neurovascular injuries and closed head injuries Flashcards

Question

Cerebral Aneurysm definition and locations

Answer 1

Definition: Thin-walled protrusions from intracranial arteries composed of very thin or absent tunica media - Develops from HTN or normal hemodynamic stress Location: Commonly occurs at junction of communicating arteries and cerebral arteries - MC: Ruptured ”Berry (saccular) aneurysm” (80%) -MC location: Anterior Circulation (Circle of Willis) – 85% -Anterior Comm. + Anterior Cerebral -Posterior Comm. + Internal Carotid Artery (MOST LIKELY TO RUPTURE) -Bifurcation of Middle Cerebral Artery

Answer 2

RF: - HTN - smoking - Female (2:1) - ETOH - Family hx aneurysm - Coartion of aortic Conditions with higher risk of formation: - polycystic kidney disease** - Ehlers-Danlos - bicuspid aortic valve

Answer 3

-CN3 palsy -most likely to rupture: Posterior communicating + internal carotid

Answer 4

INCIDENTAL finding: Asymptomatic until SAH occurs** -Headache -Visual Acuity Loss -Facial Pain May manifest as compression of CN III Palsy (PCA): -Diplopia: sudden onset, binocular, horizontal/vertical/oblique - Ptosis -Eye pain at onset Causes of rupture: - most occur without an identifiable trigger - strenuous activity (exercise, sex, physical work)

Answer 5

CTA/MRA: - can detect ≥5mm aneurysms** -Cons: Invasive d/t contrast injection, radiation Gold standard: Cerebral angiography* -XR imaging with injected contrast dye -Can detect much smaller aneurysms -Cons: More invasive, higher risk of complications -Not used for screening- no point of it** management - Observation: If <7mm incident finding without prior SAH -Monitoring unruptured aneurysms for growth: CTA/MRA annually for 2-3 years, then spread to every 2-5 years, is clinically and radiographically stable -Surgical clipping -Endovascular coiling (preferred method) **

Answer 6

-33% die before reaching the hospital -20% die in the hospital -30% recover without disability

Answer 7

- cushings reflex: increase BP, decreased HR, irregular breathing - headache - n/v

Answer 8

Def: ARTERIAL bleed between dura and the skull - MCC: trauma - MC: middle meningeal artery from temporal bone fracture Classic presentation: - initial trauma injury with brief LOC - lucid interval for several hours - neurological sx: AMS, coma - VOMITTING - other sx: headache, seizure, confusion, aphasia, hemiparesis Dx: - non contrast CT showing football sign (BICONVENX (lens-shaped, lentiform)* - blood collection that does not cross suture lines of the skull

Answer 9

management: IMMEDIATE hospitalization to REDUCE ICP** -Hyperventilation: Goal pCO2 25-30 mmHg (Temporary measure) -Mannitol: Osmotic diuretic that decreases ICP temporarily NEUROSURGICAL EVALUATION FOR CRANIOTOMY AND HEMATOMA EVACUATION: - surgical evacuation indications: volume > 30 mL, acute and in coma (GCS <8), PUPILLARY changes - if delayed surgical evaluation: BURR HOLE* Observation: - mild sx - volume < 30 mL - clot thickeness < 15mm - no midline shift - no coma - no focal neuro deficits Rarely: brain herniation, stroke, seizures occur

Answer 10

Definition: VENOUS bleed between dura and arachnoid - most often rupture of BRIDGING veins from surface of brain to dural sinuses - MC in elderly Causes: - BLUNT TRAUMA MC - "contre-coup" - shaken baby - AV malformation spontaneous hematoma - neurosurgical procedure complication - non-traumatic causes: ALCOHOLISM, SEIZURES, COAGULOPATHIES Risk factors: - cerebral atrophy - ELDERLY - TBI - M > F

Answer 11

Subdural: elderly pt becomes senile over a month and fell a week ago, seemed ok but now has a headache and acting weird - Headache - vomiting - Confusion - depressed LOC - Seizures - CN palsies -+/- focal neurologic symptoms such as hemiparesis, ipsilateral pupil dilation Epidural presentation: - initial trauma injury with brief LOC - lucid interval for several hours - neurological sx: AMS, coma - VOMITTING - other sx: headache, seizure, confusion, aphasia, hemiparesis

