TBI SAEs Flashcards
Which statement concerning management of seizures after a traumatic brain injury is TRUE?
(a) All patients with postresuscitation Glasgow Coma Scale score below 12 require 3 months
of an antiepileptic medication.
(b) Seizures occurring less than 24 hours postinjury require an antiepileptic medication for at
least 12 months.
(c) Seizures occurring 24 hours to 7 days postinjury should be treated with at least 12 months
of an antiepileptic medication.
(d) Seizures occurring more than 7 days postinjury should be treated with an antiepileptic
medication for at least 3 years.
Answer: (c)
Commentary: The American Academy of Physical Medicine and Rehabilitation and the
American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic
brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score
(GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic
seizures (defined as those occurring within 24 hours postinjury) do not require any additional
prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be
treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial
abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late
seizures – those occurring more than 7 days postinjury – should be treated with an antiepileptic
medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as
“status epilepticus” and warrants treatment with an antiepileptic medication for at least 12
months.
A 20-year-old man sustained a severe traumatic brain injury and a femur fracture 1 week ago.
Magnetic resonance imaging reveals a diffuse axonal injury with no evidence of hemorrhage or a
hematoma. His condition is stable 1 day after open reduction, internal fixation of the femur
fracture and he is nonweight bearing on that leg. What is the appropriate recommendation for
deep venous thrombosis prophylaxis in this patient?
(a) Placement of a vena cava filter
(b) Sequential compression devices
(c) Graded compression stockings
(d) Low molecular weight heparin sodium
Answer: (d)
Commentary: Prophylaxis for deep vein thrombosis (DVT) should be considered in all patients
with a traumatic brain injury after acute admission to the hospital. Graded compression stockings
are of little benefit. Thigh high intermittent compression devices help reduce DVT risk but are not
an appropriate primary prophylaxis. A vena cava filter is not appropriate prophylaxis and
chemical prophylaxis is needed as soon as feasible. In patients who are not fully ambulatory in 24
hours unfractionated heparin sodium is adequate and can be used 12 hours after surgery.
However, in all patients who have long-bone fractures, prior DVT, or more than 4 total risk
factors, low molecular weight heparin sodium should be used until the patient is fully mobilized.
You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
TRUE?
(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters.
Answer: (d)
Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer
infections and a trend towards better outcomes in terms of survival and disability. Two trials
reported the effect of route of feeding on the incidence of infection of any type, but both trials
showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition
(EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the
effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of
pneumonia was found in the PN group.
Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased
incidence of complications and lower cost compared to PN, with no significant differences in
measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut
immune function and limit deterioration of the intestinal mucosa characteristic of bacterial
translocation and its potential for contributing to sepsis.
Prolonged coma is a significant risk factor for the development of contractures in the traumatic
brain injury population. What is the most common site for a contracture to develop in this
population?
(a) Shoulder
(b) Hip
(c) Elbow
(d) Ankle
Answer: (b)
Commentary: The overall 1-year incidence was 84% for contracture development in the
population of persons with brain injury. The hip was the most common joint affected (81%),
followed by the shoulder (76%), ankle (74%) and elbow (44%).
A 23-year-old woman with a traumatic brain injury from a motor vehicle crash is seen in clinic 1
year after her injury. She is in a minimally conscious state and still requires total assistance with
all her activities of daily living. The family wants to pursue treatment with hyperbaric oxygen
therapy (HBOT). You advise them, that HBOT can
(a) reduce the size of the injury to the brain.
(b) cause short-term visual disturbances.
(c) increase the incidence of mortality.
(d) improve the functional outcome.
Answer: (b)
Commentary: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen under pressure, which
increases the amount of oxygen dissolved in the blood, thereby increasing the oxygen delivered to
the body tissues. HBOT may also enhance the formation of new blood vessels, decrease
inflammation, and increase the volume of blood flow. Treatment sessions occur inside a sealed,
pressurized space known as a hyperbaric chamber. The oxygen is delivered either by mask or
directly into the chamber. The pressures used are expressed in units of atmospheric pressure and
commonly range from 1.5 to 3 atmospheres. The sessions last from 30 to 90 minutes and many
practitioners recommend 100 sessions (range, 80-150 sessions). The cost ranges from $200 to
$400 per session.
