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Neurology Module > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

0
Q

Concussion Prevalence:

A

High school athletes - 20%
College athletes - 10%
Contact sports: football, hockey, soccer, basketball, lacrosse.
Noncontact sports: gymnastics, skiing, ice skating

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1
Q

What is a concussion?

A

Sudden deceleration injury.
Coup-countrecoup injury.
CT or MRI are typically normal.

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2
Q

What are the types of traumatic brain injuries?

A

Penetrating Injury

Closed Head Injury

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3
Q

What causes primary damage in traumatic brain injury?

A 
Skull fracture
Contusions/bruising
Hematomas/blood clots
Lacerations
Nerve damage - diffuse axonal injury
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4
Q

What is secondary damage in traumatic brain injury?

A

edema

infection

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5
Q

signs and symptoms of concussion

A

disoriented
amnesia
confusion: vacant state, delayed answers to questions, poor concentration

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6
Q

What percentage of concussions involve loss of consciousness?

A

10%

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7
Q

Concussion Grade 1

A

“Ding” Concussion
Confusion
No loss of consciousness
Symptoms <15 minutes

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8
Q

Concussion Grade 2

A

No loss of consciousness

Symptoms >15 minutes

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9
Q

Concussion Grade 3

A

Loss of consciousness.

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10
Q

What is a minor score on the Glasgow coma scale?

A

13-15

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11
Q

What is a moderate head injury on the Glasgow coma scale?

A

9-12

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12
Q

What is a severe head injury according to the Glasgow coma scale?

A

<8

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13
Q

Concussion Red Flags

A 
Mental status change.
LOC>60 seconds.
Pupillary asymmetry.
Vision change.
Muscle/sensory deficits.
Cerebellar dysfunction: gait/ataxia, finger to nose testing.
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14
Q

What is an absolute indication for a CT scan for concussion?

A

Seizure
Neuro deficit
Anticoagulants - coumadin

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15
Q

Relative indications for concussion CT

A 
Glasgow 60-65 yo
Basilar skull fracture
Moderate pretrauma amnesia >15 min
Drug/alcohol intoxication
High risk injury: pedestrian MVA, fall from height >3 feet or >5 stairs
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16
Q

Where to basilar skull fractures occur?

A

Temporal Bone
Occipital Bone
Sphenoid Bone
Ethmoid Bone

Only accounts for 4% of fractures.

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17
Q

What might you see with a basal skull fracture?

A

Hemotympanum
Battles Sign - mastoid process ecchymosis
Raccoon eyes - periorbital ecchymosis
CSF leakage via nose or ears

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18
Q

Other types of skull fractures

A

2/3 have intracranial lesion present
Simple - no treatment
Depressed - surgical intervention

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19
Q

Concussion treatment

A

Rest - second impact syndrome

Most common post-concussion symptoms: headache, dizziness, impaired executive function

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20
Q

What is the process for a patient with a concussion to return to play?

A

Asymptomatic and medication free x 24 hours
Nonimpact aerobic exercise to increase HR x 24 hours
Sport-specific light drills x 24 hours
Non-contact training drills x 24 hours
Full contact practice x 24 hours
Return to play

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21
Q

What happens if concussion symptoms return at any point?

A

STOP and rest until symptoms clear x 24 hours and restart at current level.

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22
Q

How to athletes with multiple concussions recover?

A

Take longer to heal with each successive injury.

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23
Q

Who is at higher risk for post concussion syndrome?

A 
Symptoms > 3 months
HA, dizziness, impaired executive function
Mood changes/depression
Insomnia
Tinnitus, Vertigo
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24
Q

What is a subdural hematoma?

A

Bleeding between the dura mater and arachnoid layer.

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25
Q

What causes subdural hematoma?

A

Tearing of the “bridging veins.”
Shearing injury; acceleration-deceleration.
Result of trauma: acute, chronic (elderly).

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26
Q

What do you see on CT for a subdural hematoma?

A

“Crescent-shaped”

Midline shift

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27
Q

What causes subdural hematoma in the young?

A

Head trauma - motor vehicle accident

Shaken baby syndrome

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28
Q

What causes subdural hematoma in the elderly?

A

Chronic trauma may be so minor it has been forgotten.
Anticoagulation is a risk factor
Age alone! (Cerebral atrophy, increases strength/tension on bridging veins)

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29
Q

Signs and symptoms of a subdural hematoma:

A 
Confusion
Slurred Speech
Headache
Lethargy
Loss of Consciousness
Nausea/Vomiting
Weakness
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30
Q

Treatment for a smaller Subdural Hematoma

A

Burr Holes

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31
Q

Treatment for a larger Subdural Hematoma

A

Craniotomy to evacuate clots.

