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Flashcards in Brain Injury Deck (35)
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An 18-year-old female on your inpatient traumatic brain injury service is inconsistently oriented and does not recall your name on a day-to-day basis. She can follow single-step commands. She gets more confused when stressed but can be re-directed and can finish her therapy sessions with encouragement. She is more consistent with goal-directed behavior but needs cueing. Greater participation in activities of daily living is evident and she is developing a better awareness of self and others. On the Rancho Los Amigos scale, what is her level of cognitive function? Page 3 of 23

(a) IV
(b) V
(c) VI
(d) VII

Answer: (c)
Commentary: She is presently displaying characteristics consistent with the sixth stage of recovery in the Rancho Los Amigos scale of cognitive function. This patient is not out of posttraumatic amnesia and is still confused. However, she responds appropriately to feedback and is able to participate in therapies. She is improving in goal-directed behavior and is developing greater awareness of self and others.

On the Rancho Los Amigo scale, the other options listed are described as follows:
Level V - Confused and Inappropriate;
Level VI - Confused and Appropriate;
Level VII - Automatic and Appropriate.
Level VII, you would anticipate that she
would no longer need cuing for goal-directed behavior but will still have problems with new
activities or with planning and following through with activities.

Reference: (a) Cifu DX, Kreutzer JS, Slater DN, Taylor L. Rehabilitation after TBI. In: Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsiever; 2007. p1138. (b) Sullivan KJ. Therapy intervention for mobility impairments and motor skill acquisition after TBI. In: Zasler ND, Katz DI, Zafonte RD, editors. Brain injury medicine: principles and practice. New York: Demos Medical 2007. p 937-938.



Which score range on the Galveston Orientation and Amnesia Test (GOAT) indicates the end of
posttraumatic amnesia (PTA)?

(a) 75–85
(b) 55–65
(c) 35–45
(d) 15-25

Answer: (a)
Commentary: A standard technique for assessing posttraumatic amnesia (PTA) in adults is the Galveston Orientation and Amnesia Test (GOAT), a brief structured interview that quantifies orientation and recall of recent events. The GOAT score can range from 0 to 100, with a score at or above 75 defined as normal. The end of PTA is defined as when the GOAT score is at or above 75 for 2 consecutive days.

Reference: (a) Cifu DX, Kreutzer JS, Slater DN, Taylor L. Rehabilitation after TBI. In: Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsiever; 2007. p1138. (b) Brandstater ME. Stroke rehabilitation. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2005. p 1012.



A 14-year-old with severe traumatic brain injury admitted to your rehabilitation unit has no
spontaneous movement. What is the best prevention for heterotopic ossification?

(a) Passive range of motion
(b) Nonsteroidal anti-inflammatory medications
(c) Disodium etidronate (Didronel)
(d) Radiation

Answer: (a)
Commentary: Heterotopic ossification is found in a high percentage of children immobilized by traumatic brain injury and spinal cord injury. The best prevention for the development of HO is an aggressive program of passive range of motion. Nonsteroidal anti-inflammatory medications and radiation are available as treatment options. Didronel is not used in pediatric patients due to risk of rickets or rachitic syndrome



Which statement concerning management of seizures after a traumatic brain injury is TRUE?

(a) All patients with postresuscitation Glasgow Coma Scale score below 12 require 3 months
of an antiepileptic medication.
(b) Seizures occurring less than 24 hours postinjury require an antiepileptic medication for at
least 12 months.
(c) Seizures occurring 24 hours to 7 days postinjury should be treated with at least 12 months
of an antiepileptic medication.
(d) Seizures occurring more than 7 days postinjury should be treated with an antiepileptic
medication for at least 3 years.

Answer: (c)
Commentary: The American Academy of Physical Medicine and Rehabilitation and the
American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic
brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score
(GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic
seizures (defined as those occurring within 24 hours postinjury) do not require any additional
prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be
treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial
abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late
seizures -- those occurring more than 7 days postinjury -- should be treated with an antiepileptic
medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as
“status epilepticus” and warrants treatment with an antiepileptic medication for at least 12



Which sign is associated with central dysautonomia following severe traumatic brain injury?

(a) Flaccidity
(b) Hyperthermia
(c) Hypotension
(d) Bradycardia

Answer (b)
Commentary: Central dysautonomia can occur acutely after severe traumatic brain injury. It has
also been called diencephalic seizures, autonomic or neuro storming or hypothalamic
dysregulation syndrome. Signs include elevated temperature with a normal fever work up,
tachycardia, elevated blood pressure, rapid respiratory rate and posturing. Facial flushing and
diaphoresis may also be seen.