HBOT is not FDA approved for treatment of traumatic brain injury. A number of more minor
complications may occur due to HBOT. Visual disturbance, usually a reduction in visual acuity
secondary to conformational changes in the lens, is common. While the great majority of patients
recover spontaneously over a period of days to weeks, a small proportion of patients continue to
require correction to restore sight to pretreatment levels. The second most common adverse effect
associated with HBOT is aural barotrauma. Barotrauma can affect any air-filled cavity in the
body (including the middle ear, lungs and respiratory sinuses) and occurs as a direct result of
compression. There is limited evidence that HBOT reduces the chance of dying following a
traumatic brain injury. There is little evidence that more survivors have a good outcome. Thus,
the routine adjunctive use of HBOT in these patients cannot be justified. Because evidence of
lesion resolution or change in size of persistent defect obtained by magnetic resonance imaging
(MRI) or computed tomography (CT) has not been studied, there is no evidence to suggest this
occurs.
Which statement concerning the use of prophylactic antiepileptics in the management of patients
with traumatic brain injury is TRUE?
(a) They decrease the functional disability of the injury.
(b) They reduce the occurrence of late seizures.
(c) They reduce the incidence of death.
(d) They reduce the occurrence of early seizures.
Answer: (d)
Commentary: There is no evidence that prophylactic antiepileptic medications, used at any time
after head injury, reduce death and disability. Evidence exists that prophylactic antiepileptics
reduce early seizures, but there is no clinical evidence that late seizures are reduced, or that
treatment has any effect on death or neurological disability.
You are consulted to see a 19-year-old woman with a traumatic brain injury after a motor vehicle
crash 2 days ago. She is unconscious even though the computed tomography scan of her brain is
normal. The most likely cause is
(a) diffuse axonal injury.
(b) cerebral contusion.
(c) arterial vasospasm.
(d) epidural hemorrhage.
Answer: (a)
Commentary: The initial computed tomography and magnetic resonance imaging scans taken
soon after injury are often normal. Only 10% of patients with diffuse axonal injury (DAI)
demonstrate the classic CT findings of DAI. These are hemorrhagic punctate lesions of (1) the
corpus callosum, (2) the gray-white matter junction of the cerebrum, and (3) the pontinemesencephalic
junction.
Which drug is NOT associated with increased seizure risk in patients with traumatic brain injury?
(a) methylphenidate (Ritalin)
(b) ciprofloxin (Cipro)
(c) amitriptyline (Elavil)
(d) bupropion (Wellbutrin)
Answer: A
Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with increased seizure risk among patients with traumatic brain injury. However, amitriptyline, bupropion and quinolones decrease seizure threshold.
Which electroencephalogram pattern is associated with a better prognosis after traumatic brain injury?
(a) Low amplitude delta activity
(b) Burst suppression
(c) Isoelectric activity
(d) Spindle pattern
Answer: D
Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity had the highest mortality.
In a patient with traumatic brain injury who has impaired speed of processing, inattention and decreased arousal, which medication is regarded as first-line therapy?
(a) modafinil (Provigil)
(b) methylphenidate (Ritalin)
(c) bromocriptine (Parodel)
(d) carbidopa/levodopa (Sinemet)
Answer: B
Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are not as well studied as methylphenidate or amantadine.
The physical therapist calls you concerning the patient with traumatic brain injury you
admitted last week. She tells you that his bladder incontinence is disrupting therapy. You have checked his urinalysis and there is no evidence of a urinary tract infection. A postvoid residual bladder ultrasound shows that his bladder is emptying well. Your next step is to initiate
(a) an anticholinergic medication.
(b) in/out catheterization.
(c) a condom catheter with a leg bag.
(d) a behavioral modification program and timed voiding.
Answer: D
Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his confusion. A condom catheter in this population will probably not stay in place. It may increase agitation and will not help the patient. Intermittent catheterization and a Foley catheter will increase the patient’s infection risk. The best course at this time is frequent bladder emptying and retraining, with the entire rehabilitation team encouraging the new behavioral modification.
The usual time of onset of diabetes insipidus in patients with traumatic brain injury is
(a) at time of injury.
(b) 10 days postinjury.
(c) 30 days postinjury.
(d) 3 months postinjury
Answer: B
Commentary: Diabetes insipidus after TBI usually has an onset 10 days after trauma when the antidiuretic hormone (ADH) stored in the posterior pituitary is depleted.
