Patho 2

Question 1

What direction is bad in skull fractures

Answer 1

in is bad

Question 2

what are risks associated with depressed skull fractures

Answer 2

• disruption of tightly adherent dura
• tear of meningeal vessels
• contuse/lacerate underlying brain tissue
• can communicate with facial sinuses (MC maxillary) or middle ear
• infection/meningitis

Question 3

Thinnest part of the skull is where? what blood vessel is associated?

Answer 3

• near the temple

- middle meningeal artery (epidural)

Question 4

What are the sx of a basal skull fracture?

Answer 4

• raccoon eyes

- CSF leak out nose or ear

Question 5

What is best imaging for skull fracture?

Answer 5

CT!!! Don’t bother with plain film

- start w/o, once r/o bleed, then can do contrast if needed

Question 6

What is common secondary issue with brain injury?

Answer 6

Coup contracoup injury

• coup at site of injury
• contracoup opposite side of injury

Question 7

Concussion

Answer 7

• occurs after trauma in absence of demonstrable damage to cranium or brain
• transient loss of consciousness
• amnesia (retro- and anterograde)
• minor damage to CNS
• lasting effects are minimal unless injury is repetitive

Question 8

Dementia pugilistica

Answer 8

“punch drunk”

- fighters in past who had damage due to multiple concussions

Question 9

Brain contusion
- caused by waht
- level of damage
-

Answer 9

• d/t violent motion or fast stopping - brain hits calvarium (skull)
• shaken baby syndrome and acceleration/deceleration injuries
• produces underlying local damage
• can be transient/minor OR produce enough damage to cause epilepsy

Question 10

Brain contusion

- common brain locations of damage

Answer 10

• inferior surface of frontal lobes
• anterior tip of temporal lobes
• occipital poles
• • may act as foci of seizure activity, esp. temporal lobes

Question 11

Where is location of middle meningeal artery bleed?

Answer 11

Epidural

Question 12

What type vasculature is typically bleeding in subdural bleeds?

Answer 12

• Venous – cerebral veins

- Lower pressure, sx over a longer period of time compared to epidural bleed

Question 13

What type of bleeds will produce blood in a spinal tap?

Answer 13

• Subarachnoid – blood is between arachnoid and pia where CSF is
• Not subdural

Question 14

Epidural hematoma

• location
• cause
• sx
• tx

Answer 14

• Between skull and dura mater
• Tearing of middle meningeal artery
• Characterized by transiet loss of consciousness with subsequent lucid interval
• 2 hours to repair!
• Surgical drainage prevents rapid expansion, brain herniation, death

Question 15

Subdural hematoma associated with what cause

Answer 15

blunt trauma w/o overlying skull fx

Question 16

Subdural hematoma acute vs. chronic

Answer 16

Acute

• Become clinically apparent a few days after trauma
• Fluctuating levels of consciousness

Chronic

• Clinically apparent weeks or months after trauma
• Slowly developing confusion/inattention, eventually coma

Question 17

Symptoms of ICP

Answer 17

• HA
• vomiting
• drowsy

Question 18

Describe a subarachnoid hemorrhage

Answer 18

• damage to blood vessels on surface of the brain (in the pia)
• Trauma most common, can also be aneurysm or arteriovenous malformation
• Does result in bloody tap

Question 19

What causes papilledema

Answer 19

• Increased CSF, commonly subarachnoid hemorrhage

- Epidural and subdural less likely but possible if large enough

Question 20

What should never be done if suspect increased ICP?

Answer 20

Spinal tap, risk for herniation in brain (very bad)

Question 21

What areas of brain are most sensitive to hypoxia?

Answer 21

Medial temporal lobe (contains hippocampus)

Question 22

What do neurologic changes due to hypoxia depend on?

Answer 22

Extent and duration of the hypoxia

- severe deficits can be cleared completely if hypoxia is revered quickly

Question 23

How long might sx dt hypoxia take to resolve?

Answer 23

One year, after that unlikely to see additional improvement

- it is the secondary area that is recovering (the part that was damaged by glutamate release)

Question 24

Is acute hypoxia or chronic hypoxia worse?

Answer 24

Acute is more damaging

Question 25

What are the four types of stroke?