Prolonged coma is a significant risk factor for the development of contractures in the traumatic
brain injury population. What is the most common site for a contracture to develop in this

(a) Shoulder
(b) Hip
(c) Elbow
(d) Ankle

Answer: (b)
Commentary: The overall 1-year incidence was 84% for contracture development in the
population of persons with brain injury. The hip was the most common joint affected (81%),
followed by the shoulder (76%), ankle (74%) and elbow (44%).



A 23-year-old woman with a traumatic brain injury from a motor vehicle crash is seen in clinic 1
year after her injury. She is in a minimally conscious state and still requires total assistance with
all her activities of daily living. The family wants to pursue treatment with hyperbaric oxygen
therapy (HBOT). You advise them, that HBOT can

(a) reduce the size of the injury to the brain.
(b) cause short-term visual disturbances.
(c) increase the incidence of mortality.
(d) improve the functional outcome.

Answer: (b)
Commentary: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen under pressure, which
increases the amount of oxygen dissolved in the blood, thereby increasing the oxygen delivered to
the body tissues. HBOT may also enhance the formation of new blood vessels, decrease
inflammation, and increase the volume of blood flow. Treatment sessions occur inside a sealed,
pressurized space known as a hyperbaric chamber. The oxygen is delivered either by mask or
directly into the chamber. The pressures used are expressed in units of atmospheric pressure and
commonly range from 1.5 to 3 atmospheres. The sessions last from 30 to 90 minutes and many
practitioners recommend 100 sessions (range, 80-150 sessions). The cost ranges from $200 to
$400 per session.

HBOT is not FDA approved for treatment of traumatic brain injury. A number of more minor
complications may occur due to HBOT. Visual disturbance, usually a reduction in visual acuity
secondary to conformational changes in the lens, is common. While the great majority of patients
recover spontaneously over a period of days to weeks, a small proportion of patients continue to
require correction to restore sight to pretreatment levels. The second most common adverse effect
associated with HBOT is aural barotrauma. Barotrauma can affect any air-filled cavity in the
body (including the middle ear, lungs and respiratory sinuses) and occurs as a direct result of
compression. There is limited evidence that HBOT reduces the chance of dying following a
traumatic brain injury. There is little evidence that more survivors have a good outcome. Thus,
the routine adjunctive use of HBOT in these patients cannot be justified. Because evidence of
lesion resolution or change in size of persistent defect obtained by magnetic resonance imaging
(MRI) or computed tomography (CT) has not been studied, there is no evidence to suggest this



Which statement concerning the use of prophylactic antiepileptics in the management of patients
with traumatic brain injury is TRUE?
(a) They decrease the functional disability of the injury.
(b) They reduce the occurrence of late seizures.
(c) They reduce the incidence of death.
(d) They reduce the occurrence of early seizures.

Answer: (d)
Commentary: There is no evidence that prophylactic antiepileptic medications, used at any time
after head injury, reduce death and disability. Evidence exists that prophylactic antiepileptics
reduce early seizures, but there is no clinical evidence that late seizures are reduced, or that
treatment has any effect on death or neurological disability.



You are consulted to see a 19-year-old woman with a traumatic brain injury after a motor vehicle
crash 2 days ago. She is unconscious even though the computed tomography scan of her brain is
normal. The most likely cause is

(a) diffuse axonal injury.
(b) cerebral contusion.
(c) arterial vasospasm.
(d) epidural hemorrhage.

Answer: A
Commentary: The initial computed tomography and magnetic resonance imaging scans taken
soon after injury are often normal. Only 10% of patients with diffuse axonal injury (DAI)
demonstrate the classic CT findings of DAI. These are hemorrhagic punctate lesions of (1) the
corpus callosum, (2) the gray-white matter junction of the cerebrum, and (3) the pontine mesencephalic junction


A high school athlete sustains a suspected concussion during a football game. The player should
(a) removed from play, evaluated and, if asymptomatic, be allowed to return to the game on
the same day.
(b) able to continue playing if he or she is able to perform.
(c) immediately transported to the local emergency department for evaluation.
(d) evaluated on the sideline and should not return to play that same day.

