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Spring '14 Pathophysiology > CNS > Flashcards

CNS Flashcards

1
Q

TBI is defined by the Brain Injury Association of America as?

A

A traumtic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.

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2
Q

How is the severity of a TBI described?

A

GCS

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3
Q

What is the hallmark of severe TBI?

A

Loss of consciousness for 6 hrs or more.

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4
Q

What GCS score would describe a mild TBI?

A

13-15. Associated with mild concussion

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5
Q

What GCS score would describe a moderate TBI?

A

9-12. Associated with structural injury such as hemorrhage or contusion.

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6
Q

What GCS score would describe a severe TBI?

A

3-8. Associated with cognitive and or physical disability and death.

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7
Q

What groups of people are at highest risk of TBI?

A

-young persons 15-35, infants 6mo-2yrs, young school aged children, and adults over 70. Males are 1.5 times more likely to suffer TBI. And persons living in high crime areas and blacks have the highest mortality rates.

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8
Q

What are the 2 broad categories of TBI?

A

Blunt (closed, nonmissile) and Open (penetrating, missile)

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9
Q

Which is more common, blunt or penetrating head trauma?

A

blunt

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10
Q

Of all TBIs reported in a year, what percentage are typically severe?

A

10%

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11
Q

Of all TBIs reported in a year, what percentage are typically moderate?

A

10%

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12
Q

Of all TBIs reported in a year, what percentage are typically mild?

A

80%

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13
Q

What is blunt (closed, no missile) trauma?

A

Involves the head hitting a hard surface or a rapidly moving object striking the head. Dura stays intact, tissues not exposed to the environment.

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14
Q

Does blunt (closed, non-missile) trauma cause focal brain injuries or diffuse axonal injuries?

A

both

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15
Q

What is open (penetrating, missile) head trauma?

A

The dura mater is open and the brain is exposed to the environoment.

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16
Q

Open trauma results in __________ brain injuries.

A

focal

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17
Q

What are the 2 most common types of brain injury?

A

mild concussion and classic cerebral concusion

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18
Q

What is meant by focal head trauma?

A

Trauma to one localized area

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19
Q

What is meant by diffuse axonal injury (DAI)?

A

diffuse trauma

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20
Q

Which is more deadly, focal injury or DAI?

A

Focal accounts for about half of all head injuries, but accounts for 2/3rds of all head injury deaths. DAI accounts for the greatest number of severly disabled survivors.

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21
Q

What causes the most TBIs?

A

Falls cause 28%, MVAs cause 20%, Being struck by moving objects or hitting a sationary object cause 19% and assaults cause 11%.

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22
Q

_________ are the leading cause of TBI in military personnell.

A

Blasts

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23
Q

What is a compound fracture of the skull?

A

It is caused by the head hitting an object forcefully. It may produce fractures involving the middle fossa.

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24
Q

What is a basilar skull fracture?

A

Fracture down the occipital bone and across the petrous pyramid.

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25
Q

What is the difference between primary and secondary brain injury?

A

Primary- caused by the direct impact, causes the initial tear, neural injury, and hemorrhage. Secondary- cerbral ischemia and tissue hypoxia. These include intracranial and extracranial causes of brain damage.

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26
Q

What are intracranial causes of brain damage?

A

complex. occurs as a result of impariment of cerebral blood flow autoregulation, alterations in blood-brain barrier, cerebral edema, increased ICP, brain herniation, a decrease in CPP, and inflammation.

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27
Q

What is the cascade of consequences of cerebral ischemia?

A
  1. ischemic neurons release substances that produce glial permeability to sodium (cytotoxic edema) 2. with energy failure, influxes of Ca++ through incompetent channels produce axonal injury, mitochondrial swelling, and cell death. 3. lactic acidosis
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28
Q

What is meant by tertiary causes of brain injury?

A

Cerebral ischemia caused by compromised systemic circulation with hypotension and shock or inadequate pulmonary ventilation or both.

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29
Q

Contusions and hematomas are which type of cerebral injury?

A

focal

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30
Q

Diffuse axonal injury and concussion are what type of cerebral injury?

A

Diffuse injury

31
Q

What is the difference between coup and contrecoup?

A

Coup- directly below the point of impact Contrecoup is on the pole on the opposite site of impact.

32
Q

Would a strike to the front of the head cause a coup or a contrecoup injury?

A

coup, since the occipital bone is smooth, less trauma occurs.

33
Q

Would a strike to the back of the head cause a coup or a contrecoup injury?

A

Both, but contrecoup, because the brain sloshing forward into the irregular frontal bones will cause significant trauma there.

34
Q

If an object strikes the side of the head is will it cause a coup or a contrecoup injury?

A

either, or both

35
Q

A focal brain injury will also have a local site of ______________ that can lead to decreased tissue perfusion.

A

cerebral edema

36
Q

What is a cerebral contusion?

A

Contusions are bruised areas, they tend to have infarction and necrosis, multiple hemorrhages, and edema. The tissue got a pulpy quality.

37
Q

The maximum effects of injury related to contusion, bleeding and edema peak at _____ hrs. after severe head injury.

A

18-36

38
Q

Where are contusions typically found?

A

in the frontal lobes, at the poles and along the inferior orbital surfaces, in the temporal lobes, expecially in the anterior poles and along the inferior surface, and at the frontotemporal junction. less commonly they occur at the pariental or occipital lobes.

39
Q

In contusion, the greater the force, the greater the __________; and the smaller the area, the greater the_________

A

injury x 2. the smaller area absorbs more energy and sustains a greater energy.

