Traumatic Brain Injury Flashcards
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
General symptom of skull fractures
Liquorrhea
leakage of CSF through an external opening
CSF rhinorrhea
Raccoon eyes
Suggest a(n) ___ skull fracture
Anterior basilar
CSF otorrhea
Blood behind tympanic membrane
Ecchymosis over the mastoid process
Suggest a(n) ___ skull fracture
Posterior basilar
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
___ → first-line imaging for TBI
NC Head CT
Mild TBI/Concussion → GCS __
13-15
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
Moderate TBI → GCS __
Management:
9–12
(time to intervene with ICP management:
HOB elevation, HTN control, Antipyretics, Normoglycemia)
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
- 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)
Aphasia
what lobe was affected?
Left Temporal lobe
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
Right sided numbness and paresthesia of the face, arm, and leg. Motor intact.
where is the lesion?
Left Thalamus (VPL)
Arterial bleed: rupture of middle meningeal artery
___ hematoma
Epidural
Venous bleed: rupture of bridging veins
___ hematoma
Subdural
Often followed by a lucid interval, before the onset of focal neurological deficits
Epidural Hematoma
Signs of elevated ICP
Changes in mental status
+/-Lucid interval
Subdural Hematoma
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:
- SIADH
- Seizures
- Elevated ICP/Cushing triad
- _____ (w/in first 24 hours)
- _____ (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
- ____ control
- ____ reversal
- ____ management
- Blood pressure control (nicardipine/labetalol)
- Anticoagulation reversal
(warfarin → PCC, FFP, Vit K)
(heparin → Protamine sulfate) - 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
- first-line
- diagnostic
- Duplex U/S
(high resistance or absent flow) - CT angiography- Helical*
(Changed caliber of vessel)
*(replacing MRA as diagnostic modality)
Management of Carotid Artery and Vertebral Artery Dissection:
- First r/o ___ via [imaging]
- ___ therapy
- [Interventions: 2]
- Anticoagulation (3–6 m) and/or Antiplatelet (1y)
- ICH (via NCCT head)
- Heparin therapy
- (+/-) 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
