Traumatic Brain Injuries: Diagnosis & Treatment
Intracranial Hemorrhage
TBI: Pathophysiology & Clinical Features
Common Brain Lesions ;)
TBI: Management & Complications
100

Whats the first line imaging modality in patients with TBI?

Head CT w/o IV contrast


Explanation:

Head CT is preferred because it is rapid, accurate, and easily available. Acute hemorrhage appears hyperdense on CT and is better differentiated from normal brain tissue when contrast is not used; contrast causes vascular structures to appear hyperdense and can confound the interpretation. Subsequent contrast enhancement may be helpful to better delineate vascular injury or subacute hemorrhages.



100

ICH is responsible for what percent of strokes (3 guesses, "flat even number" is your hint

  • ICH is responsible for approx. 10% of all strokes. 
100

Whats the difference between primary and secondary brain injuries? 

(Bonus for providing some examples for each)

TBI is categorized pathophysiologically into primary and secondary brain injury depending on whether the brain injury is a direct or indirect result of the inciting trauma.


Primary Brain Injuries: 

  • brain injury that occurs at the time of the trauma as an immediate consequence of head injury


Secondary Brain Injuries:

  • indirect brain injury resulting from physiological changes following acute CNS insults and/or their treatment
100

What type of Amnesia would be caused by Hippocampus injury?

(hint: there are 2 types)

Anterograde Amnesia, so you can't form NEW memories.

100

List at least 3 things recommended for the initial management of TBI's

  • Start primary survey (ABCDE survey) with simultaneous neuroprotective measures. 
    • Additional prehospital trauma care (e.g., spine immobilization, analgesics)
    • Maintain or achieve normoxia, normocapnia, blood pressure control, and euglycemia
  • Measure GCS and pupillary response. 
  • Classify TBI by severity based on GCS.
  • Transfer to a neurocritical care unit if needed. 
  • Diagnostics and imaging (usually noncontrast CT) if indicated
  • Treatment and further management based on severity scores and CT findings
200

What initial measures always take precedence over diagnostics for TBI's?

Neuroprotective Measures

Includes maintenance of Normocapnia, Normoxia, Normotension, Euglycemia

These are a set of measures designed to prevent,and or minimize secondary brain injury in immediate management of patients who have a TBI or a stroke

200

Explain what Intracerebral and Intracranial hemorrhagees are 

Intracerebral hemorrhage (ICH): bleeding within the brain parenchyma


Intracranial hemorrhage: a broad term used to describe any bleeding within the skull (including intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage) due to traumatic brain injury or nontraumatic causes


 Intracranial hemorrhage is a broader term that encompasses bleeding within any part of the skull, i.e., extradural, subdural, subarachnoid, or intracerebral bleeding.

200

Name a couple examples of Primary Brain Injuries

  • Focal primary brain injury
    • Intracranial hemorrhage
      • Epidural hemorrhage (EDH)
      • Subdural hemorrhage (SDH)
      • Subarachnoid hemorrhage (SAH)
      • Intracerebral hemorrhage (ICH)
    • Cerebral contusion: focal area of heterogeneous brain injury, varying from a bruise to a focal area of necrosis
    • Coup-contrecoup injury 
      • Coup injury: injury on the side of an impact
      • Contrecoup injury: additional injury (typically a contusion) on the opposite side of impact 
    • Brain parenchymal lacerations
    • Intracerebral or intracerebellar hematomas
  • Diffuse primary brain injury
    • Mild traumatic brain injury (concussion)
    • Cerebral edema
    • Diffuse axonal injury (DAI)
      • Multifocal shearing tears and disruption of the axons of the brain due to rotational acceleration-deceleration trauma of the head; typically seen in high-impact road traffic accidents.  
      • Commonlynly results in severe neurological injury (e.g., coma, persistent vegetative state) 
200

Someone with a lesion to the Amygdala, would have an (increased/decreased) desire for:

1. Food

2. Intercourse

3. Impulsiveness

1. Hyperphagia: inc desire for food, results in overeating and obesity

2. Hypersexuality

3. Hyperorality: type of impulsiveness that incldues behaviors like excess chewing, lip-smacking, etc.


Kluver-Bucy Syndrome is the term that describes this constellation of symptoms

200

Name at least 2 complications from TBI's

  • Cerebral edema
  • Post-concussion syndrome
  • Coma
  • Seizures 
  • Permanent focal neurological deficits, including persistent vegetative state
  • Acute traumatic coagulopathy
  • Chronic CSF rhinorrhea
  • Intracranial infections
300

Whats the recommended treatment for MILD TBI's (GCS > 13)?