40
Q

contusions result in changes in:

A

attention, memory, executive attentional function, motivation, goal selection or fomation, planning, self-monitoring, affect, emotion, and behavior.

41
Q

What is the difference between a focal cerebral contusion and a hemorrhagic one?

A

Focal contusion- superficial, often just involve the gyri; Hemorrhagic- may coalesce into a large, confluent intracranial hematoma.

42
Q

What happens in a contusion?

A
  1. Immediate loss of consciousness (no longer than 5 minutes) 2. loss of reflexes (people fall) 3. transient cessation of respiration, bradycardia, decreased BP (30 sec. to a few minutes), momentary increase in CSF pressure and changes in ECG and EEG. Patient begins to stabilize after a few minutes and regains consciousness. Full recovery can take days.
43
Q

What is the treatment for contusions?

A

monitor. If large enough and with laceration, it may be excised surgically, othewise manage ICP and symptoms.

44
Q

What is an extradural hematoma?

A

aka Epidural hematoma or hemorrhage.

45
Q

Extradural hematomas are most often caused by?

A

MVAs. They occur in people age 20-40 most commonly.

46
Q

What is the most common site of extradural hematoma?

A

A temporal fracture causes 90% of temporal lobe hematomas. (Direct frontal trauma can cause frontal extradural hematomas, etc.)

47
Q

Posterior extradural hematomas are associated with fracture across the _______________.

A

transverse sinus from an occipital blow

48
Q

The source of bleeding in 85% of extradural hematomas is?

A

an artery

49
Q

15% of extradural hematomas result from?

A

injury to the meningeal vein or dural sinus

50
Q

90% of individuals with extradural hematoma also have a______________.

A

skull fracture

51
Q

What is the most common site of extradural hematoma?

A

The temporal fossa; caused by injury to the middle meningeal artery and vein.

52
Q

An extradural hematoma at the site of the temporal lobe causes a shift and: ________________________________.

A

uncal and hippocampal gyrus herniation through the tentorial notch.

53
Q

In the young and older adult populations you may see extradural hemorrages here.

A

subfrontal area; caused by injury to the anterior meningeal artery and or venous sinus, and in the occipital- suboccipital area which results in herniation of posterior fossa through the foramen magnum

54
Q

What are the symptoms of the classic temporal extradural hematoma?

A

loss of consciousness at the time of the injury, a lucid period that lasts hours to days (if bleeding from vein), as blood accumulates, headache of increasing severity, vomiting, drowsiness, confusion, seizure, and hemiparesis. LOC dwindles as temporal lobe herniation begins.

55
Q

What happens to the pupils of a patient with a temporal extradural hematoma?

A

As the blood accumulates, and temporal lobe begins to herniate, you will see ipsilateral dilation of the pupil. If both pupils dilate, it may be too late.

56
Q

What is the surgical treatment for extradural hematoma?

A

Burr holes and evacuate the hematoma then ligate bleeding vessels.

57
Q

Are extradural hematomas considered an emergency?

A

YES!

58
Q
A
59
Q

What is the most common cause of subdural hematoma?

A

MVAs

60
Q

What percentage of subdural hematomas are associated with skull fractures?

A

50%

61
Q

Who gets chronic subdural hematomas?

A

People who fall, especially older adults and people with a hx. of long term alcohol abuse.

62
Q

What are some of the characteristics of acute subdural hematoma?

A

develop rapidly, within 48 hours, located at the top of the skull,

63
Q

In people who abuse ETOH and in older adults, why would it take longer to develop symptoms of subdural hematoma?

A

Because their brains are more atrophied and there is room for the bleed to go. eventually it will get to the point that it increases ICP which tamponades the bleed.

64
Q

What is the major cause of rapidly developing or subacutely developing subdural hematomas?

A

tearing of the bridging veins

65
Q

What are the symptoms of an acute subdural hematoma?

A

headache, drowsiness, restlessness, or agitation, slowed cognition, and confusion. These worsen over time and progress to loss of consciousness, resp. pattern changes, pupillary dialtion, and at times homonymous hemianopia, disconjugate gaze and gaze palsies.

66
Q

What are some focal manifestations of acute subdural hematoma?

A

dysphasia, dyspraxia, or hemiparesis.

67
Q

What happens in chronic subdural hematoma?

A

The existing subdural space gradually fills with blood. A vascular membrane forms aroudn the hematoma in about 2 weeks. Further enlargement can still take place at this point.

68
Q

What are some of the presting manifestations of chronic subdural hematoma?

A

80% have chronic headaches, tenderness over the hematoma on percussion, progressive dementia, with generalized rigidity (paratonia).

69
Q

What is the surgical intervention for a chronic subdural hematoma?

A

craniotomy to suck out all the gelatinous blood. You can’t get that stuff through just a burr hole like with acute bleeds. The membrane is then dissected away.

70
Q

How long does it take to develop a chronic subdural hematoma?

A

weeks to months

71
Q

What is an intercerbral hematoma? Why and when do those occur?

A

Occur in 2-3% of head injuries. Usually associated with MVAs and falls. May be single or double, and are usually associated with contusions. Most commonly in frontal and temporal lobes. As it expands it increases ICP and compresses brain tissue and causes edema.

72
Q

Intracerebral hemorrhage is often associated with?

A

a decreasing level of consciousness. , contralateral hemiplegia may occur, + Babinski relfexes, pupillary dialtion, breathing pattern changes, pupillary dilation.

73
Q

What is the treatment for intracerebral hemorrage?

A

It is not really helpful to try to drain these. Just keep ICP low and allow the hematoma to reabsorb.

Spring '14 Pathophysiology (2 decks)

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