Answer 12

May have evidence of: - broken basilar skull - +/- CSF oto/rhinorrhea Dx: Non-contrast CT - head showing a concave (crescent shaped) blood collection that DOES cross suture lines -note: Initial CT scans can often be normal

Answer 13

management: immediate hospitalization!! - mild: corticosteroids and reduction of ICP!!!! neurosurgical evaluation for craniotomy and hematoma evacuation: surgical indications - > 5 mm thickness on CT - midline shift - coma (GCS < 8) - progressively decreasing GCS of over 2 points since admission - PUPIL abnormalities - ICP > 20 mmHg Notes: - consider shaken baby syndrome in children - HIGHER mortality due to DELAYED FINDINGS and HIGHER COMORBIDITIES - rare: brain herniation

Answer 14

Definition: Arterial bleed between arachnoid and pia mater - MCC: ruptured BERRY aneurysm*, AV malformation -Can be SPONTANEOUS or from TRAUMATIC event -> rupture and bleeding into subarachnoid space -> blood in CSF -> rapid increased ICP - high mortality rate: 42% within 30 days Risk factors: - age: 40-60 - FEMALES >>>>>>>> males - SMOKING - HTN - ETOH, cocaine - first-degree fam hx SAH - AA, connective tissue disorders

Answer 15

- female 40-60s - Acute, sudden “thunderclap” headache described as “worst headache of my life” * -Meningeal signs: Nuchal rigidity, photophobia -Vomiting -Confusion, AMS -+/- brief LOC Focal signs based on location: -PCA aneurysm: CN III - oculomotor nerve paralysis (ipsilateral ptosis, eye pointed down/out, mydriasis, loss of light reflex) -Anterior or middle cerebral: numbness, muscle weakness -Brocas area: slurred speech -Wernicke’s area: difficulty understanding speech

Answer 16

Dx: - non contrast CT: blood within basal cisterns - if you are highly suspicious with negative CT -> LP* - LP: gold standard; xanthochromia (yellow CSF from broken down RBCs); increased RBCs in all vials -CTA/MRA/Digital subtraction cerebral angiography vs. Cerebral angiogram (definitive) -EKG: Increased QRS, QT intervals, Decreased PR intervals, U waves, dysrhymias

Answer 17

complications: -Re-rupture (30%)* -Vasospasm (50%)* -Hydrocephalus, SIADH, HTN, cerebral ischemia, elevated ICP, seizures, cardiac abnormalities Management: immediate hospitalization to prevent complications - lower SBP <140 mmHg: labetolol - prevent vasospasm: CCB nimodipine - seizure prophylaxis: phenytoin/phenobarbital** - Surgery: craniotomy and clipping/coiling** -Supportive care: bedrest, stool softeners, analgesia, IV fluids, VTE prophylaxis, decrease ICP

Answer 18

Definition: blood accumulation in the intraparenchymal space -> compression of blood vessels and tissue -> HYPOXIA -> hypoxemia MCC: HTN - leads to atherosclerosis of large arteries, subclinical microbleeds, microaneurysms (Charcot-Bouchard aneurysms) - BASAL GANGLIA, THALAMUS, pons, and cerebellum are most often affected Other causes: -Cerebral amyloid angiopathy: Deposition of amyloid into blood vessel walls makes them weak and prone to rupture* -AVMs* -Post-traumatic -Coagulopathies -Sickle cell disease

Answer 19

- MALE - Black, Asian - Heavy alcohol use - amphetamines, cocaine - anti-thrombotic medications - previous cerebrovascular incident Very poor prognosis