During the initial, acute evaluation of a young spinal cord injury patient, which factor would make you suspicious of a concomitant brain injury?
(a) Fall as the mechanism of injury
(b) Female patient
(c) Higher level spinal cord injury
(d) African-American patient
(c)
The following factors, evidenced at the time of a spinal cord injury, place an individual at higher risk for a concomitant traumatic brain injury: Male sex and a higher level of spinal cord injury. Up to the age of 74 years-old, a transportation accident is the major source of traumatic brain injury (TBI) and not falls. Studies have shown a potential relationship between race and the incidence of TBI, but there are too many confounding variables and no study has shown a clear evidence of a relationship.
A 19 year-old male is seen after a traumatic brain injury. The patient’s mother is at the bedside and is asking you questions about the patient’s prognosis for recovery. As you consider your response, which statement is TRUE?
(a) Severe disability is unlikely if the length of coma is less than 1 month.
(b) Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months.
(c) An initial Glasgow Coma Scale score of less than 8 is associated with a poor outcome.
(d) Neuroimaging studies are not helpful to determine a patient’s prognosis.
(b)
Multiple studies have shown that age, initial Glasgow Coma Scale (GCS) score, duration of coma, duration of posttraumatic amnesia (PTA), and neuroimaging findings are correlated with outcome. All provide valuable information that the clinician can use to mark milestones, and help with prognosis, but the most powerful of these is the duration of PTA. The longer the duration of the PTA, the worse the outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability; however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of coma is determined by the time from coma onset to the time when the patient can follow commands. On average only 7%–8% will make a good recovery if the coma lasts longer than 4 weeks, and severe disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general idea about the severity of the injury, it does not by itself yield a definitive prognosis.
Which type of traumatic brain injury results in the most morbidity?
(a) Focal cerebral contusion
(b) Subarachnoid hemorrhage
(c) Epidural hematoma
(d) Diffuse axonal injury
(d)
After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this morbidity includes impairments in cognition, behavior, and arousal.
Which factor is a risk for heterotopic ossification in traumatic brain injury?
(a) Late seizures
(b) Prolonged coma
(c) Male gender
(d) Diabetes insipidus
(b)
Significant risk factors for heterotopic ossification in traumatic brain injury include prolonged coma (>1 month), increased muscle tone, limited movement in the involved lower extremity, and associated fractures. Late seizures, gender, and diabetes insipidus are not associated with increased risk of heterotopic ossification.
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
(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.
(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.
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.
(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.
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
(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 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.
(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.
You are on call and receive a page from the mother of a 23-year-old patient with a traumatic brain
injury whose severe spasticity is managed by intrathecal baclofen (Lioresal). She reports that her
son’s spasticity is getting worse over the last 24 hours, and he is complaining of whole body itching
and a feeling like bugs crawling on his skin. He has developed nausea and just vomited. He had
been doing well up until a day ago, and mom reports no rash on his skin. You tell her to
(a) give him oral diphenhydramine (Benadryl) tablet for the itching and promethazine
(Phenergan) for the nausea. You schedule him for the next available clinic to adjust his
baclofen pump.
(b) give him oral baclofen and bring him to the clinic the next day for further evaluation.
(c) give him a diazepam (Valium) tablet and schedule him for clinic the next day for further
evaluation.
(d) give him oral baclofen and bring him to the emergency room for your further evaluation.
(d) Intrathecal baclofen withdrawal can be very serious and warrants immediate evaluation and
management. The signs of baclofen withdrawal can be subtle with an intrathecal baclofen pump,
but a sudden increase in spasticity and feeling ill with whole body itching are seen with baclofen
withdrawal. Nausea and emesis is a warning of impending severe withdraw. Prevention of severe
spasticity and the sequelae of rhabdomyolysis is critical to the health and welfare of the patient.
The treatment is to restore intrathecal baclofen.
Which diagnosis is associated with an increased risk of post-traumatic hydrocephalus?
(a) Diffuse axonal injury
(b) Subdural hematoma
(c) Epidural hematoma
(d) Subarachnoid hemorrhage
(d) Hydrocephalus is a well-recognized complication of subarachnoid hemorrhage. The fundamental
abnormality in post-traumatic hydrocephalus is an imbalance in the production and absorption of
cerebral spinal fluid (CSF). As the blood in the subarachnoid space obstructs the arachnoid villi it
impairs absorption of CSF, thus causing hydrocephalus.
