lecture 6: head trauma , seizures, headache and vertigo Flashcards
(135 cards)
1
Q
what is the primary external cause for a TBI
A
falls
2
Q
TBI rates of death were highest for people ____ years of age
A
> 75
3
Q
what is the leading cause of a TBI related death from a
>65
25-64
5-24
0-4
A
falls
intentional self harm
motor vetichle crashes
assaults
4
Q
what scale is used for TBI screen and assess eyes opening , verbal response and best motor response
A
glasgow coma scale
5
Q
what is the total scare for the glasgow coma scale ? and what is worse and what is better
A
3-15
3 is worse (dead basically)
15 is normla
6
Q
75% of cases of TBI’s are ___
A
concussion/mild
7
Q
if someone has a glasgow coma scale of 13-15 what does that indicate
A
mild tbi
8
Q
how is a mild tbi/concussion defined
A
trauma that messes that brain up and is manifested by one of these things …
any LOC
loss of memory befor or after
change in mental status
focal neurologic deficits
9
Q
if someone has a GCS score of 9-12 whst can we indicate
A
moderate TBI
10
Q
what kind of TBI is Usually associated with prolonged LOC +/- neurologic deficit
A
moderate
11
Q
if someone has a GCS of <8 what can we suspect
A
severe TBI
12
Q
if a pateitns is obtunded or comatose , has significant neurologic injury , often structural brain lesions apparents on head trauma and needs airway protection , mechanical ventilation, or intracranial pressure monitoring what kind of TBI can we susapect
A
severe
13
Q
how is the recovery for a severe TBI
A
prolonged and often incomplete
14
Q
what is the difference between a penetrating and non penetrating head injury
A
penetrating is when the skull and meninges are breached and a non pent is the soft tissues are forced into the hard skull
ex: bullet going into head (pen) … getting hit with an elbow during a basketball game (non)
15
Q
what is the difference between coup and counter coup
A
coup is where the injury takes place and counter coup is where the brain hits the skull and is usually worse then koo
ex: if u hit ur head on the table the coup is ur forehead but the counter coup is th back of ur head here the brain hit it
16
Q
what is the first phase of a TBI
A
direct consequence of trauma
diffuse axonal injury
17
Q
what is the second phase of a TBI
A
– Begins quickly after primary phase
– Hypoxia and hypoperfusion
– Inflammation
18
Q
what is the neurological assessment for a head injury
A
glasgow coma sale
19
Q
what is anisocoria
A
pupil size difference
20
Q
what are the localizing signs for a head injury
A
• Anisocoria (pupil size differences)
• Diplopia due to CN palsies
• Absence of gag (glossopharyngeal -> vagal)
• Abnormal breathing patterns
21
Q
if someone has a head injury and their pupils are dilated , fixed what is damages
A
CN 3 (uncal)
22
Q
if someone has a brain injury are their pupils are large , “fixed”, hippus what is damaged
A
pretectal
23
Q
if someone’s pupils are pinpoint after a head injury what is damaged
A
pons
24
Q
if the pupils are in midposition and fixed after a brain injury what is damaged
A
midbrain
25
if someone has a brain injury and there pupils are small , reactive what is damaged
diencephalic
26
decerebrate posture results from damage to what ?and how will someone look in this position
upper brain stem and the position is extended
27
decorticate posture results from damage to what ?and how will someone look in this position
one or both corticospinal tracts
position is flexed
28
where is the bleeding happening for the following hemorrhages
intracerebral
subarachnoid
subdural
epidural
inside the brain
in the subarachnoid spaces
b/t arachnoid matter and dura matter
b/t dura matter and skull
29
what kind of hematoma usually follows a low velocity injury
subdural
30
epidural hematoma is bleeding from ____ ____ or ____ and is torn by a ____ or ____ fc
meningeal artery or vein
temporal or parietal fracture
31
what kind oat hematoma will someone have a “lucid interval”
epidural
which means they nay be good st first and talking then hours later they die
32
what is the shape of the clot for an epidural hematoma
lens shaped
33
what is the sequelae of head injury
• Hydrocephalus
• CSFleak
• Subarachnoidhemorrhage
• Vascularinjury
• Infection
34
what syndrome will someone have Headache, fatigue, dizziness, difficulty concentrating, disturbed sleep, anxiety, depression. May persist months to years.