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32
Q

What do you see for an epidural hematoma on CT?

A

Biconcave lens

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33
Q

What is an epidural hematoma?

A

Bleeding between the dura mater and the skull.

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34
Q

What causes epidural hematoma?

A

Trauma

Skull fracture

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35
Q

What is artery causes epidural hematoma?

A

Caused by tearing of the Middle Meningeal Artery

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36
Q

What type of trauma causes epidural hematoma?

A

Blunt trauma.

37
Q

How do epidural hematomas evolve?

A

Evolve more rapidly.
Classic presentation - initial loss of consciousness and then lucid.
“Talk and Die”

Often unconscious at presentation.

38
Q

Treatment of Epidural Hematoma

A

Surgical evacuation

Ligate bleeding vessels

39
Q

What is a subarachnoid hemorrhage?

A

Bleeding into the subarachnoid space.

40
Q

What causes subarachnoid hemorrhage?

A

Usually due to rupture of cerebral aneurysm

41
Q

How is a subarachnoid hemorrhage described by the patient?

A

“Thunderclap Headache”

“Headache of a lifetime”

42
Q

How does a subarachnoid hemorrhage present?

A 
Headache of a lifetime
Nausea/vomiting
Stiff neck
Confusion
Seizures
May report a popping/snapping prior to headache
43
Q

What should be ordered for a suspected subarachnoid hemorrhage?

A

CT without contrast.
Best within first 12 hours (beyond that sensitivity decreases)
7% will not appear on initial CT.

44
Q

What will be seen with a lumbar puncture in a subarachnoid hemorrhage?

A

Blood

45
Q

How is a subarachnoid hemorrhage treated?

A

Depends on location, size, and preference of neurosurgeon.

46
Q

What is the pathophysiology of a stroke?

A

Blockage or rupture of a cerebral artery.

47
Q

What are the types of stroke?

A

Ischemic (87%)

Hemorrhagic (13%)

48
Q

What are the types of hemorrhagic stroke?

A 
Intracerebral hemorrhage (10%)
Subarachnoid hemorrhage (3%)
49
Q

What causes an intracerebral hemorrhagic stroke?

A

HTN

Aneurysm, AVM

50
Q

What is the largest cause of hemorrhagic stroke?

A

Ruptured berry aneurysm (80%)
AVM (10%)
Other (10%)

51
Q

What are arterio-venous malformation?

A

Occur in less than 1% of the population.

Sxs: pulsatile tinnitus, HA, seizures

52
Q

Prevalence of aneurysms

A

3-5 million people

0.5-3% will bleed

53
Q

Where do aneurysms develop?

A

Branching points of arteries typically over the age of 40.

54
Q

Risk factors for aneurysm development:

A

+/- women
+/- African American
Increased age, peaks ~50

55
Q

Risk factors to bleeding aneurysm:

A 
HTN
Straining
Cocaine/amphetamines
Blood thinners (Warfarin)
Alcohol use
56
Q

What is a “sentinal bleed”?

A

Warning leak. Some patients may have mild bleeding at the site one to two days prior to the larger event.

Milder HA
Neck stiffness
Nausea

57
Q

Hemorrhagic Stroke Statistics

A

10-15% die before reaching the hospital.
25% die within first 24 hours.
40% die in first month.
50% die in the first 6 months.
If rebleeding occurs, 50-80% mortality.
1/3 survivors will have no neuro deficits.
Most will experience some degree of cognitive deficits even if good prognosis.

58
Q

Complications of hemorrhagic stroke:

A

Rebleeding
Hydrocephalus
Cerebral ischemia - blood is an irritant that causes vasospasm.

59
Q

Management goals of hemorrhagic stroke:

A

SBP <20 mmHg)

Normothermia

60
Q

Ischemic Stroke Stats

A 
4th leading cause of death in US
Mortality 16%
Persistent hemiparesis at 6 mos - 15%
Persistent aphasia at 6 mos - 15%
Recovery to baseline - 15%
61
Q

Pathophysiology of Ischemic Stroke

A

Thrombotic (more common) - atherosclerosis: injured endothelial lining allows platelets to adhere; plaque formation.

Embolic- carotid arteries**, Heart

Lacunar infarcts - least common

62
Q

Risk factors for ischemic stroke:

A 
HTN
African American
Obesity
Sedentary Lifestyle
Family hx
Age >65 yo
CAD
Cigarette smoking (>35, OC use)
Increased cholesterol/triglycerides
Aortic arch plaque
\+/- migraine with aura in women >35 that smoke and or use OCs

Less common: Hypercoaguable state, hyperviscocity - polycythemia vera, subclavian steal syndrome

63
Q

What is a transient ischemic attack (TIA)?