A 26-year-old woman is admitted to the inpatient rehabilitation unit following a traumatic brain
injury. She is confused, inappropriate, agitated, and requires a padded floor bed. What is her
Rancho Los Amigos level?
(a) IV
(b) V
(c) VI
(d) VII
(a) The Rancho Los Amigos level IV applies to persons who are confused and agitated. The need of a
padded floor bed indicates that the patient is restless and agitated.
In anoxic brain injury, which area of the brain is most susceptible to hypoxemia and hypotension?
(a) Hippocampus
(b) Pons
(c) Basal ganglia
(d) Cerebellum
(a) The mechanism of brain damage in anoxic brain injury is ischemia due to hypoxemia or decreased
cerebral perfusion. Although anoxic brain injury typically causes diffuse neuronal death and injury,
there is selective vulnerability of certain neurons. Neurons in parts of the hippocampus appear to be
the most vulnerable, which correlates with the high frequency of amnesia following anoxic brain
injury.
Which pharmacologic agent should be avoided because of its cognitive side-effects in individuals
with brain injury?
(a) Metoclopramide (Reglan)
(b) Omeprazole (Prilosec)
(c) Erythromycin (E-Mycin)
(d) Sucralfate (Carafate)
(a) The use of metoclopramide (Reglan) should be avoided because it is known to cause sedation and
significant cognitive difficulties for individuals with brain injuries, especially for those regaining
consciousness. It also has potential side effects of extrapyramidal movements and tardive
dyskinesia. The other agents do not have significant cognitive effects on brain-injured individuals.
In traumatic brain injury, magnetic resonance imaging (MRI) is preferred to computed tomography
(CT) scan in the
(a) evaluation of acute brain injury.
(b) detection of subarachnoid hemorrhage.
(c) detection of epidural hematomas.
(d) evaluation of diffuse axonal injury.
(d) Magnetic resonance imaging (MRI) is considered better than computed tomography (CT) for
evaluating diffuse axonal injury (DAI). A CT scan is superior to MRI for the detection of acute
extra-axial hematomas, and in the evaluation of acute brain injury.
The association of apolipoprotein-E (APOE-4) allele and history of traumatic brain injury increases
the risk of developing
(a) hydrocephalus.
(b) alzheimer’s disease.
(c) post-traumatic epilepsy.
(d) cerebral neoplasms.
(b) Individuals with a history of traumatic brain injury (TBI) and apolipoprotein-E (APOE-4) allele
have 10 times the risk of developing Alzheimer’s disease compared with 2 times the risk for
APOE-4 allele alone and no increased risk with TBI alone.
An 18-year-old man was in a high-speed motor vehicle collision 24 hours ago. He required a
prolonged extrication from his vehicle and lost consciousness at the scene of the accident. Head
computed tomography (CT) scan was notable for a small subarachnoid hemorrhage. He has had
several episodes of hypotension and hypoxemia since admission. What information in this clinical
case makes diffuse axonal injury highly likely?
(a) High-speed motor vehicle collision
(b) Subarachnoid hemorrhage on head CT scan
(c) Episodes of hypoxia and hypotension
(d) Prolonged extrication from vehicle
(a) Diffuse axonal injury is most commonly seen after high-speed motor vehicle collisions, particularly
when immediate loss of consciousness occur.
A 30-year-old man with a recent traumatic brain injury has frequent episodes of emesis with
gastrostomy tube bolus feedings despite receiving agents to facilitate gastric emptying. The most
appropriate next course of action is to
(a) switch the tube feeding formula.
(b) switch to continuous tube feedings.
(c) order a gastric endoscopy.
(d) place a jejunostomy tube.
(b) Intolerance to feeding can be related to increased gastric distention, and adjusting from bolus to a
slower rate with longer feeding time may provide relief. Converting to a jejunostomy is appropriate
if simpler measures fail.
- Early post-traumatic seizures are defined as seizures within the first
(a) day.
(b) month.
(c) week.
(d) 3 months.
(c) Early post-traumatic seizures occur from the first day to 1 week postinjury. Immediate seizures
occur within the first 24 hours. Late seizures occur after the first 7 days.
