TRAUMA AND CSF

Question 1

What is the most important score in the GCS?

Answer 1

motor response

Question 2

Where is CSF produced?

Answer 2

choroid plexus in ventricles

Question 3

CSF flow

Answer 3

lateral ventricles –> via foramen of munro –> third ventricle –> via aquedcut of sylvius –> fourth ventricle –> foramina of magendie and luschka –> subarachoid space –> arachnoid granulations –> venous blood

Question 4

Symptoms of cerebral herniation

Answer 4

• Extensor response
• Cushing’s triad (hypertension, bradycardia and irregular breathing)
• Unreactive pupil (uncal herniation)

Question 5

Name the 3 types of herniation

Answer 5

Uncal, tonsilar, subfalcarine

Question 6

Which part of the brain herniates in uncal herniation?

Answer 6

medial temporal lobe through the tentorium

Question 7

How does an uncal herniation present?

Answer 7

1. pupillary dilatation due to involvement of ipsilateral oculomotor nerve
2. contralaterl hemiparesis

Question 8

Which part of the brain herniated in a subfalcine herniation?

Answer 8

the cingulate gyrus

Question 9

How does a subfalcine herniation present?

Answer 9

weakness in lower extremities

Question 10

What part of the brain herniates in a tonsilar herniation?

Answer 10

cerebellar tonsils are displaced into the forman magnum

Question 11

Give 2 causes of a tonsilar herniation

Answer 11

• Posterior fossa lesion
• Arnold-Chiari malformation

Question 12

How does a tonsilar herniation present?

Answer 12

medullary compression and ischaemia characterized by neck stinfness, abnormal neck posture, respiration anomaly (Cheyne-Stokes breathing; periods of tachypnea and tachycardia followed by periods of bradycardia and bradypnea) and coma.

Question 13

Following a car accident a patient presents with unilateral pupil mydriasis that does not constrict to light. Which type of herniation is this?

Answer 13

uncal herniation would present with pupillary dilatation due to compression of the ipsilateral oculomotor nerve

Question 14

Normal ICP

Answer 14

5-15 mmHg

Question 15

3 intracranial components

Answer 15

brain tissue, CSF and blood

Question 16

PC: a progressive shuffling gait and urinary incontinence. His wife is claiming that he has been forgetting his keys and taking his medication. What is the most likely diagnosis?

Answer 16

Normal pressure hydrocephalus

Question 17

Baby with big head, failure to thrive. On exam she has sunsetting eyes. Whats the most likely cause?

Answer 17

Non-communicating hydrocephalus due to aqueduct stenosis

Question 18

How does an extradural haematoma present?

Answer 18

• young adult with closed head trauma
• brief loss of consciousness then lucid interval then deterioration
• headache, vomiting, contralateral hemiparesis and ipsilatral pupillary dilatation

Question 19

Investigation of extradural haematoma

Answer 19

CT shows lens-shaped haematoma that pushes away the dura

Question 20

Between which layers is an extradural haematoma?

Answer 20

skull and dura

Question 21

Between which layers is a subdural haematoma?

Answer 21

dura and arachnoid

Question 22

Between which layers is a subarachnoid ?

Answer 22

arachnoid and pia

Question 23

How does an acute subdural haematoma present?

Answer 23

• very severe head trauma
• immediate symptoms
• severely decreased consciousness

Question 24

How long after trauma does a chronic subdural haematoma display symptoms?

Answer 24

3-7 weeks

Question 25

What is the driving factor for chronic subdural haematoma?

Answer 25

brain atrophy which stretched the bridging veins allowing them to rupture with minor trauma

Question 26

Investigate subdural haematoma

Answer 26

CT shows crescent that cannot cross falx cerebri or tentorium ## Footnote ACUTE: hyperdense crescent CHRONIC: hypodense cresent, slow growing

Question 27

How does normal pressure hydrocephalus present?

Answer 27

1. shuffling gait 2. dementia 3. urinary incontinence

Question 28

Treatment of normal pressure hydrocephalus

Answer 28

ventriculo-peritoneal shunt

Question 29

What is communicating hydrocephalus?

Answer 29

due to CSF absorption (impaired arachnoid granulations)

Question 30

What is non-communicating hydrocephalus?

Answer 30

obstruction of CSF flow - small fourth ventricle in comparison to others

Question 31

Causes of non-communicating hydrocephalus

Answer 31

* tumours compressing the ventricles * a colloid cyst obstructing the third ventricle can be seen * stenosis of the aqueduct.

Question 32

Symptoms of congenital hydrocephalus

Answer 32

* Failure to thrive. * Dilated scalp veins. * Increased head circumference. * Impaired upgaze due to compression on the tectal plate. * ‘Setting sun’ appearance: downward deviation of the globe on lid retraction. * Raised ICP and diplopia (due to sixth nerve palsy). * Vomiting. * Macewen sign: ‘cracked pot’ sound on head percussion.

Question 33

Signs and symptoms of acquired hydrocephalus

Answer 33

* Headaches: more prominent in the mornings. * Vomiting. * Diplopia. * Impaired upgaze due to compression on the tectal plate. * Raised ICP. * Papillodema * Drowsiness. * Incontinence. * Gait abnormalities.

Question 34

Investigate hydrocephalus

Answer 34

MRI

Question 35

Manage hydrocephalus

Answer 35

VP shunt or endoscopic third ventriculostomy (ETV) if non-communicating

Question 36

What are Chiari malformations?

Answer 36

* congenital or aquired * malformation of hindbrain * impaired CSF circulation through foramen magnum

Question 37

Which chiari malformation is more severe?

Answer 37

Chiari II (Arnold-Chiari)

Question 38

What is Chiari I ?

Answer 38

* most common * caudal displacement of cerebellar tonsils below foramen magnum * +/- syringomyelia

Question 39

What is syringomyelia?

Answer 39

an expanding cystic cavity or syrinx forming in the spinal cord that can cause damage to the central spinal cord

Question 40

signs and symptoms of Chiari I

Answer 40

* headache (esp with cough and neck extension) * downbeat nystagmus * central cord symptoms if syringomyelia * ataxic gait

Question 41

What is Arnold-Chiari?

Answer 41

Cerebellum and medulla are caudally displaced below the foramen magnum and herniation of fourth ventricle

Question 42

What condition is Arnold-Chiari associated with?

Answer 42

spinabifida

Question 43

What age group does Arnold-Chiari affect?

Answer 43

symptomatic during infancy or childhood

Question 44

Syptoms of Arnold-Chiari

Answer 44

* severe brainstem dysfunction causing dysphagia, apnoea, stridor and nystagmus * weakness that can progress to quadriplegia

Question 45

Treatment of chiari malformation

Answer 45

Suboccipital craniectomy and upper cervical laminectomy to decompress the malformation at the foramen magnum are usually required with cord drainage.

Question 46

Clinical featurs of idiopathic intracranial hypertension

Answer 46

* headache (worse in morning, relieved by standing) * bilateral papilloedema * N+V * sixth nerve palsy

Question 47

What size are the ventricles in idiopathic itracranial hypertension?

Answer 47

normal or reduced

Question 48

Treatment of idiopathic intracranial hypertension

Answer 48

weight loss and diuretics lumbo-peritoneal shunt (surgical)