Answer 25

1. Ischemic d/t thrombosis 2. Ischemic d/t emboli 3. Intracerebral hemorrhagic 4. Extracerebral hemorrhagic

Question 26

Is ischemic or hemorrhagic stroke more likely?

Answer 26

Ischemic – people live longer with more atherosclerosis

Question 27

Ischemic stroke - how fast is death - Main cause

Answer 27

- Death rarely in first hour, more likely to survive than hemorrhage - Atherosclerosis

Question 28

Hemorrhagic stroke - How fast is death - Main cause for intracerebral and extracerebral

Answer 28

- Death more likely in first hour (than in ischemic) - Intracerebral: striate arteries rupture (d/t HTN) - Extracerebral: arteriovenous malformation or aneurysm

Question 29

Stroke risk factors

Answer 29

- HTN - smoking - DM - HIV tx (elevates cholesterol) - bruits - previous TIAs - Protein C or S deficiency - Factor V Leiden - OCP - fam hx - age - a-fib - AA

Question 30

With what sx do you workup for stroke?

Answer 30

- HA! - LOC – only if large bleed - focal deficits initially unlikely

Question 31

Sx of intracerebral bleed

Answer 31

- HA only if large - LOC possible (usually dt uncontrolled HTN) - always local deficits bc of location

Question 32

Sx of Ischemic stroke

Answer 32

- HA unlikely - LOC unlikely - Large focal deficits dt death of downstream neurons

Question 33

Cincinnati stroke sx

Answer 33

1. Facial droop 2. arm drift 3. slurred speech 1 sx = 70% likely having stroke 2+ sx = 90%+ having stroke

Question 34

Infarction | - cause

Answer 34

- vascular thrombosis | - related to pre-existing damage to vessel wall such as atherosclerosis

Question 35

Infarction - common location - common population - usually preceded by what?

Answer 35

- Common within larger vessels (internal carotid, vertebral, basilar) - Mostly in older pts - Commonly preceded by TIAs

Question 36

What is a TIA

Answer 36

Acute onset of neurologic sx that resolve in minutes to hours

Question 37

Amaurosis fugax

Answer 37

TIA of visual field

Question 38

Emboli cause of infarction - Describe - Sx

Answer 38

- emboli break off thrombi in left heart or carotid - Tend to be multiple and involve smaller vessels - sudden onset of neurological deficit

Question 39

What do infarction sx depend on?

Answer 39

Location and size of infarct

Question 40

Infarction sx

Answer 40

- Can be as mild as confusion or a change in bp | - Hard to distinguish from hemorrhage based on presentation or early imaging

Question 41

How treat infarction?

Answer 41

- TPA w/in 3 hours of focal neurologic sign (and have ruled out hemorrhage)

Question 42

What is significant about the 3 hour mark for TPA

Answer 42

- cut off for risk of bleed vs. likelihood for improvement. - might be more willing to give TPA to young person later than 3 hours - old person wakes up with focal symptoms, not going to give them TPA bc don't know how long sx started and risk for bleed isn't worth it

Question 43

Non-traumatic hemorrhagic stroke - describe - commonly associated with what

Answer 43

- not located in a specific part of brain, will expand, doesn't obey borders - unlike infarcts, not limited to arterial distribution - HTN

Question 44

Non-traumatic hemorrhagic stroke | - type of damage in brain

Answer 44

- compress and disrupt parenchyma vs. destroy it - may rupture into ventricular system - herniation may occur secondary to expanding mass

Question 45

Berry aneurysms - aka - how common? - where occur?

Answer 45

- saccular aneurysms - 5-6% of population (eeek) - middle cerebral artery and it's branches (more often anterior, communicating, and internal carotid than posterior circulation)

Question 46

Berry aneurysm | - presentation

Answer 46

- usually as spontaneous rupture - display sx of stroke - may lead to sudden death

Question 47

Berry aneurysm tx

Answer 47

- if has a stalk - clip it | - no stalk - coil

Question 48

Vascular malformations - how common - two types

Answer 48

- 5% of population - venous (more common) - arteriovenous

Question 49

Venous malformations | - sx

Answer 49

usually asymptomatic

Question 50

Arteriovenous malformations | - risk compared to venous

Answer 50

- more likely to rupture