In a patient with traumatic brain injury and vertigo, which physical examination finding from a
Dix-Hallpike test would encourage you to perform an Epley maneuver?
(a) Persistence of responses to repeated provocation
(b) Fixed direction of nystagmus with rotary component
(c) Nonconcordant or divergent gaze
(d) Persistence of nystagmus, 30 seconds for each provocation
(b) A positive Dix-Hallpike test definitively establishes the diagnosis of benign paroxysmal positional
vertigo (BPPV). The Dix-Hallpike maneuver is performed by quickly dropping a patient backwards
from a sitting position so that the head is rotated 45 degrees and hangs over the edge of a mat.
Characteristics of BPPV are mixed torsional and vertical nystagmus, which lasts for 10–20 seconds,
associated with a sensation of rotational vertigo. Repetition of the test results in a reduction in the
intensity of vertigo and nystagmus. The Epley maneuver, which is performed at the bedside,
relocates debris from the posterior semicircular canal into the vestibule of the vestibular labyrinth.
Which factor does NOT increase a person’s risk for hydrocephalus following traumatic brain
injury?
(a) subarachnoid hemorrhage
(b) post traumatic seizures
(c) intracranial infections
(d) penetrating injury
(b) In communicating post-traumatic hydrocephalus, cerebral spinal fluid (CSF) absorption by the villi
is impaired. This occurs with inflammation or subarachnoid hemorrhage.
What is the single largest indirect cause of traumatic brain injury?
(a) Falls
(b) Alcohol
(c) Motor vehicle accidents
(d) Polypharmacy
(b) Alcohol is believed to be involved in 60% of traumatic brain injury (TBI) cases. Polymedication is
not a common indirect cause of traumatic brain injury. Motor vehicle accidents and falls are direct causes of TBI and not indirect.
A 46-year-old woman was involved in a rear-end type motor vehicle accident in which she hit her
head against the steering wheel and briefly lost consciousness. Her initial cognitive complaints
have improved. She experiences 3 throbbing, unilateral headaches a week associated with nausea.
These are graded 8/10 and last for 4 to 8 hours. Which medication would be most appropriate to
prescribe?
(a) Intranasal butorphanol (Stadol) 1 spray 6 times daily
(b) Ibuprofen (Motrin) 600mg 4 times daily
(c) Sertraline (Zoloft) 100mg daily
(d) Valproic acid (Depakote) ER 500mg twice daily
(d) Divalproex sodium reduces the number and severity of migraine headaches. With 3 migraine-like
headaches a week, prophylactic treatment for migraine is indicated. There is concern for developing
dependence and abuse potential for butorphanol. Daily use of ibuprofen is more likely to result in
rebound headaches when discontinued. There is no evidence that the selective serotonin release
inhibitors are effective in the treatment of headache.
A 24-year-old man was in a motor vehicle collision 36 hours ago. His initial Glasgow Coma Scale
score was 13 and his initial head computed tomography scan showed a small frontal contusion.
Initial blood alcohol level was .15g/dL. He is currently disoriented, combative, and tachycardic. He
reports visual hallucinations. Management of this case should include
(a) benzodiazepines for alcohol withdrawal.
(b) anticonvulsants for agitation.
(c) neuroleptics to treat hallucinations.
(d) beta-blockers to treat tachycardia.
(a) Premorbid alcohol abuse is commonly seen in people sustaining brain injury and alcohol
withdrawal causes agitation and hallucinations.
According to the Hunt and Hess Scale, which grade of subarachnoid hemorrhage would apply to a
patient who presents with moderately severe headache, meningismus, and cranial nerve deficit?
(a) 0
(b) 1
(c) 2
(d) 3
(c) Grade 2 of the Hunt and Hess Scale is moderately severe headache/meningismus, no neurologic
deficit, except cranial nerve palsy.
The criterion scale used to describe severity of brain injury is the
(a) Disability Rating Scale.
(b) Agitated Behavior Scale.
(c) FIM™ instrument.
(d) Glasgow Coma Scale.
(d) The criterion to describe the severity of a traumatic brain injury is the Glascow Coma Scale (GCS).
GCS score of 13-15 = mild
GCS score of 9-12 = moderate
GCS score of 3-8 = severe
On a pharmacologic basis, which agent used to decrease gastric acid secretion is most appropriate
after brain injury?