Tx: 

  • Observation in the ED is often sufficient.

Supportive Care/Meds:

  • Nonopioid oral analgesics (e.g., acetaminophen) and antiemetics if necessary (for as short a duration as possible)  


GCS Meaning: A standardized scale used to assess level of consciousness and neurological status. The scale scores the patient's eye response (1–4 points), verbal response (1–5 points), and motor response (1–6 points). A maximum score of 15 points indicates full consciousness, while a minimum score of 3 points can indicate deep coma or brain death



300

What are some symptoms of increased ICP? (name at least 3)

- Vomiting

- Headache (early stage)

- Nausea

- Fixed pupils

- Bradycardia

- Confusion/loss of consciousness


300

Name the 2 main causes of secondary brain injuries

  • Definition: indirect brain injury resulting from physiological changes following acute CNS insults and/or their treatment 
  • Examples: disrupted blood-brain barrier, hypoxic-ischemic encephalopathy 


300

What would a significant injury or lesion to the Red Nucleus result in? (Symptoms)

  • Decorticate posturing (flexor posturing): bilateral flexion of upper extremities and extension of lower extremities
  • Decerebrate posturing (extensor posturing): bilateral extension of upper and lower extremities

The red nucleus is a large mass of gray matter in the upper midbrain that plays a role in motor control and muscle tone maintenance. It's connected to the cerebral cortex, cerebellum, and spinal cord, and its main output is through the rubrospinal tract. 




300

This specific complication of TBI usually occurs ~ 1 week after injury and features excessive sweating, tachycardia, tachypnea, and hypertension

Paroxysmal Sympathetic Hyperactivity (PSH)


Caused by: 

  • Loss of cortical inhibition of the sympathetic system subsequent to acute brain injury → exaggerated sympathetic response to stimulation
400

Whats the recommended treatment plan for MODERATE  TBI's?

Tx:

  • Admission/transfer to neurocritical care unit
  • Neuroprotective measures and ICP management to prevent secondary brain injury
  • If < 3 hours have elapsed since the injury: Consider tranexamic acid (TXA). 
  • Consult neurosurgery and initiate surgical treatment as needed
  • Consider follow-up neuroimaging at 12–24 hours or before discharge  


Supportive Plans:

  • Parenteral analgesics and antiemetics 
  • Monitoring: vitals, GCS, blood glucose, electrolytes, pain, sedation (e.g., RASS)
  • Prevention of secondary bleeding or hematoma expansion (e.g., anticoagulant reversal)
  • DVT prophylaxis 
  • Consider empiric antibiotic therapy (CNS infection prophylaxis)



400

Whats the most common cause of spontaneous ICH generally, and then most common cause of spontaneous ICH in people over the age of 60?


Bonus: if you get most common cause in children

Hypertension: most common cause spontaneous


Cerebral Amyloid Angiopathy: most common cause spontaneous ICH in people over age of 60


Children: Arteriovenous malformations

400

Explain the pathophysiology with which acute CNS injury can cause secondary brain injury

An acute CNS insult can trigger any of the following, resulting in secondary brain injury. 

  • Disruption of physiological (homeostatic) measures
    • Blood-brain barrier disruption, cerebral vasodilation, neuronal depolarization and release of excitatory neurotransmitters → cerebral edema → ↑ ICP
    • Mitochondrial dysfunction → impaired cerebral metabolism → neuronal cell death
    • Stress-induced hyperglycemia → endothelial dysfunction of the cerebral blood vessels → cerebral vasoconstriction or vasodilation → cerebral hypoxia or cerebral hyperemia
    • Loss of cerebral autoregulation of cerebral blood flow→ increased risk of brain injury secondary to critical care measures 
    • Injury to hypothalamus and/or pituitary → neurogenic fever and central diabetes insipidus
  • Initiation of reparative responses: activation of the inflammatory cascade → hyperthermia and hyperglycemia
400

What symptoms would a frontal cord lesion cause? (at least name 2)

  • Contralateral weakness or paralysis of the leg with relative sparing of the arm
  • Disinhibition, impulsivity
  • Impaired concentration, disorientation
  • Primitive reflexes
  • Aphasia (akinetic mutism)
  • Lack of empathy
400

For initial management of TBI, explain the 5 key features of the primary survey (ABCDE)

Airway: C-spine immobilization

Breathing: Oxygenation or ventilation (normoxia)

Circulation: Control BP, bleeding, transfuse

Disability: Neurological exam, pupillary exam, ICP signs

Exposure: avoid hypothermia, assess for other conditions (spinal cord injuries, solid organ injuries, etc.)

