neurology

Question 1

What is an extradural haematoma?

Answer 1

Bleeding between the dura mater and skull

Question 2

What is a subdural haematoma?

Answer 2

Bleeding into the outermost meningeal layer

Question 3

What is a subarachnoid haemorrhage?

Answer 3

Bleeding in the subarachnoid space

Question 4

What is an intracerebral haemorrhage (interparenchymal)?

Answer 4

Collection of blood within the substance of the brain

Question 5

What are contusion brain injuries?

Answer 5

Small haemorrhages near the skull in the area of coupe and contra-coupe

Question 6

What is diffuse axonal injury?

Answer 6

Diffuse shearing of axonal tracts of white matter

Question 7

What mechanism of injuries are most likely to cause an extradural haematoma?

Answer 7

Acceleration-deceleration trauma
Blow to side of head

Question 8

What is the most common area of the brain for extradural haematomas to occur, and which vessel is likely to rupture?

Answer 8

Temporal region - skull fractures cause rupture of middle meningeal artery

Question 9

Which intracranial bleed is the following history typical of: young patient with traumatic head injury and ongoing headache has period of improved neurological symptoms and consciousness, followed by rapid decline over hours

Answer 9

Extradural haematoma

Question 10

Which vessel usually ruptures to cause a subdural haematoma?

Answer 10

Bridging veins

Question 11

What are risk factors for subdural haematoma?

Answer 11

Old age
Alcoholism
Anticoagulation

Question 12

Which intracranial bleed can be either acute or chronic?

Answer 12

Subdural haematoma

Question 13

What are the features of acute and chronic subdural haematomas?

Answer 13

Acute - fresh blood, commonly caused by high-impact trauma, may be fluctuating consciousness
Chronic - collection of blood for weeks-months, long history of progressive confusion, reduced consciousness or neurological deficit

Question 14

What is the most common cause of subarachnoid haemorrhages?

Answer 14

Spontaneous rupture of cerebral (berry) aneurysm

Question 15

What are the causes/risk factors of intracerebral haematoma

Answer 15

Hypertension
Vascular lesion (aneurism, arteriovenous malformation)
Cerebral amyloid angiopathy
Trauma
Brain tumour
Infarct (often stroke patients undergoing thrombolysis)

Question 16

What is the presentation of an intracerebral haematoma?

Answer 16

Similar to an ischaemic stroke
Decrease in consciousness

Question 17

What complication of intracerebral haematoma can develop later?

Answer 17

Hydrocephalus

Question 18

What is an important complication of subarachnoid haemorrhage presenting with fever, headache, nausea and vomiting, muscle cramps, muscle weakness and confusion?

Answer 18

Hyponatraemia caused by SIADH

Question 19

When does secondary brain injury occur in an intracranial bleed?

Answer 19

When cerebral oedema, ischaemia, infection, tonsillar or tectorial herniation exacerbates the original injury

Question 20

What is the Cushing’s reflex in intracranial bleeds?

Answer 20

Hypertension and bradycardia - occurs late and is usually a pre-terminal event

Question 21

What does unilaterally dilated pupils with a sluggish or fixed light response indicate in head trauma?

Answer 21

CN III compression secondary to tectorial (uncal) herniation

Question 22

What does bilaterally dilated pupils with a sluggish or fixed light response indicate in head trauma?

Answer 22

Poor CNS perfusion
Bilateral CN III palsy

Question 23

What does unilaterally dilated or equal pupils with an RAPD indicate in head trauma?

Answer 23

Unilateral optic nerve dysfunction or retinal dysfunction

Question 24

What does bilaterally constricted pupils indicate in head trauma?

Answer 24

Opiates
Pontine lesions
Metabolic encephalopathy

Question 25

What does unilaterally constricted pupils with a preserved light response indicate in head trauma?

Answer 25

Sympathetic pathway disruption

Question 26

What is the classification for GCS?

Answer 26

Eyes - No response - 1 - Open to pain - 2 - Open to voice - 3 - Spontaneous - 4 Verbal response - None - 1 - Incomprehensible sounds - 2 - Inappropriate words - 3 - Confused - 4 - Orientated - 5 Motor response - None - 1 - Extends - 2 - Abnormal flexion - 3 - Normal flexion - 4 - Localises pain - 5 - Obeys commands - 6

Question 27

What are the NICE indications for a non-contrast CT within 1 hour following head trauma?

Answer 27

GCS <13 on initial assessment GCS <15 at 2 hours post-injury Suspected open or depressed skull fracture Any sign of basal skull fracture - haemotympanum (blood in the middle ear), 'panda' eyes, CSF leakage from the ear or nose, Battle's sign Post traumatic seizure Focal neurological deficit More than one episode of vomiting

Question 28

What are the NICE indications for a non-contrast CT within 8 hour following head trauma?

Answer 28

Any patient on warfarin Adults with the following who have lost consciousness or experienced amnesia following injury: - Bleeding or clotting disorders, anticoagulants - Age 65 or older - More than 30 minutes retrograde amnesia of events before the head injury

Question 29

What intracranial bleed causes a hyperdense area that is biconvex and limited by cranial sutures?

Answer 29

Extradural haematoma

Question 30

What intracranial bleed causes a HYPERdense area that is crescent shaped and NOT limited by cranial sutures?

Answer 30

Acute subdural haematoma

Question 31

What intracranial bleed causes a HYPOdense area that is crescent shaped and NOT limited by cranial sutures?

Answer 31

Chronic subdural haematoma

Question 32

What intracranial bleed causes a hyperdense area within the substance of the brain?

Answer 32

Subarachnoid haemorrhage

Question 33

When is IV mannitol used in management of intracranial bleeds?

Answer 33

Where there is life-threatening rising ICP, such as in extradural haematoma While theatre is prepared or transfer arranged

Question 34

When might decompressive craniotomy be used in management of intracranial bleeds?

Answer 34

Diffuse cerebral oedema

Question 35

When might exploratory Burr holes be used in management of intracranial bleeds?

Answer 35

Not much - except where scanning may be unavailable to facilitate creation of formal craniotomy flap

Question 36

When might surgical reduction and debridement be used in management of intracranial bleeds?

Answer 36

For depressed skull fractures that are open

Question 37

How might closed skull fractures with minimal displacement be managed?

Answer 37

Non-operatively - close monitoring and repeat imaging

Question 38

When is ICP monitoring done?

Answer 38

Appropriate for GCS 3-8 and normal CT scan Mandatory for GCS 3-8 and abnormal CT scan