(a) Ranitidine
(b) Famotidine
(c) Omeprazole
(d) Sucralfate
(c) Choices a and b are both histamine type-2 (H2) blockers that are cognitively impairing.
Six months after a moderate traumatic brain injury, a 32-year-old woman complains of daytime
somnolence. Her medical work-up is negative. She has normal sleep patterns. The medication you
would most likely consider in this case is
(a) donepezil.
(b) buspirone.
(c) tolcapone.
(d) modafinil
(d) From the information given, it is clear that this patient is functioning well overall. She has some
difficulty staying awake. Of the answers given, modafinil is the medication most appropriate to
help with alertness during the day. Donepezil is an acetylcholinesterase inhibitor used most often to
improve memory. Buspirone is used to decrease anxiety. Tolcapone is a newer dopaminergic agent
that has not been studied in populations with brain injury.
A 26-year-old man was in a motor vehicle crash last night. Oxygen saturation was consistently
around 93%. Intracranial pressure was 15mmHg, with a mean arterial blood pressure of 110mmHg.
Pupils were equally reactive. This patient’s prognosis is
(a) poor because oxygen saturation was consistently below 95%.
(b) poor because of the high intracranial pressure.
(c) not affected by pupillary response in the first 24 hours.
(d) good because his cerebral perfusion pressure was greater than 70mmHg.
(d) The guideline set by the American Association of Neurological Surgeons included avoidance of
oxygen saturations of less than 90%. Cerebral perfusion pressure is a more important predictor of
outcome than ICP since CPP is more directly related to metabolic delivery and ischemia. CPP is
mean arterial pressure minus ICP and in this patient is 95. Pupillary response is a very important
early predictor of eventual outcome.
Which measure will ensure the best outcome for a 68-year-old man who is in the critical care unit
with severe traumatic brain injury?
(a) Minimizing cerebral perfusion pressure
(b) Minimizing early hypoxia
(c) Avoiding hypertension
(d) Inducing hypothermia
(b) Hypoxia in the setting of brain injury is associated with poor outcome. Maintaining perfusion
pressure and avoiding hypotension are important critical care measures to avoid secondary
complications in brain injury. Inducing hypothermia has not been found to improve outcome in
patients with brain injury.
Which genetic factor may link Alzheimer disease and chronic residual deficits in traumatic brain
injury?
(a) Apolipoprotein-4
(b) Human leukocyte antigen B27
(c) Mitochondrial protein C450
(d) Platelet aggregation factor
(a) The apolipoprotein-4 has been linked both to Alzheimer disease and to chronic effects of
traumatic brain injury.
Regarding post-traumatic seizures following brain injury,
(a) by definition, early seizures occur in the first 24 hours after an injury.
(b) prophylaxis beyond the first week postinjury does not prevent late seizures.
(c) an association exists between late post-traumatic seizures and alcohol use.
(d) most seizures are of the generalized tonicoclonic type.
(b) Early seizures occur within the first week. Late seizures are either simple partial or complex partial.
Alcohol is not a risk factor for developing late post-traumatic seizures.
Which characteristic is a risk factor for heterotopic ossification in traumatic brain injury?
(a) Male gender
(b) Flaccid tone
(c) Long bone fractures
(d) Older age
(c) Risk factors for HO include: long bone fractures, spasticity, prolonged immobilization, and
prolonged coma
Which factor is a prime determinant of successful return to work after traumatic brain injury?
(a) Presence of associated musculoskeletal injuries
(b) Glasgow Coma Scale score at 48 hours post injury
(c) Presence of post-injury depression
(d) Pre-injury occupation type
(b) There are several determinants to successful return to work for persons with traumatic brain
injuries. All studies have identified the severity of head injury as a primary factor in return to work;
the Glasgow Coma Scale is one of the robust measures of injury severity. Other factors include
preinjury work history, age, cognitive abilities, or motor limitations.
An 18-year-old man incurs a mild traumatic brain injury in a bar dispute. He presents 2 months
later complaining of persistent headaches originating in the back of the neck and radiating
circumferentially forward. After a thorough history and physical examination, you feel his
principal problem is myofascial in origin; specifically, two offending trigger points are found. Your
first approach to treatment would be
(a) amitriptyline 100mg at bed time.
(b) injection with botulinum toxin.
(c) establishing an outpatient cognitive behavioral program through psychology to address a
subacute pain syndrome.