Answer 20

Presentation: -Slow onset, gradually worsening within a few hours, increased ICP -Fever, AMS, HA, N/V - anisocoria: UNEQUAL pupil sizes * Symptoms: depend on location of bleed -Basal ganglia = Loss of contralateral sensory, motor functions, honomymous hemianopsia -Thalamus = Contralateral loss of sensory, motor functions, homonymous hemianopsia, aphasia if dominant side / neglect if non-dominant side, small pupils -Lobar = honomymous hemianopsia, seizures, contralateral leg paresis if frontal -Pons = coma within few minutes, quadraplegia miosis, deafness, speaking difficulties when awake -Cerebellum = ataxia, same side face weakness, occipital headache, neck stiffness, loss of face/body sensory functioning -ACA, MCA = numbness, weakness -PCA = Impaired vision -Broca’s area = Slurred speech -Wernicke’s area = Difficulty understanding speech

Answer 21

Dx: -!CT head non-contrast will show hyperdense blood acutely -CTA should be done to evaluate for vascular causes of hemorrhage -+/- CT venography if suspicious of cerebral vein thrombosis with hemorrhagic conversion Management: medical emergency-> BRAIN HERNIATION -Goal in early management: place an ICP monitoring device -Anticoagulation reversal -Antipyretics for fever -Osmotic diuresis (mannitol): reduce ICP -Nicardipine: BP control -Phenytoin or levetiracetam for seizure prophylaxis*

Answer 22

1) Get labs: -CMP, CBC -PT/PTT, INR, fibrinogen -Anti-Xa activity for patient on apixiban/rivaroxaban -Tox screen if warranted -Pregnancy test if warranted -ABG/VBG if intubated 2) Anticoagulation reversal 3) Control BP -Preferred agent: Nicardipine or clevidipine -Do not drop below 130mmHg as this may cause harm -If b/w 150-220 –> reduce to 130-150 -If >220 –> reduce to 140-180 4) neurosurgical consult

Answer 23

for all intracranial bleeds -Warfarin –> Vitamin K, PCC, FFP -Antiplatelets –> DDAVP, cryoprecipitate -New DOACS –> Praxbind (Idearucimab) for Dabigatran (Pradaxa), KCentra (Four factor PCC) for most others (fondaparinux, rivaroxaban, Eliquis) -Heparin –> Protamine -Thrombolytics (e.g. TPA) –> TXA, Cryo, FFFP

Answer 24

-Preferred agent: Nicardipine or clevidipine -Do not drop below 130mmHg as this may cause harm -If b/w 150-220 –> reduce to 130-150 -If >220 –> reduce to 140-180 SAH: goal of SBP <140 mmHg - use labetolol

Answer 25

rare - but serious blood clot that forms in cerebral veins or dural sinuses ethiology: -Prothrombotic states: pregnancy, post-partum, OCPs, thrombophilia (protein C and S deficiency, Factor V Leiden mutation) -Chronic inflammatory disease: SLE, IBD, malignancy, vasculitis -Local inflammation: Mastoiditis, otitis media, sinusitis presentation: - headache 90%* -benign intracranial hypertension, SAH, focal neuro deficit, seizures, meningoencephalitis, stroke (hemorrhagic conversion) CT/MR venogram

Answer 26

-Normal ICP <15 mmHg (adults), 9-12 mmHg (children) -Pathologic: >20mmHg for both Monroe-Kellie doctrine: Cranial cavity is a fixed space w fixed proportions: - Brain (1400ml) - Blood (150ml) - CSF (150ml) -Increase in a component = ↑ ICP -To decrease ICP, must decrease either brain, blood, or CSF

Answer 27

-Intracranial mass! (tumor, hematoma)* -Cerebral edema! (HIE, TBI, infarct)* -Obstructive hydrocephalus* -Idiopathic Intracranial HTN (IIH, pseudotumor cerebri) * -↑ CSF production (choroid plexus papilloma) -↓ CSF absorption (arachnoid granulation adhesion from bacterial meningitis) -Obstructive venous outflow

Answer 28

CSF is produced by choroid plexus and reabsorbed by the arachnoid granulations

Answer 29

Adults: -± Head trauma -HEADACHE (80%) -AMS -N/V -Visual changes Infants/Children: -Macrocephaly (big for age) -Bulging anterior fontanelles -Irritability (1st sign) -Nausea, vomiting -Lethargy, poor feeding, lack of interest

