Trauma

MCQ PointsPage 10 of 32

Table of Contents1Table of Contents

3Brain Trauma Foundation Guidelines

3Surgical Management of Acute Epidural Hematomas

3Indications for Surgery

3Timing

3Methods

3Surgical Management of Acute Subdural Hematomas

3Indications for Surgery

3Timing

3Methods

4Surgical Management of Traumatic Parenchymal Lesions

4Indications

4Timing and Methods

4Surgical Management of Posterior Fossa Mass Lesions

4Indications

4Timing

4Methods

5Surgical Management of Depress Cranial Fractures

5Indications

5Timing

5Methods

6Post-Traumatic Mass Volume Measurement in Traumatic Brain Injury Patients

7Evaluation of Relevant Computed Tomographic Scan Findings

7Basal Cisterns at the Midbrain Level

7Midline Shift at the Foramen of Monro

7Traumatic Subarachnoid Hemorrhage

8Diffuse Axonal Injury

8Adams Neuropathological Grading / Classification of DAI

8Diffuse Axonal Injury Radiological Grading

8Traumatic Loss of Consciousness

9Grading Systems

9Cantu and Colorado Head Injury Grading Systems

9Cantu's Guidelines for Return to Play after Concussion

9When to Return to PlayColorado Medical Society Guidelines

10COMA

10Breathing Patterns

11Pupils

12ICP

12Compliance and Elastance

13Types of Edema

14Vicious Cycle of ICP

15ICP Waves

16Abnormal Waves

17IIH

17The modified Dandy criteria suggested by Wall

18Key Online Resources for Medicos

20Multiple ring-enhancing lesions of the brain

20Causes of multiple ring-enhancing lesions of the brain

20Differential diagnosis of multiple enhancing lesions of the brain according to the size of the lesions

21Modified diagnostic criteria for neurocysticercosis

21Methods used for establishing the diagnosis in patients with multiple enhancing lesions of the brain

23Algorithm for the differential diagnosis in an immunocompetent patient with multiple enhancing lesions of the brain

24Algorithm for the differential diagnosis in a human deficiency virus infected patient with multiple enhancing lesions of the brain

24Brain Abscess - Stages

25Endoscopy

25Entry Points and Tumour Location

26Radiation

26The Four Rs of Radiobiology

27Stroke

27Cerebral Blood Flow Thresholds

28Code Stroke Algorithm

29Immediate Diagnostic Studies: Evaluation of a Patient with Suspected Acute Ischemic Stroke

30Characteristics of Patients with Ischemic Stroke Who Could Be Treated with Tissue Plasminogen Activator

31Developmental Milestones

31Gross Motor Milestones

31Fine Motor Milestones

32Communication and Language

32Cognitive Milestones

Brain Trauma Foundation GuidelinesSurgical Management of Acute Epidural Hematomas

Indications for Surgery

An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patients Glasgow Coma Scale (GCS) score.

An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center.

Timing

It is strongly recommended that patients with an acute EDH in coma (GCS score < 9) with anisocoria undergo surgical evacuation as soon as possible.

Methods

There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.

Surgical Management of Acute Subdural Hematomas

Indications for Surgery

An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patients Glasgow Coma Scale (GCS) score.

All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.

A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5mmshould undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.

Timing

In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.

Methods

If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

Surgical Management of Traumatic Parenchymal Lesions

Indications

Patients with parenchymal mass lesions and signs of progressive neurological deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on computed tomographic (CT) scan should be treated operatively.

Patients with Glasgow Coma Scale (GCS) scores of 6 to 8 with frontal or temporal contusions greater than 20 cm3 in volume with midline shift of at least 5 mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50 cm3 in volume should be treated operatively.

Patients with parenchymal mass lesions who do not show evidence for neurological compromise, have controlled intracranial pressure (ICP), and no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.

Timing and Methods

Craniotomy with evacuation of mass lesion is recommended for those patients with focal lesions and the surgical indications listed above, under Indications.

Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option for patients with diffuse, medically refractory posttraumatic cerebral edema and resultant intracranial hypertension.

Decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients with refractory intracranial hypertension and diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation.