(d) injection with 1% lidocaine.
(d) Post traumatic headaches are a common symptom after cervicocranial trauma. The differential
diagnosis includes cervical disease, occipital neuralgia and migraines, and myofascial pain. In this
scenario, points that reproduce the headaches should be treated either with or without local
anesthesia. This helps to reduce pain, inhibit the muscle contracture band, and enhance local muscle
blood flow.
Risk factors for heterotopic ossification in a 27-year-old man with severe traumatic brain injury
include
(a) total parenteral nutrition.
(b) prolonged coma.
(c) seizure disorder.
(d) hypotonicity.
(b) Risk factors for the development of heterotopic ossification include prolonged coma,
immobilization, and limb spasticity
You are asked to evaluate a 25-year-old man who sustained a traumatic brain injury (TBI) in a car
crash. In the emergency department, he was unable to follow commands but withdrew to pain,
opened his eyes when spoken to, and was disoriented. Head computed tomography revealed a frontal
contusion. According to the Glasgow Coma scale, his injury can be classified as
(a) uncomplicated mild TBI.
(b) complicated mild TBI.
(c) moderate TBI.
(d) severe TBI.
(c) Based on the information presented in the question, the Glasgow Coma Scale score for this patient
is 11 (eyes open when spoken to 3, withdraws to pain 4, converses but is disoriented 4 = total score
11). Moderate injury is defined by GCS scores of 9 to 12.
A 28-year-old PM&R resident had a mild traumatic brain injury. He is now having problems
organizing and leading team meeting, although his ability to perform other aspects of his job as an
individual are unimpaired. Of the following, the most useful neuropsychologic test for assessing his
deficits is the
(a) Galveston Orientation and Amnesia Test.
(b) Wechsler Adult Intelligence Scale–Revised.
(c) Wechsler Memory Scale.
(d) Trails A and B test.
(d) From the details given in the case, this resident appears to be having problems in mental flexibility
and paying attention to multiple stimuli. The Trails A and B test examines simple and alternating
attention. The Galveston Orientation and Amnesia Test, which is used to measure the presence of
post-traumatic amnesia, would not be helpful. The Wechsler Adult Intelligence Scale–Revised and
Wechsler Memory Scale, while necessary in a complete neuropsychological examination, do not
directly measure attentional abilities
A 29-year-old woman with a traumatic brain injury is seen by you for consultation. On chart
review, it is noted that she has frequent episodes of emesis with percutaneous endoscopic
gastrostomy tube bolus feeding. Your initial recommendation would be
(a) placement of a jejunostomy tube.
(b) surgical consult for pyloroplasty.
(c) continuous tube feeding.
(d) switch to elemental formula tube feeding
(c) Feeding issues for patients with traumatic brain injury can become quite complex. It is important to
use stepwise approaches when investigating emesis in this population. Quite frequently a
percutaneous gastrostomy tube is placed in the neurointensive care unit. Intolerance to feeding can
be related to increased gastric distention, and adjusting from bolus to continuous feeding may
provide relief. Other steps might then include converting to a jejunostomy or using agents to
facilitate gastric emptying.
Characteristic x-ray findings of new bone formation in heterotopic ossification include densities
that are
(a) noncircumscribed, extra-articular, and extracapsular.
(b) noncircumscribed, extra-articular, and intracapsular.
(c) circumscribed, extra-articular, and extracapsular.
(d) circumscribed, intra-articular, and intracapsular.
(a) Typically, heterotopic ossification occurs in the more proximal joints. X-ray findings are a
“popcorn” appearance of fluffy (noncircumscribed), immature bone, extracapsular and extraarticular.
A 22-year-old man with a severe brain injury has repeated episodes of inappropriate sexual
touching of female staff. An initial treatment option for decreasing this behavior would include
(a) assigning only male staff.
(b) precribing clomipramine (Anafranil) 25 mg BID.
(c) using of soft hand restraints for 3 minutes.
(d) offering firm verbal discouragement.
(d) Inappropriate sexual touching occurs more commonly in patients with a history of frontal lobe
damage. Treatment is best directed at staff education to make certain all team members are
consistent in responses. Behavior modification is directed at telling the patient his behavior is
wrong and firmly taking his hand and putting it closer to his person. Restraints are only indicated
as temporary solutions to prevent acute bodily injury.
