Traumatic Brain Injury Flashcards by Stephanie Escobar

Symptoms of brain injury:

Loss of consciousness or AMS
Headache
Amnesia
Symptoms of increased intracranial pressure (ICP) like
( \_\_, \_\_, \_\_) non-specific
Focal neurologic deficits
\_\_\_\_ [obvious on physical exam]

Dizziness, nausea, vomiting

Posturing
decorticate → hugs core; decerebrate → arms extended

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General symptom of skull fractures

Liquorrhea

leakage of CSF through an external opening

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CSF rhinorrhea
Raccoon eyes
Suggest a(n) ___ skull fracture

Anterior basilar

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CSF otorrhea
Blood behind tympanic membrane
Ecchymosis over the mastoid process
Suggest a(n) ___ skull fracture

Posterior basilar

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Glasgow Coma Score Interpretation
GCS _ (minimum score): Deeply comatose or imminent brain death
GCS ≤ 8: severe TBI → ___
GCS 9–12: moderate TBI
GCS ≥ 13: mild TBI
GCS _ (maximum score): Full consciousness

3
intubate
15

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___ → first-line imaging for TBI

NC Head CT

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Mild TBI/Concussion → GCS __

13-15

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Mild TBI/Concussion (GCS 13-15) Management →
If at least one of the following:

AMS at the time of the injury
loss of consciousness < 30 minutes
post-traumatic amnesia < 24 hours
minor neurological abnormalities

Observation in the ED is often sufficient.

NSAIDs & antiemetics PRN

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Moderate TBI → GCS __

Management:

9–12

(time to intervene with ICP management:
HOB elevation, HTN control, Antipyretics, Normoglycemia)

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LLE paralysis only

Where is the lesion and what is the artery supplying the area?

Primary Motor Cortex
(Precentral gyrus in the posterior Frontal Lobe)

Right ACA

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LUE complete sensory loss
RLE complete sensory loss

Where is the lesion located and what artery supplies it?

Right MCA
Left ACA

Primary somatosensory cortex
(post-central gyrus of the anterior Parietal lobe)

*central sulcus divides the frontal and parietal lobe.
The Primary motor cortex is in the pre-central gyrus of the posterior Frontal lobe)

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Aphasia

what lobe was affected?

Left Temporal lobe

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Contralateral hemiparesis of the face, arm, and leg, but no sensory impairment
where is the lesion?

Posterior limb of the internal capsule

lenticular striate arteries

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Right sided numbness and paresthesia of the face, arm, and leg. Motor intact.
where is the lesion?

Left Thalamus (VPL)

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Arterial bleed: rupture of middle meningeal artery

___ hematoma

Epidural

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Venous bleed: rupture of bridging veins

___ hematoma

Subdural

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Often followed by a lucid interval, before the onset of focal neurological deficits

Epidural Hematoma

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Signs of elevated ICP
Changes in mental status
+/-Lucid interval

Subdural Hematoma

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Nontraumatic brain hemorrhage
Sudden, severe thunderclap headache
\+ Meningeal signs
Kernig sign (flexing hip = painful)
Brudzinski sign (flexing neck = painful)

Subarachnoid hemorrhage

Crescent-shaped
concave
hyperdense extra-axial lesion
Lesion does NOT cross the midline
Lesion can cross cranial suture lines

Subdural Hematoma

Biconvex
lens shaped
Lesion can cross the midline
Lesion can NOT cross cranial suture lines

Epidural Hematoma

Lesion can cross the midline (because on top of dura)

Lesion can NOT cross cranial suture lines (because it is directly below the cranium, skull bone)

Management for Subdural & Epidural Hematoma

Urgent craniotomy

Neuroprotective measures:↓ ICP, ↓ metabolic demand via ↓ temperature, etc.

Hemorrhage into the space on top of the dura mater and directly below the cranium (skull bone)

Epidural hematoma

Pterion fracture, thinnest part of Temporal bone where middle meningeal artery exits

Epidural hematoma → transtentorial __ herniation →

brain stem compression → rapid neurological decline & ___ (classic triad).

Uncal
Cushing triad (HR <65, HTN, irregular resp)

Hemorrhage into the space under the dura mater and on top of arachnoid mater.

Subdural hematoma Lesion does NOT cross the midline (b/c the dura stops it) Lesion can cross cranial suture lines (because it's 1 layer under the skull bone)

Subdural hematoma can be __ or __

Acute: within 3 days (hyperdense CT) Chronic: onset 21+ days (hypodense CT)

Shaken baby syndrome can lead to what type of brain bleed?

