25. Neuropath: Trauma

Question 1

what are the high and low scores for the GCS?

Answer 1

3-15

Question 2

what types of responses does the GCS take into account?

Answer 2

eye response, verbal response, motor response

Question 3

define concussion

Answer 3

reversible loss of neuronal function.

totally reversible, transient, may be associated with brief LOC or postural tone.

Question 4

define contusion

Answer 4

direct bruising of the brain, disruption of the brain parenchyma

Question 5

early v later symptoms of concussion?

Answer 5

early: HA, N/V, dizziness
late: low grade HA, blurry vision, hearling loss, irritability, poor attention….

Question 6

Primary v secondary damage to the brain?

Answer 6

primary: direct damage to the brain, immediate. laceration, fracture, contusion, etc
secondary: not immediate, sequelae of trauma, can be more devastating. ischemia, hypoxia, swelling, infection.

Question 7

diffuse axonal injury: primary or secondary?

Answer 7

primary. occurs at time of trauma

Question 8

open v closed CNS trauma?

Answer 8

open: skull or skin is broken, exposed
closed: no exposure

Question 9

define galea

Answer 9

dense, tough collagenous tissue that sits on a layer of CT that is right on the periosteum

Question 10

sub-galeal hematoma?

Answer 10

blood collects in loose CT between galeal layer and skull.

Question 11

what is a site of fracture that can open up the MMA?

Answer 11

temple area, where there is a cranial suture line. MMA runs in the dura right under that, and a fracture can rip open the artery –> epidural hematoma.

Question 12

what are included in the category of focal injuries?

Answer 12

contusions, lacerations, hematomas, focal damage due to expanding masses.

Question 13

where do contusions tend to do damage? what happens there?

Answer 13

on the crowns of the gyri. can be punctate hemorrhages, then clot off, then ischemia and tissue dies. scarring may cause later seizures.

Question 14

where are contusions likely to occur?

Answer 14

anterior/undersurfaces of the frontal lobe and temporal lobes.

Question 15

are the sulci affected by contusions?

Answer 15

not usually; usually it is the crowns of the gyri and tissue immediately surrounding.

Question 16

what is it called when dead tissue is removed from the location of a contusion?

Answer 16

plaques jeunes. brain matter looks constricted, tan in color.

Question 17

what else will cause plaques jeunes?

Answer 17

nothing except trauma. (not inflammation, infarction, tumor)

Question 18

why does the brain tend to sustain coup-counter coup injuries?

Answer 18

it is not well attached to the skull, has a lot of room to slosh around.

Question 19

subarachnoid bleeding that is traumatic is usually associated with what?

Answer 19

contusions, penetrating injuries.

Question 20

subarachnoid bleeding that is non-traumatic is usually associated with what?

Answer 20

rupture of a berry aneurysm

Question 21

Epidural hemorrhage is associated with what kind of trauma?

Answer 21

fracture to lateral surface of skull, damaged MMA.

Question 22

epidural hemorrhage: blood is under high or low pressure?

Answer 22

usually a broken artery; high pressure.

Question 23

epidural: the blood collects between what layers?

Answer 23

skull and dura

Question 24

subdural: blood collects between what layers?

Answer 24

dura and arachnoid.

Question 25

epidural: blood collects quickly or slowly?

Answer 25

quickly; within minutes to hour.

Question 26

epidural: shape of accumulation? ends at sutures or not?

Answer 26

lens-shaped (like a clam). stops at suture lines where dura is tacked to skull.

Question 27

subdural hemorrhage: shape of accumulation? ends at sutures or not?

Answer 27

crescent shaped. does not end at suture lines.

Question 28

subdural: what kind of bleed? fast/slow?

Answer 28

venous (usually bridging veins). slow bleed. may not present for a few days.

Question 29

subdural: complications?

Answer 29

if continues to bleed, can get brain shift and subfalcine herniation.

Question 30

both epidural and subdural: tx? sequelae?

Answer 30

tx is neurosurg. if blood removed, brain will shift back to normal location.

Question 31

the movement of a bullet in the skull depends on what two factors?

Answer 31

caliber of the bullet and its velocity.

Question 32

what are some sources of diffuse damage to the brain?

Answer 32

diffuse axonal injury, brain swelling, hypoxia-ischemia.

Question 33

definition of diffuse axonal injury

Answer 33

widespread damage to axons within the CNS that results from severe acceleration or deceleration of the head. you get rips to the axons due to shear force.

Question 34

what is the most common movement that will result in diffuse axonal injury?

Answer 34

rotation. think of spinning a bowl of jello and stopping it quickly.

Question 35

with diffuse axonal injury, what types of pathological process happens to the axon?

Answer 35

shear, like Wallerian degeneration

Question 36

what happens to the still-viable end of the axon after it is sheared in diffuse axonal injury?

Answer 36

it will swell –> axonal spheroid.

Question 37

diffuse axonal injury: associated with what injuries (specific types of accidents)

Answer 37

car accidents, falls.

Question 38

after DAI, how do most patients present?

Answer 38

comatose

Question 39

DAI: patient appearance, and progression?

Answer 39

Most patients are comatose immediately after injury, do not experience a lucid interval, and remain unconscious, vegetative, or at least severely disabled until death.

Question 40

DAI: occurs mainly in what areas of the brain? why those locations?

Answer 40

white matter: corpus callosum, walls of 3rd ventricle, dorsolateral surface of brainstem, periaqueductal grey matter. these are the locations where the brain is attached, where twisting movement will be especially damaging.

Question 41

what is the mortality rate with DAI?

Answer 41

15% with mild DAI; 65% if severe.

Question 42

time course of DAI?

Answer 42

4-5 hours: axonal accumulation of beta-amyloid precursor protein
12-24 hrs: axonal varicosities evident on H&E
24h-2months: axonal swelling and microglial nodules
long-term: wallerian degeneration, atrophy.
axonal spheroids will remain for years

Question 43

diffuse edema: ipsilateral due to what? bi-hemispheric in children due to what?

Answer 43

ipsilateral: subdural hemorrhage
children: swelling due to trivial trauma, could be due to abnormal vasoregulation

Question 44

diffuse hypoxic brain damage is a combination of what factors?

Answer 44

brain shifts, raised ICP, systemic hypoxia, arterial spasm

Question 45

see ischemic changes often where?

Answer 45

at arterial boundary zones - get hypoxia and subsequent ischemia at the outer reaches of arterial perfusion.

Question 46

why is it easy for kids to get shaken baby syndrome?

Answer 46

head relatively large on body, poor neck muscles

Question 47

what are clues to shaken baby syndrome?

Answer 47

retinal hemorrhage, kiddo may present with coma, inconsistent history/physical, there may or may not be external head trauma.