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MB3 Neurology > Trauma and CSF > Flashcards

Trauma and CSF Flashcards

1
Q

uses of GCS

A

preduct coma or other prognosis

diagnosis of coma

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2
Q

3 classes within GCS and which is the most important

A

eye opening
verbal response
motor - most important

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3
Q

classification within eye opening - GCS

A

4 - Spontaneous
3 - Verbal
2 - To pain
1 - None

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4
Q

classification within verbal response - GCS

A 
5 - orientated 
4 - confused 
3 - inappropriate words 
2 - incomprehensible sounds 
1 - nothing
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5
Q

classification within motor response - GCS

A 
6 - obeys 
5 - localises to pain 
4 - withdrawal to pain 
3 - decorticate motor response 
2 - decerebrate motor response 
1 - unresponsive
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6
Q

what is decorticate positioning

A

severe damage to cerebrum, internal capsule and thalamus but midbrain spared
abnormal arm flexion, hands clenched to fist and legs extended with feet inwards
disturbance to lateral CST and hence rubrospinal causes abnormal UL flexion and reticulospinal causes leg extension

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7
Q

what is decrebrate positioning

A

severe brainstem damage, below the red nucleus
head arched back and arms and legs extrended
rubrospinal and lateral CST are compromised
reticulospinal tract takes over to lead to full body extension

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8
Q

describe CSF production in the brain

A

produced in the choroid plexus of the ventricles
flows from lateral ventricles to third ventricle by foramen of munro
flows through cerebral acqueduct/sylvius to reach 4th ventricle
circulates to SA space by formamen of magendie and luschka and absorbed by arachnoid granulations back to venous blood

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9
Q

what is the normal ICP

A

5-15mmHg

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10
Q

describe how the monroe kellie hypothesis may be compromised by increased ICP

A

brain autoregulates cerebral blood flow and so as ICP rises autoregulation becomes compromised
this leads to ischaemia, swelling and herniation

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11
Q

possible causes raised ICP?

A 
SOL - tumour, haemorrhage, haematoma 
cerebral oedema - ischaemia, liver failure, hypercarbia 
CSF obstruciton 
IIH
raised venous pressure
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12
Q

features of raised ICP

A 
headache 
nausea and vomiting 
papilloedema 
drowsy 
cushings triad
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13
Q

what is cushings triad

A

hypertension
bradycardia
decreased respiration

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14
Q

what is uncal herniation and how may it present

A

medial temporal lobe herniation through tensorium
pupillary dilatation due to CN III compression
can compress pyramidal tracts to lead to contralateral hemiparesis

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15
Q

what is subfalcine herniation and how may it present

A

herniation of cingulate gyrus below falx

can lead to LL weakness due to compression of ACA

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16
Q

what is transcalvarial herniation

A

herniation through the skull

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17
Q

what is central herniation

A

descent of the diencephalon and midbrain

can lead to VI palsy and brainstem dysfunction

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18
Q

what is tonsillar herniation

A

displacement of cerebellar tonsils through foramen magnum
can be posterior fossa lesion or arnold chiari
medullary compression, neck stiffness, abnormal neck posture
cheyne stokes breathing
coma
death

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19
Q

what is an epidural haematoma and what is the usual cause

A

bleeding between dura and skull

MMA damage, usually temporoparietal skull fracture leading to damage to pterion

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20
Q

clinical features of an epidural haematoma

A

often a young adult with closed head trauma
brief loss consciousness, lucid interval and then deterioration with headache, vomiting, contralateral hemiparesis or ipsilateral pupil dilatation

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21
Q

imaging for epidural haematoma

A

CT with lens shapes appearance not crossing suture lines

possible mass effect and herniation

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22
Q

management of an epidural haematoma

A

immediate surgical evacuation if neuro deficit

if small can be managed conservatively if small and no neuro deficit

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23
Q

what is a subdural haematoma

A

bleeding below dura and above arachnoid mater

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24
Q

describe the features of an acute SDH

A

immediately symptomatic, often following head trauma
cerebral blood flow may be reduced so there is cerebral oedema and ischaemia
in acute cases presentatiob is a severely decreased state of consciousness