post concussion syndrome
35
what is – Trauma induced alteration in mental status that may or may not involve loss of consciousness
concussion (mild TBI)
36
what is the hallmark of concussions
confusion and amnesia
37
how long does a concussion last and when do the symptoms start
lasts up to 1 month and symptoms can start early or later
38
* Physical
– Headache
– Nausea/Vomiting
– Photophobia (sensitvie to light)
– Phonophobia (sensitive to loud noise)
– Dizziness
– Slurred speech
– Blurred vision
– Incoordination
these are all physcial symptoms of what
concussion
39
– Inattention
– Slowed thinking
– Confusion
– Amnesia
– Disorientation
– Vacant stare
– Loss of Consciousness
these are all mental symptoms of what
concussion
40
– Emotional lability
– Depression – Anxiety
– Mania
these are all affective symptoms of what
concussion
41
– Increased sleep latency
– Frequent waking
– Increased or decreased sleep time
these are all sleep symptoms of what
concussion
42
what sports related concussion are highest in boys
football, ice hockey, lacrosse > soccer, wrestling, basketball
43
what sports related conccusion are highest in girls
-soccer
-ice hockey
-lacrosse
-basketball
44
are female or males higher for sports concussion injury
female
45
a CT head should not be utilized to diagnosis a sports related concussion but rather what..
to exclude more severe traumatic brain injury
46
what retunr to plat protocol is this
goal: more intense but non contact n
time: close to typical routine
activities: running , high intensity stationary biking , the players regular weight lifting routine , non contact sports specific drills
step 3 : non contact training drills
47
for each step of the retunr to play protocol for concussion the player must be asymptomatic for how long before going to the next steps
24 hours
48
how long are symptoms persist for post concussive syndrome
> 1 month
49
what is a chronic traumatic encephalopathy
spectrum of disorders aosscited with long term consequences of a single or repetitive TBI
50
what are some of the behavioral changed seen with chronic. traumatic encephalopathy
• Aggression
• Agitation
• Impulsivity
• Depression
• Suicidality
51
what motor involvement is invovled with chronic traumatic encephalopathy
• Dysarthria
• Spasticity
• Motor neuron disease
• Parkinsonism, tremors
• Ataxia
52
• You are the PT working with a patient who has had a stroke when he suddenly starts having an apparent seizure..
what do u do for safety?
what do you NOT do?
what do u push ?
get him to bed and lying on side with rails up
do not put anything in his mouth
push the nurse call button
53
what is the leading causes for epilepsy
brian tumor
54
Single provoked/unprovoked episode
Episode of transient behavioral, sensory, motor, visual symptom, associated with abnormal excessive cortical activity in the brain.
May be provoked or occur spontaneously
what does this describe
seizure
55
what is Two or more unprovoked seizures separated in time by greater than 24 hours or single seizure with heightened risk of future seizures
epilepsy
56
what are 2 examples of genetic syndromes of epilepsy
Juvenile myoclonic epilepsy, Lennox-Gastaut
57
any lesion to disrupt neuronal network: stroke, hemorrhage, tumor, encephalitis, meningitis, gliosis from trauma or severe hypertension.. this is what kind of epilepsy
structural
58
hypo-/hyperglycemia; hypocalcemia, hyponatremia, uremia, drugs or illicit substances… these are what type of epilepsy etiology
metabolic
59
what is Lennox-Gastaut
multiple different sezuire types
60
what is the most common causes of epilepsy world wide
infections
61
– GAD65
– Rasmussen syndrome
these are what kind of etiology for epilepsy
immune
62
what seizure
- begins on ONE SIDE OF THE BODY
- does NOT IMPAI CONSCUOUSNESS
-motor : clonic or tonic
-sensory: parenthesis, visual hallucination
-EEG with CONTRLATERAL focal discharge
focal onset seizure without loss of awareness (AKA: simple partial seizures
63
what seizure has
-impairment of consciousness , cognitive , affective symptoms
- auditory hallicucinations
- formed visual hallucinations
-olfactory hallucinations
-psychomotor phenomenon, chewing movements , wetting lips
-dysphasia
-when they seize they shake and then turn and seize and then they are fine
-EEG shoes left temporal lobe seizure
focal onset seizure with loss of awareness (complex partial seizures)
64
• Withoutlossofawareness:oftenlastseconds
• With loss of awareness: usually>1min
• May have had febrile seizures in childhood
• Sensory aura–olfactory,gustatory,epigastricrising, auditory hallucinations
• Experiential aura–psychic feeling,déjà vu, depersonalization, fear, panic
• Autonomic aura–flushing, nausea, pallor
• Aphasia if dominant temporal lob onset
• Typically followed by post-ictal confusion,fatigue ,with gradual recovery
what seizure is this
temporal lobe
65
what seizure may have
-aura “jacksonian march”
-early posturing or clonic activity
-may have large amplitude , irregular, complex movements ,
-clusters of seizures AT NIGHT
- BRIEF in duration but can quickly secondarily generalize
-AUTONOMIC FEAUTURES
- brief post-ictal phase
frontal lobe
66
what sezuire is Sudden onset of unresponsiveness lasting seconds, with interruption of ongoing activity but **no loss of muscle tone.**
absence
67
what seizure is
-Sudden onset of unresponsiveness lasting seconds, with interruption of ongoing activity but no loss of muscle tone.