Answer 30

- Papilledema (4-9%)* - Cushing reflex: bradycardia, HTN, irregular breathing ** -CN VI palsy -Periorbital bruising -Children more likely to get abnormal gait or poor coordination -Herniation: Decorticate or decerebrate posturing, Change in GCS Absent: Hypotension, Hypoxemia, Hypothermia

Answer 31

1) Decreased cerebral perfusion pressure (CPP): ISCHEMIA - CPP = MAP - ICP; normal CPP = 60-100 - as↑ ICP, ↓ CPP -> reduced cerebral blood flow -> ischemia 2) HERNIATION: -↑ ICP -> brain shifts to other spaces of the skull -> brain tissue herniation -Ischemia or death 3) Cushing’s reflex: -HTN: as ↑ ICP ,↓ CPP -> compensatory activation of the sympathetic nervous system to ↑ Systolic BP - Bradycardia: aortic arch baroreceptors activate the parasympathetic nervous system -> bradycardia -↑ Pressure on brain stem -> dysfunction of respiratory drive -> irregular breathing

Answer 32

Non-contrast CT head = initial step -Look for causes: acute obstructive hydrocephalus, edema, or space-occupying lesions such as intracranial hematoma, masses -Consider repeat CT if clinical deterioration -> Not everything shows on a CT scan* Signs of ↑ ICP on CT scan: -Midline shift -Effacement of the ventricles, basal cisterns and other CSF spaces (loss of visibility) -Brain herniation (uncal, tonsillar) -Edema: Loss of grey-white matter differentiation LP opening pressure of >20cm is indicative of ↑ ICP -Always image first r/o space occupying lesion… sudden and rapid decrease of ICP from the LP can trigger a brain herniation

Answer 33

CPP (cerebral perfusion pressure) = MAP – ICP -Generally ICP>20mmHg is considered elevated Intraventricular catheter = gold standard with external ventricular drain (EVD)**** - allows for continuous ICP monitoring and is therapeutic for drainage -Complications: infection (20%), hemorrhage (2%) -Other monitoring devices: intraparenchymal, subarachnoid, epidural -------- -ICH (regardless of cause) is considered a medical emergency due to danger of brain herniation -Goal in early management: place an ICP monitoring device

Answer 34

resuscitation efforts: - head of bed at 30 degrees* - therapeutic hyperventilation: goal of pCO2 of 26-30 mmHg -> induces vasoconstriction and reduce cerebral blood flow aggressively treat fever: acetaminophen, mechanical cooling hyperosmolar therapy (in emergencies) - mannitol: osmotic diuretics - mechanical ventilation - AVOID free water solutions that can worsen edema like D5W, half NS; USE ISOTONIC fluids (0.9% NS)** other tx: -Furosemide: sometimes given as adjunct therapy to potentiate effects; Can worsen dehydration and hypokalemia -Decompressive Craniectomy (last line)

Answer 35

Use: -Reduces brain volume by drawing free water out of tissue and into circulation -Excreted by kidneys -> volume depletion, hypotension + hypernatremia -Caution in patients with renal insufficiency IV Mannitol: - initial dose: 1 g/kg bolus, re-dose 0.25-0.5 g/kg PRN q 6-8 h -Effects peak at 1 hour and last 4-24 hours, can have “rebound” increase in ICP after it wears off -Monitor: serum Na, osmolality, renal function -Side effects: hyperosmolarity, hypovolemia, hypo-K, hyper-Na, renal failure

Answer 36

B -Innermost temporal lobe is compressed and moves towards the brainstem, causing pressure on CN III -Classic presentation of uncal herniation: -!Ipsilateral fixed dilated pupil + contralateral hemiplegia + cushing reflex

Answer 37

-Idiopathic increased intracranial pressure with no known cause Classic presentation: OVERWEIGHT FEMALE of childbearing age, with worsening headache, worse with straining, and vision changes - Exam reveals papilledema - Imaging normal -Other symptoms: N/V, pulsatile tinnitus, vision loss, NECK STIFFNESS, back pain, retrobulbar pain -Other signs: Papilledema (hallmark), 6th nerve palsy, visual field loss Treatment: -Weight loss -Acetazolamide -Consider CSF shunt