Subdural hematoma | also: SAH, diffuse axonal injury, Retinal w/ central white Roth spots

Subdural hematoma requires craniotomy with evacuation if 1+ of following: Hematoma size ≥ _ mm Signs of cerebral herniation syndromes ( __, __) Rapid neurological deterioration otherwise Empiric ICP management

10mm (1cm) | extensor posturing, anisocoria (unequal pupil sizes)

__ is the most common cause of SAH.

Head trauma *Ruptured cerebral aneurysm is the most common cause of nontraumatic SAH. Risk factors: Smoking, HTN, FMH

Complications linked to Subarachnoid Hemorrhage: 1. SIADH 2. Seizures 3. Elevated ICP/Cushing triad 4. _____ (w/in first 24 hours) 5. _____ (3–10 days later)

Re-bleeding → w/in first 24 hours ``` Vasospasm → ischemic stroke (3–10 days later) ```

Causes of Intracerebral Hemorrhage: Trauma ____ most common cause of spontaneous ICH ____ most common cause of spontaneous ICH 60+ AV malformations CNS infections (___) ___ use

Hypertension Cerebral amyloid angiopathy HSV encephalitis Stimulants (cocaine and amphetamines)

Acute Stabilization in Intracerebral Hemorrhage 1. ____ control 2. ____ reversal 3. ____ management

1. Blood pressure control (nicardipine/labetalol) 2. Anticoagulation reversal (warfarin → PCC, FFP, Vit K) (heparin → Protamine sulfate) 3. ICP management (head elevation, mannitol, shunts, etc.)

Definitive management of Intracerebral Hemorrhage with signs of brain herniation: Unconscious, Pupillary changes, +/- Posturing

Decompressive craniotomy | & Hematoma evacuation

Dissection of the carotid and the vertebral artery Etiology: Penetrating or blunt trauma (neck or inside mouth) Spontaneous dissection: HTN Ehlers-Danlos syndrome & Marfan syndrome _____

Fibromuscular dysplasia | px: middle age woman, Bruits, HTN, Kidney disease, strokes

Dissection of the _____ Ischemic features: MCA stoke (UE & face) Amaurosis fugax (ischemic retina)

carotid artery

Dissection of the carotid artery Non-ischemic features: Ipsilateral _____ pain Partial Horner syndrome: ptosis & miosis Ipsilateral headache tinnitus

facial/neck pain

Non-ischemic features: Occipital headache Posterior nuchal pain Ischemic features: Horner syndrome Ipsilateral Dysphagia, ↓ Gag reflex, Hoarseness, Nystagmus Dissection of the ____

vertebral artery

Imaging for suspected dissection of the carotid and the vertebral artery 1. first-line 2. diagnostic

1. Duplex U/S (high resistance or absent flow) 2. CT angiography- Helical* (Changed caliber of vessel) *(replacing MRA as diagnostic modality)

Management of Carotid Artery and Vertebral Artery Dissection: 1. First r/o ___ via [imaging] 2. ___ therapy 3. [Interventions: 2] 4. Anticoagulation (3–6 m) and/or Antiplatelet (1y)

1. ICH (via NCCT head) 2. Heparin therapy 3. (+/-) Angioplasty or Stenting

NCCT Head → first-line imaging for TBI Intracranial hemorrhage or hematoma: ____ lesions Diffuse axonal injury (DAI): multiple ____ lesions

hyperdense (bright) punctate hyperintensities (bright)* *small hemorrhages usually at jxn of gray & white matter, or in the white matter or blurring of white/grey matter (shearing/acc/decel forces)

Mild TBI/Concussion → GCS 13-15 ``` 1+ of the following: AMS at the time of the injury loss of consciousness < 30 minutes post-traumatic amnesia < 24 hours minor neurological abnormalities ``` What is the next best step in management?

Observation NSAIDs & antiemetics (PRN)

Pt with Moderate TBI → GCS 9–12 is admitted to Neuro ICU. What are the next best steps in management? (3)

Conservative → HOB 30º elevation, sedation, analgesia, antipyretics, seizure control ppx ICP management → Therapeutic hyperventilation, +/-Mannitol (Target ICP < 20) Surgery → Decompressive craniectomy, CSF drainage via EVD shunt

patient with severe TBI and episodic hypertension, tachycardia, and diaphoresis most likely has

paroxysmal sympathetic hyperactivity (PSH) (conservative tx: Opioid sedation, Anti-pyretic, Hyperventilation, Beta Blocker) depending on sxs.

Subfalcine herniation (cingulate gyrus is displaced under the falx cerebri) Typically does not cause pupillary changes but may cause ipsilateral [artery] compression resulting in contralateral [finding].

ACA compression Contralateral LE weakness/paralysis

Expanding intracranial hemorrhage can cause brain herniation (tonsillar, uncal). Resulting in: ____ compression and ____ changes.

brainstem compression (unconsciousness, irregular breathing) pupillary changes

Tonsillar herniation (cerebellar tonsils through the foramen magnum) causes ___, ___ pupils due to disruption of both sympathetic and parasympathetic innervation in the midbrain (brainstem).

fixed, midposition fixed (non-reactive), midposition (4-6mm) (tonsillar herniation; midbrain compression)

Uncal (Temporal lobe) herniation causes a(n) ipsilateral ___ & ___ pupil due to compression/infarction of the ipsilateral parasympathetic fibers of CN3 in the midbrain.

ipsilateral fixed and dilated | non-reactive; 5+mm