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MB3 Neurology > Trauma and CSF > Flashcards

Trauma and CSF Flashcards

1
Q

uses of GCS

A

preduct coma or other prognosis

diagnosis of coma

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2
Q

3 classes within GCS and which is the most important

A

eye opening
verbal response
motor - most important

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3
Q

classification within eye opening - GCS

A

4 - Spontaneous
3 - Verbal
2 - To pain
1 - None

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4
Q

classification within verbal response - GCS

A 
5 - orientated 
4 - confused 
3 - inappropriate words 
2 - incomprehensible sounds 
1 - nothing
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5
Q

classification within motor response - GCS

A 
6 - obeys 
5 - localises to pain 
4 - withdrawal to pain 
3 - decorticate motor response 
2 - decerebrate motor response 
1 - unresponsive
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6
Q

what is decorticate positioning

A

severe damage to cerebrum, internal capsule and thalamus but midbrain spared
abnormal arm flexion, hands clenched to fist and legs extended with feet inwards
disturbance to lateral CST and hence rubrospinal causes abnormal UL flexion and reticulospinal causes leg extension

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7
Q

what is decrebrate positioning

A

severe brainstem damage, below the red nucleus
head arched back and arms and legs extrended
rubrospinal and lateral CST are compromised
reticulospinal tract takes over to lead to full body extension

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8
Q

describe CSF production in the brain

A

produced in the choroid plexus of the ventricles
flows from lateral ventricles to third ventricle by foramen of munro
flows through cerebral acqueduct/sylvius to reach 4th ventricle
circulates to SA space by formamen of magendie and luschka and absorbed by arachnoid granulations back to venous blood

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9
Q

what is the normal ICP

A

5-15mmHg

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10
Q

describe how the monroe kellie hypothesis may be compromised by increased ICP

A

brain autoregulates cerebral blood flow and so as ICP rises autoregulation becomes compromised
this leads to ischaemia, swelling and herniation

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11
Q

possible causes raised ICP?

A 
SOL - tumour, haemorrhage, haematoma 
cerebral oedema - ischaemia, liver failure, hypercarbia 
CSF obstruciton 
IIH
raised venous pressure
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12
Q

features of raised ICP

A 
headache 
nausea and vomiting 
papilloedema 
drowsy 
cushings triad
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13
Q

what is cushings triad

A

hypertension
bradycardia
decreased respiration

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14
Q

what is uncal herniation and how may it present

A

medial temporal lobe herniation through tensorium
pupillary dilatation due to CN III compression
can compress pyramidal tracts to lead to contralateral hemiparesis

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15
Q

what is subfalcine herniation and how may it present

A

herniation of cingulate gyrus below falx

can lead to LL weakness due to compression of ACA

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16
Q

what is transcalvarial herniation

A

herniation through the skull

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17
Q

what is central herniation

A

descent of the diencephalon and midbrain

can lead to VI palsy and brainstem dysfunction

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18
Q

what is tonsillar herniation

A

displacement of cerebellar tonsils through foramen magnum
can be posterior fossa lesion or arnold chiari
medullary compression, neck stiffness, abnormal neck posture
cheyne stokes breathing
coma
death

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19
Q

what is an epidural haematoma and what is the usual cause

A

bleeding between dura and skull

MMA damage, usually temporoparietal skull fracture leading to damage to pterion

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20
Q

clinical features of an epidural haematoma

A

often a young adult with closed head trauma
brief loss consciousness, lucid interval and then deterioration with headache, vomiting, contralateral hemiparesis or ipsilateral pupil dilatation

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21
Q

imaging for epidural haematoma

A

CT with lens shapes appearance not crossing suture lines

possible mass effect and herniation

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22
Q

management of an epidural haematoma

A

immediate surgical evacuation if neuro deficit

if small can be managed conservatively if small and no neuro deficit

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23
Q

what is a subdural haematoma

A

bleeding below dura and above arachnoid mater

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24
Q

describe the features of an acute SDH

A

immediately symptomatic, often following head trauma
cerebral blood flow may be reduced so there is cerebral oedema and ischaemia
in acute cases presentatiob is a severely decreased state of consciousness

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25
Q

causes of chronic SDH

A

brain atrophy - age, dementia, alcohol
anticoagulation
inflammation, previous head trauma

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26
Q

describe how brain atrophy leads to SDH

A

as atrophy occurs bridging veins are stretched leading to bleeding
leaky vessels accumulate blood into SD space and osmotic gradient causes pull into space

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27
Q

features of a chronic SDH

A 
headache 
confusion 
urinary incontinence 
weakness
seizure
cognitive dysfunction 
gait abnormality
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28
Q

imaging of SDH

A

CT

crescent shaped hyperdense if acute and hypodense if chronic

29
Q

what is normal pressure hydrocephalus and what are possible causes

A

build up of CSF due to impaired resorption at arachnoid granulations or overproduction of CSF
usually idiopathic but can be secondary to trauma, haemorrhage, meningitis

30
Q

clinical features of normal pressure hydrocephalus

A

apraxia - shuffling gait
reversible dementia
urinary incontinence

31
Q

imaging and management of normal pressure hydrocephalus

A

massively enlarged ventricles

VP shunt, reserved for ventriculomegaly with severe symptoms or after marked improvement with CSF removal

