Flashcards in Traumatic Brain Injury Deck (90):
What is a concussion?
Sudden deceleration injury.
CT or MRI are typically normal.
High school athletes - 20%
College athletes - 10%
Contact sports: football, hockey, soccer, basketball, lacrosse.
Noncontact sports: gymnastics, skiing, ice skating
What are the types of traumatic brain injuries?
Closed Head Injury
What causes primary damage in traumatic brain injury?
Nerve damage - diffuse axonal injury
What is secondary damage in traumatic brain injury?
signs and symptoms of concussion
confusion: vacant state, delayed answers to questions, poor concentration
What percentage of concussions involve loss of consciousness?
Concussion Grade 1
No loss of consciousness
Symptoms <15 minutes
Concussion Grade 2
No loss of consciousness
Symptoms >15 minutes
Concussion Grade 3
Loss of consciousness.
What is a minor score on the Glasgow coma scale?
What is a moderate head injury on the Glasgow coma scale?
What is a severe head injury according to the Glasgow coma scale?
Concussion Red Flags
Mental status change.
Cerebellar dysfunction: gait/ataxia, finger to nose testing.
What is an absolute indication for a CT scan for concussion?
Anticoagulants - coumadin
Relative indications for concussion CT
Glasgow 60-65 yo
Basilar skull fracture
Moderate pretrauma amnesia >15 min
High risk injury: pedestrian MVA, fall from height >3 feet or >5 stairs
Where to basilar skull fractures occur?
Only accounts for 4% of fractures.
What might you see with a basal skull fracture?
Battles Sign - mastoid process ecchymosis
Raccoon eyes - periorbital ecchymosis
CSF leakage via nose or ears
Other types of skull fractures
2/3 have intracranial lesion present
Simple - no treatment
Depressed - surgical intervention
Rest - second impact syndrome
Most common post-concussion symptoms: headache, dizziness, impaired executive function
What is the process for a patient with a concussion to return to play?
Asymptomatic and medication free x 24 hours
Nonimpact aerobic exercise to increase HR x 24 hours
Sport-specific light drills x 24 hours
Non-contact training drills x 24 hours
Full contact practice x 24 hours
Return to play
What happens if concussion symptoms return at any point?
STOP and rest until symptoms clear x 24 hours and restart at current level.
How to athletes with multiple concussions recover?
Take longer to heal with each successive injury.
Who is at higher risk for post concussion syndrome?
Symptoms > 3 months
HA, dizziness, impaired executive function
What is a subdural hematoma?
Bleeding between the dura mater and arachnoid layer.
What causes subdural hematoma?
Tearing of the "bridging veins."
Shearing injury; acceleration-deceleration.
Result of trauma: acute, chronic (elderly).
What do you see on CT for a subdural hematoma?
What causes subdural hematoma in the young?
Head trauma - motor vehicle accident
Shaken baby syndrome
What causes subdural hematoma in the elderly?
Chronic trauma may be so minor it has been forgotten.
Anticoagulation is a risk factor
Age alone! (Cerebral atrophy, increases strength/tension on bridging veins)
Signs and symptoms of a subdural hematoma:
Loss of Consciousness
Treatment for a smaller Subdural Hematoma
Treatment for a larger Subdural Hematoma
Craniotomy to evacuate clots.
What do you see for an epidural hematoma on CT?
What is an epidural hematoma?
Bleeding between the dura mater and the skull.
What causes epidural hematoma?
What is artery causes epidural hematoma?
Caused by tearing of the Middle Meningeal Artery
What type of trauma causes epidural hematoma?
How do epidural hematomas evolve?
Evolve more rapidly.
Classic presentation - initial loss of consciousness and then lucid.
"Talk and Die"
Often unconscious at presentation.
Treatment of Epidural Hematoma
Ligate bleeding vessels
What is a subarachnoid hemorrhage?
Bleeding into the subarachnoid space.
What causes subarachnoid hemorrhage?
Usually due to rupture of cerebral aneurysm
How is a subarachnoid hemorrhage described by the patient?
"Headache of a lifetime"
How does a subarachnoid hemorrhage present?
Headache of a lifetime
May report a popping/snapping prior to headache
What should be ordered for a suspected subarachnoid hemorrhage?
CT without contrast.
Best within first 12 hours (beyond that sensitivity decreases)
7% will not appear on initial CT.
What will be seen with a lumbar puncture in a subarachnoid hemorrhage?
How is a subarachnoid hemorrhage treated?
Depends on location, size, and preference of neurosurgeon.
What is the pathophysiology of a stroke?
Blockage or rupture of a cerebral artery.
What are the types of stroke?
What are the types of hemorrhagic stroke?
Intracerebral hemorrhage (10%)
Subarachnoid hemorrhage (3%)
What causes an intracerebral hemorrhagic stroke?
What is the largest cause of hemorrhagic stroke?
Ruptured berry aneurysm (80%)
What are arterio-venous malformation?
Occur in less than 1% of the population.