A

Sudden onset of neurologic deficit

  • speech
  • monocular blindness
  • hemiparesis
64
Q

What is amaurosis fugax and what is it associated with?

A

Sudden, monocular blindness described as a shade or curtain being pulled over the eye (and then being pulled back up).

TIA

65
Q

What imaging abnormalities will you see with a TIA?

A

None

66
Q

How do the symptoms of a TIA progress?

A

Resolve within 24 hours - most within 10 minutes.

67
Q

What can follow a TIA?

A

Stroke will follow TIA within 90 days in 20-25% of cases.

68
Q

How do you evaluate for an ischemic stroke?

A

Head CT (or MRI)
If cardiac source of emboli suspected - TEE
Carotid US for carotid artery stenosis.

69
Q

What is carotid artery stenosis?

A

Plaque forms in the common carotid.

Typically affects the bifurcation and flow into the internal carotid artery.

70
Q

When would you hear a carotid artery bruit?

A

At 50% occlusion

71
Q

What are the diagnostics for carotid artery disease?

A

Gold Standard: Angiography (highly invasive)

Carotid US or Carotid artery MRA ($$$$$)

72
Q

What are the treatments for carotid artery disease?

A

Surgery - endarterectomy

Medical Management

73
Q

When do you perform an endartectomy for carotid artery disease?

A

Asymptomatic patients with >80% stenosis.

Symptomatic patients with >50% stenosis.

74
Q

When do you perform medical management for carotid artery disease?

A

Asymptomatic patients >60% but 50%.

75
Q

What drugs are used for the medical management of carotid artery disease?

A

ASA 18-22% RR Reduction
Plavix OR dipyridamole + ASA (Aggrenox) 37%
NO PLAVIX + ASA

76
Q

What is a lacunar infarct?

A

Occlusion of single deep penetrating artery.

Specific lacunar syndromes described but may also be “silent”

77
Q

What does a lacunar infarct effect?

A

Deep nuclei: caudate, thalamus, putamen

78
Q

Where does an ischemic stroke occur in anterior circulation?

A

Anterior Cerebral Artery

Middle Cerebral Artery

79
Q

Where does an ischemic stroke occur in posterior circulation?

A

Posterior Inferior Cerebellar Artery
Vertebrobasilar Artery
Posterior Cerebral Artery

80
Q

What are the symptoms of an anterior cerebral artery occlusion?

A 
Confusion
Amnesia
Personality change: flat, apathetic
Cognitive change: short attention span, slowness
Contralateral hemiparesis
Contralateral sensory impairment.
If left- expressive aphasia.
Eyes deviate toward affected side.
81
Q

What is the most common artery for an embolus-caused ischemic stroke?

A

Middle Cerebral Artery

82
Q

What are the symptoms for a middle cerebral artery occlusion?

A

Contralateral sensory/motor deficits - Face and arm> leg
Head/eyes deviate towards infarct.
NEGLECT to affected side.
Dysphagia
Initially decreased muscle tone then spasticity develops.
Homonymous hemianopia.
If left dom hemisphere effected: global aphasia then Broca’s (expressive)

83
Q

What are the signs/symptoms of posterior circulation blockage?

A 
Nystagmus
Ataxia
Vertigo
Dysphagia
Dysarthria
84
Q

What are the signs of a posterior cerebral artery blockage?

A

May have sensory aphasia (cannot comprehend spoken or written words)
Alexia

85
Q

How do you assess a stroke patient pre-hospital

A

Cincinnati Prehospital Stroke Scale
-Facial droop - show teeth (abnl if asymptomatic)
Arm drigt - abnl with drifts or unable to lift
Dysarthria - “you can’t teach an old dog new tricks”

86
Q

Cincinnati Stroke Scale Scoring

A

Score of 1 - CVA in 72% of cases

Score of 3 - CVA in 85% of cases

87
Q

What else should be ordered if you suspect a CVA?

A

Fingertsick glucose.

88
Q

How long should your hospital assessment last?

A

General Assessment - <25 min

- If hemorrhagic - angiography, neurosx consult
- Neg. but high suspicion for SAH, LP
89
Q

What is the scoring for the NIH Stroke Scale for imaging and assessment?

A 
0 = No Stroke
1-4 = Minor Stroke
5-15 = Moderate Stroke
16-20 = Mod-Severe Stroke
21-41 = Severe Stroke

Neurology Module (7 decks)

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