normal ICP in adults
what are the 3 intracranial components
brain parenchyma, CSF, blood
what is a “critical parameter for brain function and survival?”
cerebral blood flow
complications a/w elevated ICP
brainstem compression (herniation); reduction in CBF
most common herniation
uncal herniation
cushing’s triad
bradycardia, respiratory depression, HTN (correlates with brainstem compression)
decorticate
hands to the body core
-lesion in the corticospnial tract from cortex to upper midbrain
decerebrate
extension of arms
-damage to corticospinal trac at level os the pons or upper medulla
what causes a blown pupil
CN III compression
CN a/w direct and indirect pupillary repsonse
CN II and CN III
CN a/w EOM’s
CN III, IV, VI
CN s/w vestibulo-ocular reflexes
CN VIII, III, VI
CN a/w mastication
CN V
CN a/w corneal reflex
CN V (sensory) and VII
CN a/w cough/gag reflex
CN IX and X
management of ICH/ICP
refer to neurosurgery (decompressive craniectomy)
- maintain O2 sat >90%
- BP; cerebral perfusion pressure >60mmHg
- ICP
leading cause of TBI
falls (esp 65yo+)
linear skull fx
single fracture that most often extends throught the entire thickness of the calvarium
depressed skull fx
traume and drives a segment of the skull below the level of the adjacent skull
-often injury to brain parenchyma
basilar skull fx
at least 1/5 bones that comprise the base of the skull
signs of basilar skill fx
hemotypmanum, raccoon eyes, battle sign, CSF otorrhea or rhinorrhea
most commonly affected bone in basilar skull fx
temporal bone
basilar skull fx at risk for which type of hematoma
epidural hematoma
imaging of choice for suspect skull fracture
noncontrast CT
what is diffuse axonal injury (DAI)
shearing of white matter tracts
-a/w posttraumatic coma
CT of DAI
blurring of gray to white matter margin, cerebral hemorrhages, or cerebral edema
epidural hematoma
a/w skull fracture
- middle meningeal artery
- lucid interval
- lens shaped CT
subdural hematoma
tears of bridging veins
- a/w brain atrophy (elderly and alcholics)
- crescent shape CT
most common type of intracranial hematoma (hemorrhagic or ischemic)
ischemic
a/w “worst HA of my life”
subarachnoid hemorrhage
dx of SAH
CT without contrast!
-if normal and no papilledema->LP (bilirubin peak)
gold standard for detecting intracranial aneurysms
digital subtraction angiography
most common cause of intracerebral hemorrhage
hypertension
ICH management
admit to ICU and emergent neurosurg. consult, same as ischemic CVA (BP control, manage elevated ICP, avoid hyperglycemia keep glucose between 140-180, seizure prophylaxis and treatment)
pts with intraventricular hemorrhage are at risk for what?
hydrocephalus
dx of IVH with neuro deterioration
CT
tx of IVH
ventriculostomy and external ventricular drainage
acute ischemic CVA management
eval for thrombolytic therapy, ASA if not tPA candidate
management if not candidate for IV thombolysis
allow for permissive HTN (no intervention unless SBP >220 or DBP >120
management if candidate for IV thromblysis
target BP
thombolytics inclusion criteria
clinical dx of ischemic stroke, onset of sxs
Head CT scan exclusion criteria (slide 64 FYI but this was highlighted)
multilobar infarction with hypodensity involving >33% of the cerebral hemisphere
initial tx of seizure
immediate ABC’s and IV anticonvulsants (although not indicated during an uncomplicated seizure)
management of eclamptic pt with seizure
emergent OB constult, admin magnesium sulfate
what is a jefferson fx
most common fracture of C1 (atlas)
-caused by axial compression
cause of C2 (axis) fx
forceful flexion or extension
-type I is stable, types II and III unstable
C2 fracture involving both pedicles
hangmans fx
-caused by hyperextension with compression
most common level of disc herniation in the C spine
C6-7
clinical presentation of cauda equina syndrome
urinary retention, radic., BLE weakness, saddle anesthesia, decreased anal sphincter tone
following what type of injury does neurogenic shock usually occur?
after cervical spine injury
signs/sxs of complete spinal cord injury
early->flaaccid paralysis, absent reflexes, priapism
within 1-3days->hyperactive reflexes, +babinski, spasticity
central cord syndrome
- hyperextension injury
- UE motor impairment
- sensory loss or bladder dysfunction
brown-sequard syndrom
- penetration trauma
- ips. loss of motor function, proprioception, and vibration sensation
- contr. loss of pain and temp. sensation
management of CSI
- airway!
- immobilize spine
- imaging
- neuro/spine consult
ventilation impairment based on location of SCI
- complete injury above C3: near total ventilatory muscle paralysis
- injury at C3-5: variable impairment of diaphragmatic strength and accessory muscles of ventilation
- C6 or above (*per notes, but I think it should be below): may compromise resp. function
Guillian-Barre Syndrome
- ascending paralysis that is symmetric
- mild URI or gastroenteritis precedes 1-3 weeks
- progresses over a period of 2 weeks
most common demyelination neuropathy
GBS
dx of GBS
LP-elevated CSF protein without pleocytosis
tx of GBS
admit, neuro consult, high dose IVIG and plasmapheresis
when is imaging indicated if bell’s palsy is in the differential?
Bi involvement/atypical; forehead sparing; hx of trauma
tx of bell’s palsy
steroids and antiviral
which type of meningitis is a neurologic emergency
bacterial
sxs of meningitis
HA, stiff neck, and fever, rash
dx of meningitis
LP with CSF analylsis
tx of meningitis
early IV dexamethasone and abx
encephalitis
- viral infection
- culture of blood AND CSF
- empiric antiviral tx
most common sx of brain abscess
HA
when is LP contraindicated when brain abscess is present
focal sx or signs
definitive dx of brain abscess
brain bx