- patient returns to normla activity with NO POSTICITAL STATE
- EEG with 3 Hz spike and wave
-MOST COMMON IN CHILDERN
absence seizures
68
what seizure is this ..
• Sudden onset of loss of consciousness with onset of rigid muscle tone (tonic phase) followed by rhythmic convulsive movements lasting up to several minutes (clonic phase)
• Postictal somnolence minutes to hours
• Ictal EEG shows BITLATEAL DISCHANRGES
generalized tonic clonic seizures
69
what are myoclonic seizures
- SINGLE brief jerks
- many involve any limbs or all
- occur with other seizures
-Ictal EEG shows generalized spike and wave
70
is all myoclonus a seizure ?
no
71
what is a atonic seizure
-head drop
-falls forward
VERY HARD TO CONTROL
72
what seiuzre is this ..
• Occur in 2-5% of children
• Most occur between 6 months-3 years (upto6yo)
• GTC seizure lasting a few minutes
• 33% will have at least one recurrence ,<10% will have 3 or more.
• Prognosis excellent
- NO NEED FOR ANTIEPILEPTIC DRUG
FEBRILE SEZIURE
73
if someone is having a gradual onset of a seizure , PROLONGED duration , thrashing , struggling , crying , pelvi thrusting , motor activity that STARTS AND STOPS , arrhythmic jerking and RETAINED consciousness despite BILATERAL jerking what do we think ???
no epileptic event
74
is someone is experiencing syncope what may happe??
-lightheaded , dizzy , sweating
-change of vison
-sweating and pallor
-urinary incontinence
75
after a seizure what will most people need
EEG and contrast MRI of brain to see if high risk for reoccurrence
*40% of epilepsy patients will have normal initial EEG*
76
what conditions is this
• Generalized seizure activity lasting >5 min or recurrent seizures without return of consciousness for > 5 min
• Generalized tonic-clonic seizures
• Morbidity and mortality risk increases with
duration
• Rapid diagnosis and treatment necessary
status epilepticus
77
who is most likely to be diagnosed with epilepsy syndrome
children
78
what is the recommendation for treating seizures in children
treat after 1st seizure when risk of 2nd seizure outweighs risk of drug side effects
79
___ ideation is black box warning on many AEDs on current market
Suicidal
80
what are the general side effects of AEDs
-somnolence (excessive sleepiness)
-nausea
-ataxia
-nystagmus
-confusion
-rash
81
what is the side effects of Valproic acid medications for epilepsy
weight gain
tremor
82
what is the side effects of phenytoin medications for epilepsy
gum hyperplasia , cerebellar ataxia, rash
83
what is the side effects of topiramate medications for epilepsy
kidney stones
cognitive
weight loss
84
what is the side effects of carbamazepine medications for epilepsy
dizzy , N/V , rash
85
what is the side effects of levetriaceatam medications for epilepsy
behavioral changes , psychosis
86
• Cognitive impairment
• Symptoms of depression, anxiety, or other
changes in mood or behavior
• Problems sleeping
• Unexplained injuries, falls, or other illnesses
• Thinning of the bones or osteoporosis (due to AEDs)
• risk of death
these are all impacts of what
epilepsy
87
Migraine (with or without aura), tension HA, cluster HA… these are all what kind of headache disorders
primary
88
brain tumor, increased intracranial pressure, meningitis, encephalitis, aneurysm, hypertension… these are all examples of what kind of HA disorder
secondary
89
what are one of the most common reasons patients visit. a primary care physician or ER
HA
90
are most headaches primary or secondary
primary
91
what are the red flags for headaches
SSNOOP4
* Systemic Symptoms–fever or weightloss
* Secondary Disease–HIV,cancer,immunosupression
* Neurologic Symptoms–confusion,impaired alertness, focal weakness
* Onset–sudden,abrupt,orsplitsecond
* Older–new onset and progressive >50 year old