Commentary: When an athlete sustains a concussion in a game or during practice, he or she
should not return to play on the same day of the injury. The athlete should be removed from play
and be evaluated on the sidelines. Standard emergency medical management principles should be
applied when appropriate; serial monitoring should be performed and the athlete’s disposition
should be determined. The athlete should follow up with an appropriate healthcare provider
before he or she is returned to play.



You are consulted on the surgical floor of the hospital to manage an agitated patient with traumatic brain injury. Which antipsychotic medication has the most favorable side-effect profile for this patient?

a. Haloperidol (Haldol)
b. Olanzapine (Zyprexa)
c. Risperidone (Risperdal)
d Quetiapine (Seroquel)

Option d is correct.

Quetiapine is a frequently selected agent for post-TBI agitation for its favorable side-effect profile and its relatively low action as a D2 receptor antagonist. A recent pilot study suggests that quetiapine is clinically effective in reducing agitation symptoms post-TBI, with associated improvements in cognition. Animal studies showed the detrimental effect that the antipsychotic medication, haloperidol (a classic D2 receptor antagonist), has on motor recovery. Experimental studies using many atypical antipsychotic medications, including olanzapine and risperidone, have shown negative effects on cognitive recovery.



The usual time of onset of diabetes insipidus in patients with traumatic brain injury is

(a) at time of injury.
(b) 10 days postinjury.
(c) 30 days postinjury.
(d) 3 months postinjury

Answer: B
Commentary: Diabetes insipidus after TBI usually has an onset 10 days after trauma when the
antidiuretic hormone (ADH) stored in the posterior pituitary is depleted



The physical therapist calls you concerning the patient with traumatic brain injury you
admitted last week. She tells you that his bladder incontinence is disrupting therapy. You have
checked his urinalysis and there is no evidence of a urinary tract infection. A postvoid residual
bladder ultrasound shows that his bladder is emptying well. Your next step is to initiate

(a) an anticholinergic medication.
(b) in/out catheterization.
(c) a condom catheter with a leg bag.
(d) a behavioral modification program and timed voiding.

Answer: D
Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder
infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his
confusion. A condom catheter in this population will probably not stay in place. It may increase
agitation and will not help the patient. Intermittent catheterization and a Foley catheter will
increase the patient's infection risk. The best course at this time is frequent bladder emptying and
retraining, with the entire rehabilitation team encouraging the new behavioral modification



In a patient with traumatic brain injury who has impaired speed of processing, inattention and
decreased arousal, which medication is regarded as first-line therapy?

(a) modafinil (Provigil)
(b) methylphenidate (Ritalin)
(c) bromocriptine (Parodel)
(d) carbidopa/levodopa (Sinemet)

Answer: B
Commentary: The present evidence suggests that methylphenidate should be regarded as first-line
therapy when an agent from this medication class is used. If methylphenidate proves ineffective or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than
methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is
controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are
not as well studied as methylphenidate or amantadine.



Which electroencephalogram pattern is associated with a better prognosis after traumatic brain

(a) Low amplitude delta activity
(b) Burst suppression
(c) Isoelectric activity
(d) Spindle pattern

Answer: D
Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and
burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity
had the highest mortality



As compared to children with severe traumatic brain injuries, children with severe anoxic
encephalopathy are more likely to have

(a) rigidity and decreased rate of regaining consciousness.
(b) rigidity and increased rate of regaining consciousness.
(c) hypotonia and decreased rate of regaining consciousness.
(d) hypotonia and increased rate of regaining consciousness.  

Answer: A
Commentary: Compared to children with severe traumatic brain injury, children with severe
anoxic encephalopathy are less likely to regain consciousness; they also have shorter survival
time, and often have profound rigidity



Which drug is NOT associated with increased seizure risk in patients with traumatic brain

(a) methylphenidate (Ritalin)
(b) ciprofloxin (Cipro)
(c) amitriptyline (Elavil)
(d) bupropion (Wellbutrin)

Answer: A
Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with
increased seizure risk among patients with traumatic brain injury. However, amitriptyline,
bupropion and quinolones decrease seizure threshold.



A 19 year-old male is seen after a traumatic brain injury. The patient’s mother is at the bedside and is asking you questions about the patient’s prognosis for recovery. As you consider your response, which statement is TRUE?
(a) Severe disability is unlikely if the length of coma is less than 1 month.
(b) Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months.
(c) An initial Glasgow Coma Scale score of less than 8 is associated with a poor outcome.
(d) Neuroimaging studies are not helpful to determine a patient’s prognosis.