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25
causes of chronic SDH
brain atrophy - age, dementia, alcohol anticoagulation inflammation, previous head trauma
26
describe how brain atrophy leads to SDH
as atrophy occurs bridging veins are stretched leading to bleeding leaky vessels accumulate blood into SD space and osmotic gradient causes pull into space
27
features of a chronic SDH
``` headache confusion urinary incontinence weakness seizure cognitive dysfunction gait abnormality ```
28
imaging of SDH
CT | crescent shaped hyperdense if acute and hypodense if chronic
29
what is normal pressure hydrocephalus and what are possible causes
build up of CSF due to impaired resorption at arachnoid granulations or overproduction of CSF usually idiopathic but can be secondary to trauma, haemorrhage, meningitis
30
clinical features of normal pressure hydrocephalus
apraxia - shuffling gait reversible dementia urinary incontinence
31
imaging and management of normal pressure hydrocephalus
massively enlarged ventricles | VP shunt, reserved for ventriculomegaly with severe symptoms or after marked improvement with CSF removal
32
what is communicating hydrocephalus
excess CSF in ventricles leading to enlarged ventricular system with no flow obstruction impaired resorption by arachnoid granulations
33
what is non communicating hydrocephalus
excess CSF in ventricles due to obstruction of flow usually determined as 4th ventricle is smaller than 3rd and lateral causes are colloid cyst, stenosis of acqueduct, tumour
34
common causes of congenital hydrocephalus
acqueductal stenosis | spina bifida or arnold chiari
35
common causes of acquired hydrocephalus
tumour infection trauma
36
presentation of congenital hydrocephalus
``` fail to thrive dilated scalp veins increased head circumference sunsetting gaze impaired upgaze diplopia vomiting macewen sign ```
37
presentation of acquired hydrocephalus
``` headache - mostly morning vomiting diplopia impaired upgaze papilloedema drowsy incontinence gait anomaly ```
38
investigation of congenital hydrocephalus
detailed hx and antenatal hx with milestones head circumference, full ophthalamic exam palpate ant fontanelle MRI is best but CT more available
39
management of hydrocephalus
CSF diversion VP shunt or endoscopic third ventriculostomy - needs functional CSF absorption as drains to basal cistern so only for non-comms hydrocephalus
40
what is a Chiari I malformation
most common and least severe malformation | caudally displaced cerebellar tonsils below foramen magnum
41
signs and symptoms of a chiari I malformation
headache, esp on cough and neck extension and suboccipital pain downbeat nystagmus central cord symptoms - sensory loss of pain and temp and progressive paralysis starting with UL ataxic gait
42
what is a chiari II malformation and what is it associated with
less common and more severe more frequent in children and clear association with spina bifida can lead to hydrocephalus caudal displacemnt of cerebellum and medulla below foramen magnum with herniation of the 4th ventricle
43
signs and symptoms of chiari II malformation
severe brainstem dysfunction - apnoea, stridor, nystagmus, dysphagia weakness progressingt o quadriplegia
44
management of chiari malformations
non surgical operative depending on imaging or symptoms suboccipital craniotomy and upper cervical laminectomy to decompress
45
what is IIH
raised ICP in absence of any SOL or hydrocephalus | more common in obese and female
46
presentation of IIH
headache worst in morning and relief by standing moderate to gross bilateral papilloedema nausea and vomiting VI nerve palsy
47
investigation of IIH
CT/MRI may show slit like ventricles visual field testing and fundoscopy LP if not contraindicated
48
management of IIH
weight loss LP shunt potentially azetazolamide
49
head injury severity scale on GCS - mild
14/15
50
head injury severity scale on GCS - moderate
9-13
51
head injury severity scale on GCS - severe
<8
52
when to have a CT within an hour
``` GCS <13 GCS <15 post 2hr suspected open or depressed skull fracture signs of basal skull fracture post trauma seizure focal neuro deficit >1 episode vomiting NAI ```
53
when to have an immediate head CT
Loss of consciousness or amnesia and one of the following | >65, dangerous mechanism injury or coagulopathic
54
what is an intracerebral haematoma
bleeding in the brain substance
55
what is the coup/contracoup effect
head strikes a solid object but brain continues to move and strikes skull at the opposite side
56
what is a diffuse axonal injury
appears as small hyperdense areas at grey/white matter interface, brainstem or corpus callosum shearing force damaging axon LOC,
57
medical management of raised ICP
``` sedate max venous drainage Lower Co2 on intubation osmotic diuretica CSF release last ditch ```
58
sedatives for raised ICP
propofol BZD barbiturates
59
venous drainage options for raised ICP
cervical collar head of bed tilt loosen ETT ties
60
osmotic diuretics for raised ICP
mannitol | hypertonic saline
61
CSF release or last ditch options for raised ICP
external drain hemicraniectomy bifrontal craniectomy
62
describe the features of brainstem death on exam and requirements for it to be carried out
no drugs, hypothermia or metabolic disturbance no pupil response, corneal reflex no motor response no vestubulo-ocular response no gag or cough no respiration tested twice by two doctors and one must be a consultant
63
calculation of CPP
MAP-ICP
64
calculation of cerebral blood flow
CPP/vascular resistance
65
describe cerebral blood flow autoregulation
remainst constant under changing BP regulation of vascular resistance arterioles dilate in presence of lactate or CO2 pressure constriction/dilatation as needed
66
early features raised ICP
``` decreased consciousness headache pupil dysfunction ±papilloedema change in vision N&V ```
67
late features raised ICP
``` coma fixed and dilated pupils, unilateral then bilateral hemiplegia bradycardia, hypertension hyperthermia reduced urine output ```
68
who often gets normal pressure hydrocephalus
the elderly

MB3 Neurology (19 decks)

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