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CT finding in cerebral contusion?
Heterogeneous with mixed areas of high and low densityQ
What is Cushing Reflex?
- Cushing reflex classically presents as an increase in systolic blood pressure, reduction of the heart rate (bradycardia), and irregular respirationQ.
- It is caused by increased intracranial pressureQ.
Most common cranial nerves involved in Base of Skull Fractures?
7th or 8th nerve palsiesQ
Treatment of persistent CSF leak?
A delayed craniotomyQ and anterior fossa dural repair is occasionally requiredQ to prevent meningitis
Causes of Secondary Brain Injury
- HypoxiaQ: PO2 <8 kPa
- HypotensionQ: SBP< 90 mmHg
- Raised ICPQ: ICP >20 mmHg
- Low cerebral perfusion pressureQ: CPP <65 mmHg
- Pyrexia (hyperthermia)Q
- Metabolic disturbance (HypergycemiaQ)
Physical signs of uncal herniation?
- Early: ipsilateral dilated pupils, signs of supratentorial mass lesionQ
- – Late: Ipsilateral hemiplegia, progressive ptosis and 3rd nerve palsy, Cheyne-stokes respirationQ
- – Very late: Quadriparesis, bilateral fixed and dilated pupils, erratic respiration and death
Sequence of compression in uncal herniation?
Ipsilateral 3rd nerve, contralateral brainstem (later) and whole brainstem (eventually) occursQ
Physical signs of central herniation?
- – Early: Erratic respiration, small reactive pupils, increased limb tone and bilateral extensor plantarQ
- – Late: Cheyne-stokes respiration, decorticate rigidityQ
- – Very late: fixed and dilated pupils, decerebrate posturing
Sequence of compression in central herniation?
Upper midbrain (first), pons (later) and medulla (finally)Q
What is Allodynia?
It is a situation in which a non-painful stimulus, once perceived, is experienced as painful, even excruciating
What is Hyperalgesia?
Severe pain in response to a mildly noxious stimulus
What is DAI?
Presence of widespread axonal damage (white matter) in both hemispheres secondary to severe head injuryQ
MC location of DAI?
Lobar white matter at the junction of grey and white matterQ >Corpus callosum >Brain stemPathology
IOC for DAIQ?
MRI (better than CT scan)
Targeted ICP in raised ICP after treatment?
ICP <20 mmHg and CPP 60 mmHgQ
For ICP >20–25 mmHg for >5 min, what are the treatment modalities?
- −−Drain CSF via ventriculostomyQ (if in place)
- −−Elevate head of the bedQ; midline head position
- −−Osmotherapy—mannitolQ 25–100 g q4h as needed (maintain serum osmolality <320Q mosmol) or hypertonic salineQ (30 mL, 23.4% NaCl bolus)
- −−Glucocorticoids—dexamethasone 4 mg q6h for vasogenic edema from tumor, abscessQ (avoid glucocorticoids in head trauma, ischemic and hemorrhagic strokeQ)
- −−SedationQ (e.g., morphine, propofol, or midazolam); add neuromuscular paralysis if necessary (patient will require endotracheal intubation and mechanical ventilation at this point, if not before)
- −−HyperventilationQ—to PaCO2 30–35 mmHg
- −−Pressor therapyQ—phenylephrine, dopamine, or norepinephrine to maintain adequate MAP to ensure CPP 60 mmHg (maintain euvolemia to minimize deleterious systemic effects of pressors)
Second-tier therapies for refractory elevated ICP?
- a. High-dose barbiturate therapy (“pentobarb coma”)Q
- b. Aggressive hyperventilation to PaCO2 <30 mmHgQ
- c. HypothermiaQ
- d. HemicraniectomyQ
NICE Guidelines for CT in Head Injury?
- 1. GCS < 13 at any point
- 2. GCS 13 or 14 at 2 hours
- 3. Focal neurological deficit
- 4. Suspected open, depressed or basal skull fracture
- 5. Seizures
- 6. Vomiting > one episode
Best predictor of outcome in GCS?
- Motor responseQ
- Patients scoring 3 or 4 have an 85% chance of dying or remaining vegetative, while scores above 11 indicate only a 5-10% likelihood of death
QEtiology and Location of brain abscess?
- Otitis media, mastoiditis - Temporal lobeQ >Cerebellum
- Paranasal sinusitis, dental infections - Frontal lobesQ
- Hematogenous - Parietal lobeQ
Treatment of brain abscess?
- • Surgical drainage + IV antibiotics for at least 6 weeksQ.
- • Multiple small abscesses may be treated medically with antibiotics targeted against organisms
- • Steroids are reserved for cases with significant edema or mass effectQ