Sxs: pulsatile tinnitus, HA, seizures
Prevalence of aneurysms
3-5 million people
0.5-3% will bleed
Where do aneurysms develop?
Branching points of arteries typically over the age of 40.
Risk factors for aneurysm development:
+/- African American
Increased age, peaks ~50
Risk factors to bleeding aneurysm:
Blood thinners (Warfarin)
What is a "sentinal bleed"?
Warning leak. Some patients may have mild bleeding at the site one to two days prior to the larger event.
Hemorrhagic Stroke Statistics
10-15% die before reaching the hospital.
25% die within first 24 hours.
40% die in first month.
50% die in the first 6 months.
If rebleeding occurs, 50-80% mortality.
1/3 survivors will have no neuro deficits.
Most will experience some degree of cognitive deficits even if good prognosis.
Complications of hemorrhagic stroke:
Cerebral ischemia - blood is an irritant that causes vasospasm.
Management goals of hemorrhagic stroke:
SBP <20 mmHg)
Ischemic Stroke Stats
4th leading cause of death in US
Persistent hemiparesis at 6 mos - 15%
Persistent aphasia at 6 mos - 15%
Recovery to baseline - 15%
Pathophysiology of Ischemic Stroke
Thrombotic (more common) - atherosclerosis: injured endothelial lining allows platelets to adhere; plaque formation.
Embolic- carotid arteries**, Heart
Lacunar infarcts - least common
Risk factors for ischemic stroke:
Age >65 yo
Cigarette smoking (>35, OC use)
Aortic arch plaque
+/- migraine with aura in women >35 that smoke and or use OCs
Less common: Hypercoaguable state, hyperviscocity - polycythemia vera, subclavian steal syndrome
What is a transient ischemic attack (TIA)?
Sudden onset of neurologic deficit
What is amaurosis fugax and what is it associated with?
Sudden, monocular blindness described as a shade or curtain being pulled over the eye (and then being pulled back up).
What imaging abnormalities will you see with a TIA?
How do the symptoms of a TIA progress?
Resolve within 24 hours - most within 10 minutes.
What can follow a TIA?
Stroke will follow TIA within 90 days in 20-25% of cases.
How do you evaluate for an ischemic stroke?
Head CT (or MRI)
If cardiac source of emboli suspected - TEE
Carotid US for carotid artery stenosis.
What is carotid artery stenosis?
Plaque forms in the common carotid.
Typically affects the bifurcation and flow into the internal carotid artery.
When would you hear a carotid artery bruit?
At 50% occlusion
What are the diagnostics for carotid artery disease?
Gold Standard: Angiography (highly invasive)
Carotid US or Carotid artery MRA ($$$$$)
What are the treatments for carotid artery disease?
Surgery - endarterectomy
When do you perform an endartectomy for carotid artery disease?
Asymptomatic patients with >80% stenosis.
Symptomatic patients with >50% stenosis.
When do you perform medical management for carotid artery disease?
Asymptomatic patients >60% but 50%.
What drugs are used for the medical management of carotid artery disease?
ASA 18-22% RR Reduction
Plavix OR dipyridamole + ASA (Aggrenox) 37%
NO PLAVIX + ASA
What is a lacunar infarct?
Occlusion of single deep penetrating artery.
Specific lacunar syndromes described but may also be "silent"
What does a lacunar infarct effect?
Deep nuclei: caudate, thalamus, putamen
Where does an ischemic stroke occur in anterior circulation?
Anterior Cerebral Artery
Middle Cerebral Artery
Where does an ischemic stroke occur in posterior circulation?
Posterior Inferior Cerebellar Artery
Posterior Cerebral Artery
What are the symptoms of an anterior cerebral artery occlusion?
Personality change: flat, apathetic
Cognitive change: short attention span, slowness
Contralateral sensory impairment.
If left- expressive aphasia.
Eyes deviate toward affected side.
What is the most common artery for an embolus-caused ischemic stroke?
Middle Cerebral Artery
What are the symptoms for a middle cerebral artery occlusion?
Contralateral sensory/motor deficits - Face and arm> leg
Head/eyes deviate towards infarct.
NEGLECT to affected side.
Initially decreased muscle tone then spasticity develops.
If left dom hemisphere effected: global aphasia then Broca's (expressive)
What are the signs/symptoms of posterior circulation blockage?
What are the signs of a posterior cerebral artery blockage?
May have sensory aphasia (cannot comprehend spoken or written words)
How do you assess a stroke patient pre-hospital
Cincinnati Prehospital Stroke Scale
-Facial droop - show teeth (abnl if asymptomatic)
Arm drigt - abnl with drifts or unable to lift
Dysarthria - "you can't teach an old dog new tricks"
Cincinnati Stroke Scale Scoring
Score of 1 - CVA in 72% of cases
Score of 3 - CVA in 85% of cases
What else should be ordered if you suspect a CVA?
How long should your hospital assessment last?
General Assessment - <25 min
-If hemorrhagic - angiography, neurosx consult
- Neg. but high suspicion for SAH, LP