* Previous Headache History–first headache or different (change in attack frequency, different features)
* Positional
* Papilledema (swelling of the optic nerve)
* Precipitants–cough,Valsalva
92
– Subarachnoid hemorrhage (Ruptured aneurysm)
“worst headache of my life”
– Intracerebral hemorrhage
– Carotid or vertebral artery dissection
– Carotid cavernous fistula (arteriorvenous connection)
– Cerebral venous sinus thrombosis
– Subdural/Epidural hematoma
– Hydrocephalus
– Bacterial meningitis
– Idiopathic intracranial hypertension
– Brain tumor
these are causes of ___ HA
secondary
93
• 24yearoldpresentswithsevere throbbing unilateral headaches which have been occurring since she was a teenager. She gets them once a week and needs to lie down in a dark room. She as associated nausea and vomiting as well as sensitivity to light and sound. She takes Ibuprofen which helps a little. They have not changed in frequency or character since they started but they are interfering with her life. Normal exam.
any red flags ??
no things migraine
94
when is the peak onset for migraine
20-24 for women and 15-19 for male
95
what is the highest indecenc for migraines
between 20-35
96
what is the criteria for a migraine
- > 5 HA
- 4-72 hours
- 2 out of the 4
throbbing
unilateral
mod to sever
worse w activity
-1 out of 2
nause/vomit
photophobia (bright light) or phonophobia (loud noise )
97
this decribes what aura .. positive scintillating scotomata with fortification spectra (like bright flashing lights with blindness)
classic
98
what is a stereotypes prodromal symptoms for migraine with aura
aura … can be visual , motor , sensory or cognitive
99
are migraine with aura or without aura more common
without
100
what are the 3 pronged treatment or HA
lifestyle changes
acute abortive >3 days
prophylaxis > 5
101
what is the medication that is taken everyday with HA
prophylaxis
102
when should u consider to take prophylaxis for HA
-when they interfere with patients life
- HA are frequent or prolonged
- atypical migraines
103
if someone has a HA lasting longer then 5 days what shoudl they take
prophylaxis
104
what could possibly works on inhibition of the peripheral and central sensitization of the trigeminovascular neurons
botulinum toxin (botox)
105
how many injections would someone get for botulinum toxin for chronic migraines
31
106
what HA does this describes
* Very common and underdiagnosed
* **Worse in the AM** – after not having medicine in system overnight
* Patient takes ever increasing doses of OTC medicine but slight drop in blood levels leads to rebound headache
* Particularly drugs with **caffeine**
analgesic rebound/withdrawal headache
107
what HA does this describe
Severe **unilateral** orbital, supraorbital, or temporal pain lasting 15-180 min
- Either or both of the following:
–
1 of the following ipsilateral symptoms or signs: a) conjunctival injection / lacrimation; b) nasal congestion c) eyelid edema; d) forehead and facial sweating; e) forehead and facial flushing;
f) sensation of ear; g) miosis / ptosis a sense of restlessness or agitation
-Frequency from 1/2 d to 8/d for > half the time when active
cluster
108
• 30 year old man presents with altered mental status, headache, and vomiting. He has had headaches in his 20s episodically but for the past 3 months has had a constant headache that is more occipital and associated with much more nausea and vomiting
primary or secondary
secondary
109
what type of HA would u think with this patient
* 27yearoldfemalelawyercomes to your office complaining of:
– **Bioccipital** non-throbbing moderate intensity squeezing pain.
– Radiates like a band around the head.
– Started 3 years ago, remains unchanged
– No other associated symptoms
– Resolves somewhat with ibuprofen
tension
110
what HA is this
• May not be due to muscle tension!
