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Surgery > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

1
Q

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]
A

Dizziness, nausea, vomiting

Posturing
decorticate → hugs core; decerebrate → arms extended

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2
Q

General symptom of skull fractures

A

Liquorrhea

leakage of CSF through an external opening

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3
Q

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

A

Anterior basilar

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4
Q

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

A

Posterior basilar

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5
Q

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

A

3
intubate
15

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6
Q

___ → first-line imaging for TBI

A

NC Head CT

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7
Q

Mild TBI/Concussion → GCS __

A

13-15

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8
Q

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

A

Observation in the ED is often sufficient.

NSAIDs & antiemetics PRN

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9
Q

Moderate TBI → GCS __

Management:

A

9–12

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

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10
Q

LLE paralysis only

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

A

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

Right ACA

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11
Q
  1. LUE complete sensory loss
  2. RLE complete sensory loss

Where is the lesion located and what artery supplies it?

A
  1. Right MCA
  2. 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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12
Q

Aphasia

what lobe was affected?

A

Left Temporal lobe

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13
Q

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

A

Posterior limb of the internal capsule

lenticular striate arteries

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14
Q

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

A

Left Thalamus (VPL)

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15
Q

Arterial bleed: rupture of middle meningeal artery

___ hematoma

A

Epidural

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16
Q

Venous bleed: rupture of bridging veins

___ hematoma

A

Subdural

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17
Q

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

A

Epidural Hematoma

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18
Q

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

A

Subdural Hematoma

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19
Q 
Nontraumatic brain hemorrhage
Sudden, severe thunderclap headache
\+ Meningeal signs
Kernig sign (flexing hip = painful)
Brudzinski sign (flexing neck = painful)
A

Subarachnoid hemorrhage

20
Q 
Crescent-shaped
concave
hyperdense extra-axial lesion
Lesion does NOT cross the midline
Lesion can cross cranial suture lines
A

Subdural Hematoma

21
Q

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

A

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)

22
Q

Management for Subdural & Epidural Hematoma

A

Urgent craniotomy

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

23
Q

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

A

Epidural hematoma

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

24
Q

Epidural hematoma → transtentorial __ herniation →

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

A 
Uncal
Cushing triad (HR <65, HTN, irregular resp)
25
Q

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

A

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)

26
Q

Subdural hematoma can be __ or __

A

Acute: within 3 days (hyperdense CT)

Chronic: onset 21+ days (hypodense CT)

27
Q

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

A

Subdural hematoma

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

28
Q

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

A

10mm (1cm)

extensor posturing, anisocoria (unequal pupil sizes)

29
Q

__ is the most common cause of SAH.

A

Head trauma

*Ruptured cerebral aneurysm is the most common cause of nontraumatic SAH.

Risk factors: Smoking, HTN, FMH

30
Q

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)
A

Re-bleeding →
w/in first 24 hours

Vasospasm → 
ischemic stroke (3–10 days later)
31
Q

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

A

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

32
Q

Acute Stabilization in Intracerebral Hemorrhage

  1. ____ control
  2. ____ reversal
  3. ____ management
A
  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.)
33
Q

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

A

Decompressive craniotomy

& Hematoma evacuation

34
Q

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
_____

A

Fibromuscular dysplasia

px: middle age woman, Bruits, HTN, Kidney disease, strokes

35
Q

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

A

carotid artery

36
Q

Dissection of the carotid artery
Non-ischemic features:

Ipsilateral _____ pain
Partial Horner syndrome: ptosis & miosis

Ipsilateral headache
tinnitus

A

facial/neck pain

37
Q

Non-ischemic features:
Occipital headache
Posterior nuchal pain

Ischemic features:
Horner syndrome
Ipsilateral Dysphagia, ↓ Gag reflex, Hoarseness, Nystagmus

Dissection of the ____

A

vertebral artery

38
Q

Imaging for suspected dissection of the carotid and the vertebral artery

  1. first-line
  2. diagnostic
A
  1. Duplex U/S
    (high resistance or absent flow)
  2. CT angiography- Helical*
    (Changed caliber of vessel)

*(replacing MRA as diagnostic modality)

39
Q

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)
A
  1. ICH (via NCCT head)
  2. Heparin therapy
  3. (+/-) Angioplasty or Stenting
40
Q

NCCT Head → first-line imaging for TBI

Intracranial hemorrhage or hematoma: ____ lesions

Diffuse axonal injury (DAI): multiple ____ lesions

A

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)

41
Q

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?

A

Observation

NSAIDs & antiemetics (PRN)

42
Q

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

A

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

43
Q

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

A

paroxysmal sympathetic hyperactivity (PSH)

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

44
Q

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].

A

ACA compression

Contralateral LE weakness/paralysis

45
Q

Expanding intracranial hemorrhage can cause brain herniation (tonsillar, uncal).

Resulting in:

____ compression and
____ changes.

A

brainstem compression
(unconsciousness, irregular breathing)

pupillary changes

46
Q

Tonsillar herniation (cerebellar tonsils through the foramen magnum)

causes ___, ___ pupils

due to disruption of both sympathetic and parasympathetic innervation in the midbrain (brainstem).

A

fixed, midposition

fixed (non-reactive), midposition (4-6mm)

(tonsillar herniation; midbrain compression)

47
Q

Uncal (Temporal lobe) herniation

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

A

ipsilateral fixed and dilated

non-reactive; 5+mm

Surgery (36 decks)

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