Traumatic Brain Injury Flashcards by CABS Cabanela

causes of tbi

vehicle crashes, falls, firearms, sports/recreation, others

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common ages and groups at risk for tbi

<5 yo, 15-24 yo, >70 yo

males, 0-4 yo, 15-19 yo, >75 (most hospitalization and deaths)

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coup vs contrecoup forces

coup: produce effects at or near impact site
contrecoup: remote from the area of impact (opposite side)

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> 2 sqin vs <2 sqin objects

> 2 sqin: localized skull bending immediately beneath the impact point
<2 sqin: penetrating injury

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examples of local effects

linear fractures (hairline crack)
depressed fractures
epidural hematoma
subdural hematoma
coup contusion

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examples of remote contact effects

due to skull distortion or stress waves

remote vault fractures

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what are inertial injuries: shearing and vessel injury

differential movement of the skull and brain produced by head acceleration
(brain lags behind skull for a brief moment after acceleration begins)

can tear bridging vessels, and cause structural or functional brain damage

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types of head acceleration

translation (linear)
rotation
angular (most damaging)

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what are bridging veins

parasagittal bridging veins connect brain and sagittal sinus

located in subdural space

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what are inertial injuries: parenchymal injury

strain manifesting as classic “cerebral concussion”, diffuse axonal injury, hemorrhage, and contrecoup contusions

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types of parenchymal injuries

shear* (different directions)
forward backward affects projection fibers
side to side affects commissural fibers (in corpus callosum)
rotational affects association fibers (front to back)

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primary vs secondary brain damage

primary: effects of actual trauma on the brain at the moment of injury (not preventable)
secondary brain damage: complication of primary brain damage, usually inc icp

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categories of brain injuries

skull fracture
focal injury
diffuse injury
penetrating injury
blast injury

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types of skull fractures

open (compound)
closed (simple)
depressed
diastatic
basilar

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t/f open fractures require more aggressive treatment

true, due to exposure to external environment

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indications for nonsurgical intervention in closed fractures

not depressed

linear type for fracture

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indication for surgery in depressed fractures

if depressed fracture is greater than thickness of calvaria and those not meeting criteria for nonsurgical management

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indications for non-surgical management in depressed fracture

no evidence of dural penetration
no significant intracranial hematoma
depression <1 cm
no frontal sinus involvement
no wound infection or gross contamination
no gross cosmetic deformity

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t/f elevating depressed fractures can reduce post traumatic seizures

false, no evidence of this

DEPTH OF FRACTURE correlates to how much pressure on brain

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what are fractures through suture lines called

diastatic fractures

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types of petrous bone fracture

longitudinal fracture through petrosqumousal suture

transverse fracture: perpendicular to eac –> cn 7 and 8 defects, peripheral facial palsy

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what are postauricular ecchymoses called

battle’s sign

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management of csf leak at eardrum

slow type of bleeding: venous origin = can be stopped with pressure
put cotton ball in ear (tamponade effect)
refer to neurosurgeon/ent

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tx for basilar skull fracture

prophylactic antibiotics

specific treatments

key sign of frontal sinus fractures

pneumocephalus --> dural laceration

what is a cerebral contusion

due to damage on small blood vessels on brain surface

t/f contusions can expand over time

true, require monitoring monitor icp to prevent contusions from expanding and deteriorating brain

types of contusions

coup contrecoup intermediate coup: deep within neural parenchyma between impact and opposite side of the brain

indications for surgery of hemorrhagic contusion

progressive neurological deterioration referable to contusion volume > 30 cc frontal or temporal contusion >20 cc, WITH MIDLINE SHIFT >/=5 MM, compressed basal cisterns

common area for epidural hematomas

temporoparietal regions, middle meningeal arteries and diploic veins limited by suture lines

classic presentation of epidural hematoma

brief post-traumatic loss of consciousness lucid interval of a few hours obtundation, contralateral hemiparesis, ipsilateral pupillary dilatation

common causes of subdural hematoma

accumulation around parenchymal lacerations (from laceration of bridging veins/superficial vessels) surface of bridging vessels torn from cerebral acceleration-deceleration during violent head motion

indications for surgery in acute subdural hematoma

asdh with thickness >10 mm or midline shift >5 mm OR gcs drops by 2 points & icp >20 mmhg

ct scan findings in chronic subdural hematoma

crescentic mass of increased attenuation adjacent to inner table

t/f there may be gradual or repeated bleeding from neo membranes in chronic subdural hematoma

true

what is a diffused brain injury

occurs without macroscopic damage most prevalent cause of disability in TBI survivors mildest form: concussion most severe: diffuse axonal injury

presentation of concussion

transient loss of consciousness, no visible structural damage but there is disturbance in brainstem or cortex

t/f in diagnosing concussion the patient should have shown signs of recovery before the 24th hour

true

category 1 for concussion

cantu: pta <30 mins, no loc aan: transient confusion, no loc, symptoms resolve in <15 mins

category 2 for concussion

cantu: pta >30 mins, loc <5 mins aan: transient confusion, symptoms resolve in <5 mins, no loc, (+) pta

category 3 for concussion

cantu: pta >24 hrs, loc >5 mins aan: any loc

management of post-concussion syndrome

symptomatic | reassure patient that symptoms will resolve in 4-6 weeks

definition of diffuse axonal injury

clinicopathologic syndrome in patients unconscious form the time of trauma with widespread traumatic damage throughout the brain in the absence of intracranial lesion with mass effect disrupted connections of axons

histologic findings in dai

axonal swelling, disruption of axons, retraction balls, punctate hemorrhages in pons midbrain and corpus callosum

dai classification

1: axonal injury of parasagittal white matter of cerebral hemisphere 2: grade 1 + focal lesion in corpus callosum 3: grade 2 + focal lesion in cerebral peduncle

mild, mod, and severe dai

mild: coma 6-24 h mod: gcs 6-8 and coma >24 h sev: gcs 4-5 and coma >24 h

t/f dai does not mean severe traumatic injury

false

what are retraction balls

twisted, stretched, and lost connection of axons which retract found in: corpus callosum, periventricular white matter, basal ganglia, brainstem

presentation of subarachnoid hemorrhage

no inc icp severe headaches nape pain (irritated meninges) spontaneous resolution in 2-3 wks

what is intracranial hypertension

persistent elevation of icp above 20 mmhg for >5 mins (poor outcome)

normal cerebral perfusion pressure

60-65 mmhg ``` 45-55 = ischemia <45 = neuronal death ```

pressure monitoring objectives

maintain map 75-100 keep icp <15 mmhg cpp 60-70 mmhg cpp = map-icp

t/f when it's not possible to intervene surgically or to relieve the pressure, patients are sedated and place in a coma

true, to reduce the metabolic demands of the brain

what is the carotid cut off sign

contrast only reaches level of mandible, aca and mca do not appear on angiogram due to compression can be seen in extreme increase of icp

hallmarks of uncal herniation

ipsilateraly pupillary dilation (cn 3) | kernohan's notch: false localizing paradoxical ipsilateral hemiparesis

gcs table

table 4, page 11

cushing's triad

increasing bp, decreasing hr, decreasing rr

indications for ct scan

``` <15 gcs 2 hrs post op evident head injury seen clinically otorrhea or rhinorrhea suspect for basal skull fracture has repeated vomiting episodes >65 yo ```

indicators of prognosis in severe tbi

``` gcs score age pupillary diameter and light reflex hypotension ct scan features ```