500

Name 4 Findings Characteristic of CT Findings in TBI's

1. Intracranial hemorrhage or hematoma: hyperdense lesions (see “Differential diagnosis of intracranial hemorrhage” for a comparison of CT findings)

2. Mass effect

  • Compression of cerebral parenchyma adjacent to hematoma
  • Midline shift to the contralateral side of the hematoma
  • Brain herniation: displacement of brain tissue from one compartment to another  [36]


3. Diffuse axonal injury (DAI): can be normal in mild DAI; multiple punctate hyperdensities indicating small hemorrhages typically at the junction of gray and white matter, brainstem, internal capsule, and corpus callosum  [23][36]


4.Cerebral contusion: heterogeneous lesion (mixed hemorrhagic, necrotic, and edematous tissue) surrounded by cerebral edema [23]


5. Cerebral edema: compression of ventricles, loss of defined sulci and gyri, and effacement of basal cisterns [36]


6. On bone window

  • Evidence of skull fractures: linear, depressed, or basilar skull fractures 
  • Pneumocephalus: air within the cranium; typically associated with an open skull fracture
500

Pathophysiology of NON-traumatic causes of intracranial hemorrhage?

Chronic arterial hypertension:   lipohyalinosis of lenticulostriate vessels (which supply the basal ganglia) and/or formation and rupture of Charcot-Bouchard microaneurysms → lacunar strokes (ischemia) of the basal ganglia

Cerebral amyloid angiopathy: deposition of β-amyloid peptides in vessel walls → focal damage with formation of microaneurysms → rupture → recurrent lobar intracerebral hemorrhage


Structural abnormalities: 

  • exposure of parts of the abnormal vascular segment to excessive strain → rupture


Venous outflow obstruction and stimulant use (cocaine): acute arterial hypertension


Inflammatory tissue necrosis: damage to vessels

500

Explain the site of injury, andoveractive tract differences in Decorticate vs Decerebrate posturing?

Abnormal posturing: characteristic posture of the limbs that typically signifies severe brain injury (most commonly involving the brainstem) 


Decorticate posturing:

- Bilateral flexion of upper extremities and extension of lower extremities

Decerebrate posturing:

- Bilateral extension of upper and lower extremities

Injury Site:

- Decorticate: proximal brainstem

- Decerebrate: distal brainstem or pons 

Tracts Affected:

- Decorticate: Rubrospinal tract and vestibulospinal tract

- Decerebrate: vestibulospinal only


***Best prognosis: 

  • Decorticate posturing is associated with a better prognosis than decerebrate posturing
500

What would a lesion to the ventral pons characteristically present with?

LOCKED IN SYNDROME:

- A neurologic disorder characterized by quadriplegia and bulbar or pseudobulbar palsy with preserved consciousness. Blinking and vertical eye movements are generally preserved. Caused by bilateral damage to the ventral pons, most often due to stroke.


Whats bulbar palsy?

- A lower motor neuron palsy caused by bilateral damage or injury of the nerve nuclei of cranial nerves IX, X, XI, and XII. Clinical features include dysphagia, drooling, anarthria, fasciculations of the tongue, and loss of the gag reflex.






500

Whats the difference between a primary and secondary survey to the initial management of TBI's?

Primary: The primary survey should follow the ATLS algorithm (ABCDE). The goal is to identify and treat any life-threatening conditions and avoid secondary brain injury.


Secondary: An assessment of critically ill or injured patients if they are considered stable after a primary survey. Includes a focused history, more thorough physical examination than the primary survey, and select diagnostic studies (e.g., imaging). Can detect commonly missed injuries (e.g., aortic, rectal, and ureteral injuries).

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