Answer 38

Excessive amount of CSF within cerebral ventricles and/or subarachnoid spaces = Ventricular dilation and increased ICP Two Types: 1) Obstructive (Non-Communicating) - CSF accumulation due to structural blockage of flow within ventricles - MCC in children 2) Absorptive (Communicating) - CSF accumulation due to impaired absorption; rarely excessive CSF production - normal pressure hydrocephalus

Answer 39

-MCC of congenital hydrocephalus : myelomeningocele (15-25%) -MCC of acquired hydrocephalus: hemorrhage

Answer 40

Low birth weight prematurity maternal DM male sex low socioeconomic status race/ethnicity

Answer 41

Symptoms -HEADACHE: early morning, worse with cough/micturition/defecation/recumbency* -Irritability, Lethargy , weakness -Altered mental status / behavioral changes* -Nausea, vomiting -Diplopia, abnormal eye movements Signs: -Head circumference in children: full anterior fontanelles, frontal bossing, prominent scalp veins -Developmental delays in children -Spasticity -“Setting sun” sign - papilledema -Sacral dimpling *

Answer 42

Dx: - first line: CT head - Fundoscopy – papilledema -Lumbar puncture will have ↑ opening pressure - Not usually necessary management: Asymptotic: Watchful waiting, serial head measurements, serial US, monitor development if Symptomatic, acute, rapid, progressive: - VP shunt* -Endoscopic third ventriculostomy (for non-communicating) -Temporary: External ventricular drain (EVD) -Avoid rapid aspiration of CSF… aim for 1-2mL/min for 2-3 minutes at a time - Goal ICP <20 mm Hg

Answer 43

Definition: Pathologically enlarged ventricular size with normal CSF opening pressures (ICP normal) -A form of COMMUNICATING hydrocephalus caused by structural blockage of the CSF within the ventricular system (e.g. stenosis of aqueduct of Sylvius) - wet, whacky, wobbly Risk factors: -Idiopathic NPH increases in prevalence with age, MC >60*

Answer 44

Proposed Etiologies: -Congenital/Chronic -Cerebrovascular Disease -Decreased CSF Absorption -Increased Central Venous Pressure -Neurodegenerative Disorders (dementia) Secondary NPH: Symptomatic NPH due to “pressure effect” on brain -MOA: Impaired CSF resorption - accumulation within ventricular system - local “pressure effect” on periventricular white matter -MCC: intraventricular (IVH) or subarachnoid hemorrhage (SAH) ******** - other MCC: 2/2 aneurysm or trauma, or prior acute/ongoing chronic meningitis

Answer 45

Gait Disturbance - Magnetic, glued foot gait: small wide based steps - Difficulty with ambulation: reduced ability to walk Cognitive Disturbance: - Dementia that develops over months-years - early: impaired executive function -Apathy, depression, psychomotor slowing, decreased attention and concentration Urinary Incontinence: - early: Urgency - Slow gait makes it hard to reach bathroom - late: lack of concern due to frontal lobe impairment

Answer 46

Sx: -Normally have NO ICP symptoms (other than wet, whacky, wobbly) -No headache, N/V, vision loss, papilledema Dx: -Lumbar puncture: Normal opening pressure** -Check labs for other causes of AMS: Include B12, TSH -MRI brain : Ventriculomegaly (hallmark) without obstruction*** -Diagnosis of exclusion Confirmatory tests: -Remove 30-50mL CSF via LP, then test gait ~60 minutes after, if improvement of gait, would benefit from VP shunt

Answer 47

Confirmatory tests: -Remove 30-50mL CSF via LP, then test gait ~60 minutes after, if improvement of gait, would benefit from VP shunt Treatment: VP shunt ! ----- Dx: -Lumbar puncture: Normal opening pressure** -Check labs for other causes of AMS: Include B12, TSH -MRI brain : Ventriculomegaly (hallmark) without obstruction*** -Diagnosis of exclusion

neurovascular injuries and closed head injuries Flashcards

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