ICP in acute TBI management?

A

Increased ICP causes decreased cerebral perfusion pressure (CPP)

CPP = MAP - ICP

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11
Q

Threshold for increased ICP?

A

> 20 mmHg (normal is < 15mm Hg, most people 2-5mm Hg)

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12
Q

Acute management methods for lowering ICP in TBI?

A

Elevating head
Diuretics (mannitol, acetazolamide)
Hypertonic saline
Barbituates/sedatives
Forced hyperventilation (temporarily, decreased PaCO2 causes cerebral vasoconstriction, lowering blood volume in brain)
Hypothermia - decreased metabolic demands of brain
Surgical decompression (burr holes, craniotomy/craniectomy)

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13
Q

Important exam finding in acute TBI management with prognostic value?

A

pupillary responsiveness

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14
Q

Unilateral blown pupil is an impending sign of what?

A

uncal herniation (surgical emergency)

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15
Q

What is diaschisis?

A

Lesions/damage to one region of CNS can produce altered function in other areas of the brain if there is a connection b/t the two sites (fiber tracts). Function is lost in both injured and in morphologically intact brain tissue (resolusion parallels recovery of focal lesion)

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16
Q

What is vicariation?

A

functions taken over by brain areas not originally managing that function (these areas alter their properties in order to subvert that function)

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17
Q

Plasticity consists of which two mechanisms?

A

Neuronal regeneration/neuronal collateral sprouting = intact axons establish synaptic connections through axon sprouting in areas where damage has occured

Functional reorganization/unmasking neural reorganization = healthy neural structures not formerly used for a given purpose are developed or reassigned to do functions performed by the lesioned area

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18
Q

Decorticate posturing

A

Arms flexed, legs extended

Lesion above midbrain (better prognosis)

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19
Q

Decerebrate posturing

A

Arms extended, legs extended

Lesion in midbrain (worse prognosis)

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20
Q

Most common bleed in TBI?

A

Subdural hematoma

Crescent shaped, 2/2 shearing of bridging veins or arterial vessel damage (increased risk w/ older age and brain atrophy; alcoholics)

Can cause midline shift

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21
Q

Lens-shaped brain bleed?

A

Epidural hematoma (EDH), 2/2 damage to middle meningeal artery/temporal bone fracture

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22
Q

Brain bleed from ruptured AVM or berry aneurysm?

A

Subarachnoid hemorrhage (SAH)

Aneurysm usually Acomm or Pcomm

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23
Q

Treatment for ruptured AVM/berry aneurysm w/ SAH?

A

nimodipine x 21 days to prevent cerebral vasospasm

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24
Q

most commonly injury cranial nerve in TBI?