Multiple studies have shown that age, initial Glasgow Coma Scale (GCS) score, duration of coma, duration of posttraumatic amnesia (PTA), and neuroimaging findings are correlated with outcome. All provide valuable information that the clinician can use to mark milestones, and help with prognosis, but the most powerful of these is the duration of PTA. The longer the duration of the PTA, the worse the outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability; however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of coma is determined by the time from coma onset to the time when the patient can follow commands. On average only 7%--8% will make a good recovery if the coma lasts longer than 4 weeks, and severe disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general idea about the severity of the injury, it does not by itself yield a definitive prognosis.



Which type of traumatic brain injury results in the most morbidity?
(a) Focal cerebral contusion
(b) Subarachnoid hemorrhage
(c) Epidural hematoma
(d) Diffuse axonal injury

After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this morbidity includes impairments in cognition, behavior, and arousal.



The family of your 15-year-old patient who had a severe traumatic brain injury 6 weeks ago asks you if they may feed their son. You observe that the patient is agitated at times, has a hoarse voice, and drools. You try to feed him applesauce and notice that he seems to swallow part of it and does not cough. The most likely finding on the videofluoroscopic swallowing study will be
(a) Silent aspiration
(b) Reflux
(c) Coughing and gagging
(d) Normal swallow

The lack of coughing in a patient with neurologic impairment when presented with food may mean a normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing study is unlikely in a patient with a TBI who is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI is more likely to mean vocal cord abnormality.



Which factor is a risk for heterotopic ossification in traumatic brain injury?
(a) Late seizures
(b) Prolonged coma
(c) Male gender
(d) Diabetes insipidus

Significant risk factors for heterotopic ossification in traumatic brain injury include prolonged coma (>1 month), increased muscle tone, limited movement in the involved lower extremity, and associated fractures. Late seizures, gender, and diabetes insipidus are not associated with increased risk of heterotopic ossification.



A 20-year-old man sustained a severe traumatic brain injury and a femur fracture 1 week ago.
Magnetic resonance imaging reveals a diffuse axonal injury with no evidence of hemorrhage or a
hematoma. His condition is stable 1 day after open reduction, internal fixation of the femur
fracture and he is nonweight bearing on that leg. What is the appropriate recommendation for
deep venous thrombosis prophylaxis in this patient?
(a) Placement of a vena cava filter
(b) Sequential compression devices
(c) Graded compression stockings
(d) Low molecular weight heparin sodium

Answer: (d)
Commentary: Prophylaxis for deep vein thrombosis (DVT) should be considered in all patients
with a traumatic brain injury after acute admission to the hospital. Graded compression stockings
are of little benefit. Thigh high intermittent compression devices help reduce DVT risk but are not
an appropriate primary prophylaxis. A vena cava filter is not appropriate prophylaxis and
chemical prophylaxis is needed as soon as feasible. In patients who are not fully ambulatory in 24
hours unfractionated heparin sodium is adequate and can be used 12 hours after surgery.
However, in all patients who have long-bone fractures, prior DVT, or more than 4 total risk
factors, low molecular weight heparin sodium should be used until the patient is fully mobilized.



What is the greatest risk factor for late post-traumatic seizures in patients with a traumatic brain injury?
(a) Multiple subcortical contusions
(b) Subdural hematoma with evacuation
(c) Midline shift greater than 5mm
(d) Bilateral parietal contusions

(d) In a 4-site Model System Center observational study, the highest risk factors for late post-traumatic seizures were found to be bilateral parietal contusion (66%), penetration of the dura (62.5%), and multiple intracranial operations (36.5%), multiple subcortical contusions (33.4%), subdural hematoma with evacuation (27.8%), and midline shift greater than 5mm (25.8%).



A 25-year-old man with a history of a traumatic brain injury is noted to have a marked functional decline from his normal level of functioning. You order a computed tomography (CT) scan, which reveals large ventricles with flattening of the sulci and periventricular lucency. You tell the family that a ventriculoperitoneal shunt
(a) is emergently needed, and immediate referral to neurosurgery is indicated.
(b) will not be helpful, because the findings on the CT scan are due to irreversible atrophy of brain tissue (hydrocephalus ex vacuo).
(c) is not indicated, because he does not have the triad of incontinence, gait disorder, and dementia.
(d) may be helpful, because about 50% of patients with post-traumatic brain injury hydrocephalus experience significant improvement.