32
Q

what is communicating hydrocephalus

A

excess CSF in ventricles leading to enlarged ventricular system with no flow obstruction
impaired resorption by arachnoid granulations

33
Q

what is non communicating hydrocephalus

A

excess CSF in ventricles due to obstruction of flow
usually determined as 4th ventricle is smaller than 3rd and lateral
causes are colloid cyst, stenosis of acqueduct, tumour

34
Q

common causes of congenital hydrocephalus

A

acqueductal stenosis

spina bifida or arnold chiari

35
Q

common causes of acquired hydrocephalus

A

tumour
infection
trauma

36
Q

presentation of congenital hydrocephalus

A 
fail to thrive 
dilated scalp veins 
increased head circumference 
sunsetting gaze
impaired upgaze
diplopia 
vomiting 
macewen sign
37
Q

presentation of acquired hydrocephalus

A 
headache - mostly morning 
vomiting 
diplopia 
impaired upgaze
papilloedema 
drowsy 
incontinence 
gait anomaly
38
Q

investigation of congenital hydrocephalus

A

detailed hx and antenatal hx with milestones
head circumference, full ophthalamic exam
palpate ant fontanelle
MRI is best but CT more available

39
Q

management of hydrocephalus

A

CSF diversion
VP shunt or endoscopic third ventriculostomy - needs functional CSF absorption as drains to basal cistern so only for non-comms hydrocephalus

40
Q

what is a Chiari I malformation

A

most common and least severe malformation

caudally displaced cerebellar tonsils below foramen magnum

41
Q

signs and symptoms of a chiari I malformation

A

headache, esp on cough and neck extension and suboccipital pain
downbeat nystagmus
central cord symptoms - sensory loss of pain and temp and progressive paralysis starting with UL
ataxic gait

42
Q

what is a chiari II malformation and what is it associated with

A

less common and more severe
more frequent in children and clear association with spina bifida
can lead to hydrocephalus
caudal displacemnt of cerebellum and medulla below foramen magnum with herniation of the 4th ventricle

43
Q

signs and symptoms of chiari II malformation

A

severe brainstem dysfunction - apnoea, stridor, nystagmus, dysphagia
weakness progressingt o quadriplegia

44
Q

management of chiari malformations

A

non surgical
operative depending on imaging or symptoms
suboccipital craniotomy and upper cervical laminectomy to decompress

45
Q

what is IIH

A

raised ICP in absence of any SOL or hydrocephalus

more common in obese and female

46
Q

presentation of IIH

A

headache worst in morning and relief by standing
moderate to gross bilateral papilloedema
nausea and vomiting
VI nerve palsy

47
Q

investigation of IIH

A

CT/MRI may show slit like ventricles
visual field testing and fundoscopy
LP if not contraindicated

48
Q

management of IIH

A

weight loss
LP shunt potentially
azetazolamide

49
Q

head injury severity scale on GCS - mild

A

14/15

50
Q

head injury severity scale on GCS - moderate

A

9-13

51
Q

head injury severity scale on GCS - severe

A

<8

52
Q

when to have a CT within an hour

A 
GCS <13
GCS <15 post 2hr 
suspected open or depressed skull fracture
signs of basal skull fracture 
post trauma seizure 
focal neuro deficit 
>1 episode vomiting 
NAI
53
Q

when to have an immediate head CT

A

Loss of consciousness or amnesia and one of the following

>65, dangerous mechanism injury or coagulopathic

54
Q

what is an intracerebral haematoma

A

bleeding in the brain substance

55
Q

what is the coup/contracoup effect

A

head strikes a solid object but brain continues to move and strikes skull at the opposite side

56
Q

what is a diffuse axonal injury

A

appears as small hyperdense areas at grey/white matter interface, brainstem or corpus callosum
shearing force damaging axon
LOC,

57
Q

medical management of raised ICP

A 
sedate 
max venous drainage 
Lower Co2 on intubation 
osmotic diuretica 
CSF release 
last ditch
58
Q

sedatives for raised ICP

A

propofol
BZD
barbiturates

59
Q

venous drainage options for raised ICP

A

cervical collar
head of bed tilt
loosen ETT ties

60
Q

osmotic diuretics for raised ICP

A

mannitol

hypertonic saline

61
Q

CSF release or last ditch options for raised ICP

A

external drain
hemicraniectomy
bifrontal craniectomy

62
Q

describe the features of brainstem death on exam and requirements for it to be carried out

A

no drugs, hypothermia or metabolic disturbance
no pupil response, corneal reflex
no motor response
no vestubulo-ocular response
no gag or cough
no respiration
tested twice by two doctors and one must be a consultant

63
Q

calculation of CPP

A

MAP-ICP

64
Q

calculation of cerebral blood flow

A

CPP/vascular resistance

65
Q

describe cerebral blood flow autoregulation

A

remainst constant under changing BP
regulation of vascular resistance
arterioles dilate in presence of lactate or CO2
pressure constriction/dilatation as needed

66
Q

early features raised ICP

A 
decreased consciousness
headache 
pupil dysfunction ±papilloedema 
change in vision 
N&V
67
Q

late features raised ICP

A 
coma 
fixed and dilated pupils, unilateral then bilateral 
hemiplegia 
bradycardia, hypertension 
hyperthermia 
reduced urine output
68
Q

who often gets normal pressure hydrocephalus

A

the elderly

MB3 Neurology (19 decks)

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