• Can begin at any age
• Generally bitemporal, bioccipital, or bifrontal
• “tight band” around head with sense of “pressure” or “bursting”
• May be perceived as continuous for months or even years
tension type
111
what do u think with this pateint
• 48 year old man without significant PMH comes to your office with:
– 1 month history of momentary jabs of severe pain over right cheek
– Occurs at least once per day
– Triggered by brushing his teeth, drinking liquids,
cold wind touching affected area
– No significant Family History
facial pain (trigeminal neuralgia)
112
• Develops in mid to late life
• Sharp lightninglike momentary jabs of severe
pain in V2 and V3 distribution – V1 involved in < 5% of cases
• Pain may be spontaneous or may be triggered by sensory stimulation
• DDx: in young patients consider MS and brainstem mass
what is this
trigeminal neuralgia (tic douloreux)
113
what is the medical treatment from trigeminal neuralgia
carbamazepine, oxcarbamazepine
114
what is the sx treatment for trigeminal neuralgia
microvascular decompression of trigeminal ganglia
115
what is defined as the sensation that u are moving
vertigo
116
what is defined as the sensation that the world is moving
opscillopsia
117
u want to figure out if the vertigo is cerebellar or vestibular related what would u do
finger to nose for cerebellar and balance for vestibular
118
if vertigo has to do with the vestibular portion of CN VIII , vestibular nuclei with brainstem and center connection what is the localization
central
119
if there is dysfucntion of the semicircular canals , utricle and saccule what locatiation of vertigo is it
peripheral
120
– Peripheral vestibulopathy
– Benign paroxysmal positional vertigo (BPPV) – Ménière’s disease
– Vertebrobasilar ischemia
– Migraine (rare)
– Seizures (rare
these are DD of attacks of what
vertigo
121
– Peripheral vestibulopathy – Cerebellopontine tumor – Multiple sclerosis
– Brainstem infarct
– Ototoxic drugs
these are DD of what
chronic vertigo
122
* Most **common** cause of **recurrent** vertigo
* Most episodes last a few weeks,but maybe
recurrent, can persist for years
what vertigo is this
Benign Paroxysmal Positional Vertigo
(BPPV)
123
Benign Paroxysmal Positional Vertigo is an episodic vertigo lasting how long and what is it triggered by
10-30 seconds
-tilting the head
-rolling over
-straightening after bending
124
in Benign Paroxysmal Positional Vertigo 85% is due to involvement of what canal
posterior semicircular
125
what test is used for Benign Paroxysmal Positional Vertigo
dix hallpike (vertigo)
126
• Most cases probably viral
• Sudden onset of prolonged vertigo that is
constant, lasting days (worst in the first couple)
• Hearing loss
• Nausea/vomiting common
• ±Tinnitus
• No focal neurologic signs
• Often affects young people
what vertigo is this
Peripheral Vestibulopathy: “Viral Labyrinthitis” and Vestibular Neuritis
127
* Episodic severe vertigo and vomiting, lasting minutes to an hour.
* Feeling of **fullness in ear and tinnitus**
* Hearing loss,often progressive
what disease is this
ménière’s disease
128
Vertigo Due to Posterior Fossa Mass or Infarction
is describes as what
-acute , severe vertigo (infarction ) or slow (mass)
- limb ataxia IPSILATERAL to lesion
- +/- BS signs
- +/- intractable nausea/ vomit
129
what are the accompanying BS signs with vertigo due to BS ischemia
– Diplopia
– Cortical blindness
– Dysarthria/Dysphagia – Quadriparesis
– Tinnitus
– Hearing loss
130
what does provoactive maneuvers show
nystagmus of long duration not fatigable
131
vestibular migraine has at lease ___ episodes & current or post history plof miagrane
5
132
At least 50% of viestibualr migraine episodes associated with at least one of the following migrainous features:
– Migraine headache
– Photo/phono
– Visual aura
133
what is the most common chronic vestibular condition
persistent postural perceptual dizziness
134
Diagnostic criteria:
– Non-room-spinning, unsteadiness, and difficulties with a balance must be present for most of the **days over a 90 period** lasting for hours.
– Symptoms **cannot** be provoked but can be exacerbated by changes in position and exposure to certain stimuli.
– Must be **preceded by a condition **with acute, episodic, or chronic vestibular symptoms.
– Causes impairment.
– Cannot be explained by another medical condition or disorder
this is the criteria for what
Persistent Postural-Perceptual Dizziness
135
what is the best treatment option for vertigo
vestibular rehabilitation