(d) A series reported by Tribl and Oder found that of 48 patients who underwent ventriculoperitoneal shunting for post-traumatic hydrocephalus slightly more than half experienced significant benefit



A 23-year-old woman who is unresponsive after an acute traumatic brain injury can visually track. She periodically pushes the nurse’s hand away when the nurse administers a subcutaneous heparin injection. The patient is exhibiting
(a) a coma state.
(b) a minimally conscious state.
(c) a vegetative state.
(d) a sleep/wake cycle.

(b) A minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self, or environmental awareness, is demonstrated by any or all these actions: simple gestures, purposeful behavior, appropriate smile/cry or vocalization to stimulation, reach for object, purposeful visual tracking. The vegetative state is associated with preserved hypothalamic and brainstem autonomic function and the patient exhibits a sleep/wake cycle, but there is an absence of cortical activity, judged behaviorally. The patient may exhibit visual pursuit but not in relation to meaningful behavior. The term persistent vegetative state is confusing and it is suggested that the term be abandoned, since it combines diagnosis (vegetative) with prognosis (persistent). Coma is a transient state after a traumatic brain injury (TBI) of being not awake and not aware of surroundings, and is seen in patients with a severe TBI and a Glasgow coma scale (GCS) of 8 or lower



Which of the following is NOT a feature of central autonomic dysfunction in traumatic brain injury in children?
(a) Hypertension
(b) Tachypnea
(c) Rigidity
(d) Hypothermia

(d) Central autonomic dysfunction occurs in some children following severe brain injury. It is characterized by hypertension, hyperpyrexia, rigidity, tachypnea, tachycardia, and diaphoresis. Various medications are used to treat this dysfunction, but no studies prove the value of one medication over another



In patients with a traumatic brain injury, which factor suggests a poor prognosis for emergence from unresponsiveness?
(a) Decorticate posturing
(b) Flaccid muscle tone
(c) Conjugate eye movement
(d) Reactive pupils

(b) After a traumatic brain injury, the following factors are associated with a better prognosis: younger age, reactive pupils, conjugate eye movement, decorticate posturing, early spontaneous eye opening, absence of ventilatory support, and higher Disability Rating Score on admission. Factors associated with poor prognosis include decerebrate posturing and flaccid muscle tone



Which statement is TRUE about the relative responses of the brain and the spinal cord after concussive trauma?
(a) The brain is more sensitive to trauma than the spinal cord.
(b) The spinal cord is more sensitive to trauma than the brain.
(c) The brain and the spinal cord are equally sensitive to trauma.
(d) The brain’s neurologic recovery is less predictable than the spinal cord’s in its response to a given amount of trauma.

(b) Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain. Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe concussive trauma to the brain results in a more severe neurologic dysfunction.



Disorders of executive functioning are common in children after severe traumatic brain injury.
Which sign indicates problems of executive function?
(a) Low intelligence quotient
(b) Attention and memory problems
(c) Aphasia
(d) Agitation

(b) Problems of executive function include impairments in attention, memory, and abstract reasoning.
While aphasia and low intelligence may be seen following traumatic brain injury (TBI), they are
not problems of executive function. Agitation is usually seen early in recovery from TBI, at the
Rancho Los Amigos stage 4. The full consequences of a TBI that occurs in a young child may not
be seen until much later, at an age when the child is expected to have that skill. For example,
problems in abstract reasoning in a child who had a TBI at age 5 may not be seen until the child
reaches 9 or 10 years of age.



A 29-year-old man with paraplegia who plays sledge hockey presents after a concussion with a loss
of consciousness of less than 30 seconds. When would you suggest that he return to hockey?
(a) If he has a headache that resolves after 48 hours, he may return to play 1 week from the
provoking incident.
(b) If he does not have postconcussion symptoms, he may return to play 1 week from the provoking incident.
(c) If he does not have postconcussion symptoms, he may return to play the same day.
(d) If he has dizziness, he may return to play as soon as the dizziness resolves.

(b) The International Congress of the Concussion in Sports Group (CISG) convened in 2001 to provide recommendations on the care of concussions. According to the Vienna Group guidelines, when a player shows any symptoms or signs of concussion, they should not be returned to play in the current game or practice. They should be monitored and follow a stepwise process to return to
play. Like anyone else, paraplegics who have suffered a concussion should be asymptomatic for 1
week prior to returning to play