A

CN 1 - olfactory; susceptible to shear injury

Altered smell/taste, lack of interest in eating, possible weight loss

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25
Common cranial nerve injuries in TBI?
CN1 - olfactory CN2 - visual field deficits CN7 - facial n; deficits in 2/3 tongue taste, facial expression, salivation, tears CN8 - vestibulocochlear; hearing and balance loss (BBPV is common in TBI, however - if patient complaining of dizziness) *often associated w/ temporal and skull base fractures
26
Most common presentation of brain tumors?
HA w/ cognitive deficits Order MRI w/ contrast
27
Most common brain tumor in kids?
#1 cerebellar astrocytoma #2 medulloblastoma
28
Most common primary brain tumor in adults?
glioblastoma multiforme
29
Most common brain metastatic tumor?
Lung
30
What brain structure is responsible for consciousness?
the reticular activating system
31
Level of consciousness? eyes closed, no sleep/wake cycle, no purposeful behavior
Coma
32
Level of consciousness? Eyes open, + sleep/wake cycle, no localization of objects, reflexive behaviors
Unresponsive Wakefulness Syndrome (Vegetative State)
33
Difference between persistent and permanent Unresponsive Wakefulness Syndrome (UWS - Vegetative State)?
Persistent = lasting for over 1 month Permanent = lasting for over 1 year after TBI (over 3 months if non-traumatic brain injury, such as anoxic)
34
Level of consciousness? Evidence of self or environmental w/ inconsistent purposeful behaviors and crossing midline
Minimally conscious state
35
What is the standardized assessment used to distinguish between unresponsive wakefulness syndrome (vegetative state) and minimally conscious state?
The JFK Coma Recovery Scale -Revised (CRS-R) = standardized neurobehavioral assessment designed to help differentiate between unresponsive wakefulness syndrome and minimally conscious state
36
Current practice guidelines for pharmacologic interventions in DOC? MOA of neurostimulation?
Practice guidelines recommend trialing amantadine for traumatic vegetative state/unresponsive wakefulness between 4 and 16 weeks post-injury to hasten functional recovery MOA: increase dopamine in the brain
37
Which component of the glascow coma scale is the most important predictor of outcome in TBI?
Motor response Motor response 1-6 Verbal Response 1-5 Eye Opening 1-4
38
What indicates that a patient is out of post-traumatic amnesia (PTA)?
Galveston Orientation and Amnesia Test score of 75 or more for 2 consecutive days (technically PTA is over once you've scored 75 or higher on the first of the two days) Orientation Log (O-log) Score of 25 or higher for two straight days
39
Classification of TBI Severity? LOC < 30min, CGS 13-15, PTA 0-1 day
Mild TBI
40
Classification of TBI Severity? LOC 30min - 24hr, GCS 8-12, PTA 1-7 days
Moderate TBI
41
Classification of TBI Severity? LOC > 24hr, GCS 3-8, PTA > 7 days
Severe TBI
42
Prognosis for severe disability is PTA < 2 months?
Severe disability unlikely
43
Prognosis if PTA is > 3 months?
Good recovery unlikely
44
Difference b/t immediate, early, and late post-traumatic seizures?
Immediate < 24hrs Early: 1-7 days Late: > 7 days *Check prolactin level if seizure suspected, will be increased *keppra/phenytoin recommended ppx x 7 days to prevent early post-traumatic seizures
45
Risk factors for post-traumatic epilepsy?
Having things in the brain that shouldn't be there - Foreign bodies (bullets, knife) - Blood (EDH, SDH, SAH, IPH) - Bony fracture (depressed) - abnormal neuronal discharge (early seizure) B/l contusions (esp parietal and temporal lobes) Dural tear Midline shift > 5mm Severe TBI as measured by GCS
46
minimum AED treatment time for a late post-traumatic seizure?
2 years (can consider discontinuing if seizure-free after 2 years) Valproic acid and carbamazepine recommended for preferable side effect and mood-stabilizing effects in TBI. EEG often performed prior to cessation of AEDs.
47
Management of immediate post-traumatic seizures?
cont standard prophylaxis x 7 days (keppra/phenytoin), not predictive of future seizures
48
Management of early posttraumatic seizures?
Typically treat w/ AEDs for 6 months 25% of pts w/ early posttraumatic seizure will have a subsequent seizure
49
What potential complication should be considered if a TBI patient has an unexpected functional plateau or deterioration during rehabilitation? N/V, HA, confusion w/ dilated ventricles on imaging?
Posttraumatic hydrocephalus (occurs in up to 45% of TBI patients). Usually caused by impaired resorption of CSF (particularly w/ subarachnoid hemorrhages). Tx: VP shunt placement
50
Threshold for severe agitation on the Agitation Behavioral Scale?
> 34 = severe agitation < 21 is normal
51
TBI pt w/ cyclical tachycardia, HTN, tachypnea, fever, diaphoresis, and dystonia - diagnosis and treatment?
Paroxysmal Sympathetic Hyperactivity (PSH) Mechanism: thought to be loss of cortical inhibition on sensory afferent information activating the sympathetic nervous system. Occurs in approx 1/3 of TBI patients. Tx: minimizing stressors (pain/noise), environmental measures (cooling blanket), pharmacologic interventions (propranolol, clonidine, benzodiazepines, bromocriptime, morphine, gabapentin, dantrolene, ITB)
52
Most common site for HO formation in TBI? Common risk factors?
Hip (other common sites = knees, elbows, shoulders) Risk factors: long bone fractures, coma > 2 months, immobility
53
Recommendations for neuroendocrine screening following TBI?
3-6 months, and then 1 year post injury Test: morning cortisol, FSH, LH, testosterone, prolactin, insulin-like growth factor 1 [IGF-1], estradiol, thyroid panel 30-50% of pts who survive TBI have endocrine abnormalities
54
Sodium abnormality in TBI? hyponatremia, low serum osmolality, high urine osmolality, increased urine output
Syndrome of Inappropriate antidiuretic hormone (SIADH) - euvolemic hyponatremia Tx: free water restriction (do not correct Na faster than 10mEq/L over 24hrs until Na reaches 125 due to risk of pontine myelinolysis) Chronic SIADH: can treat w/ democlocycline (inhibits ADH action in the kidney)
55
Sodium abnormality in TBI? hyponatremia, low serum osmolality, normal urine osmolality; signs of hypovolemia
Cerebral Salt Wasting - hypovolemic hyponatremia; ADH appropriately elevated Tx: IVF, isotonic saline, fludrocortisone
56
Sodium abnormality in TBI? Hypernatremia, high serum osmololality, low urine osm
Diabetes Insipidus - hypernatremia due to excessive volume depletion Tx: fluid replacement, DDAVP/vasopressin
57
Assessment tools for concussion symptoms?
Neurobehavioral Symptom Inventory (NSI): 22-item self resport questionnaire (measures somatic, affective and cognitive symptoms) - adopted by Dept of Defense and VA Post-Concussion Symptom Scale (PCSS): 21 item self-report measure that identifies concussion in athletes w/ high specificity, shown to discriminate b/t concussed and non-concussed athletes Graded Symptom Checklist (GSC)
58
Poor prognostic factors on exam for concussion recovery?
Abnormalities in saccades, smooth pursuits, convergence insufficiency, nystagmus Fiber tracts that connect frontal cortex w/ cerebellum sensitive to shear injury
59
General management of concussion?
Relative rest for first 24-48 hours, then exercise can improve brain function through favorable effects on brain neuroplasticity Moderate aerobic exercise (60% of max HR) performed for 150min/week is cognitively protective
60
Supplements shown to be beneficial for posttraumatic headaches?
Riboflavin 400mg Magnesium oxide (have a role in mitochondrial energy production and electron transport in mitochondrial membrane. Decreased levels of micronutrients have been found in plasma and brains of migraine patients)
61
Return to Play Protocol for Concussion?
Each stage lasts at minimum 24hrs Stage 1 - do nothing (relative rest) Stage 2 - light cardio Stage 3 - directional cardio (cardio + directional movement) Stage 4 - Sport-specific cardio (drills) Stage 5 - full practice Stage 6 - cleared to play
62
Role of S-100B in concussion?
Scandinavian Neurotrauma Committee guidelines for adults recommend S-100B values < 0.10ug/L, if sampled within 6hrs of injury, can help rule out need for head CT in pts < 65yo with a GCS of 14, or GCS of 15 w/ + LOC and N/V

PM&R Recap (10 decks)

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