Surgical Management of Posterior Fossa Mass Lesions

Indications

Patients with mass effect on computed tomographic (CT) scan or with neurological dysfunction or deterioration referable to the lesion should undergo operative intervention. Mass effect on CT scan is defined as distortion, dislocation, or obliteration of the fourth ventricle; compression or loss of visualization of the basal cisterns, or the presence of obstructive hydrocephalus.

Patients with lesions and no significant mass effect on CT scan and without signs of neurological dysfunction may be managed by close observation and serial imaging.

Timing

In patients with indications for surgical intervention, evacuation should be performed as soon as possible because these patients can deteriorate rapidly, thus, worsening their prognosis.

Methods

Suboccipital craniectomy is the predominant method reported for evacuation of posterior fossa mass lesions, and is therefore recommended.

Surgical Management of Depress Cranial Fractures

Indications

Patients with open (compound) cranial fractures depressed greater than the thickness of the cranium should undergo operative intervention to prevent infection.

Patients with open (compound) depressed cranial fractures may be treated nonoperatively if there is no clinical or radiographic evidence of dural penetration, significant intracranial hematoma, depression greater than 1 cm, frontal sinus involvement, gross cosmetic deformity, wound infection, pneumocephalus, or gross wound contamination.

Nonoperative management of closed (simple) depressed cranial fractures is a treatment option.

Timing

Early operation is recommended to reduce the incidence of infection.

Methods

Elevation and debridement is recommended as the surgical method of choice.

Primary bone fragment replacement is a surgical option in the absence of wound infection at the time of surgery.

All management strategies for open (compound) depressed fractures should include antibiotics.

Post-Traumatic Mass Volume Measurement in Traumatic Brain Injury Patients

1. Direct volumetric measurement with imaging software using a modern computer tomographic CT scanner is the gold standard. This has been applied only on rare occasions.

2. The "ellipsoid method" was developed to calculate the volume of arteriovenous malformations. It is based on the concept that the volume of an ellipsoid is approximately one-half of the volume of the parallelepiped (a six-faced polyhedron, all of whose faces are parallelograms lying in pairs of parallel planes) into which it is placed. By measuring three diameters of a given lesion in the arterial phase of an angiogram, a parallelepiped is constructed, and its volume, divided in half, is close to the actual volume of the malformation. By extending this concept from angiography to CT scanning, calculation of space-occupying lesions becomes possible. The "ABC" method has been described by Kothari et al. for the measurement of intracerebral hemorrhages, and is also based on the concept of measuring the volume of an ellipsoid. The formula for an ellipsoid is:

Ve = 4/3 (A/2) (B/2) (C/2)

where A, B, and C are the three diameters. For = 3, the formula becomes Ve = ABC/2

The volume of an intracerebral hemorrhage can be approximated by following the steps listed below:

Identify the CT slice with the largest area of hemorrhage (Slice 1)

A: measure the largest diameter, A.

B: measure the largest diameter 90 to A on the same slice, B.

C: count the number of 10-mm slices.

Compare each slice with slice 1.

If the hemorrhage is greater than 75% compared with slice 1, count the slice as 1.

If the hemorrhage is 25 to 75%, count the slice as 0.5.

If the hemorrhage less than 25%, do not count the slice.

Add up the total C.

3. More recently, the "Cavalieri direct estimator" method has been introduced. It breaks down the lesion on the CT scan into a corresponding number of points. The volume of a lesion is the product of the sum of the points that fall into the lesion, the area associated with each point, and the distance between the scan slices. A grid that is used to determine the number of points can be obtained by photocopying a template provided in the original article or by preparing a uniformly spaced point grid by computer.

Evaluation of Relevant Computed Tomographic Scan Findings

Computed tomographic (CT) scanning is the imaging modality of choice for traumatic brain injury because of its widespread availability, the rapid imaging time, the low associated costs, and its safety. CT scanning measures the density of tissues using x-rays. To standardize the imaging procedure, 5-mm slices should be obtained from the foramen magnum to the sella and 10-mm slices should be obtained above the sella, parallel to the orbitomeatal line. The following early CT scan findings correlate with outcome:

Status of the basal cisterns.

Midline shift.

Subarachnoid hemorrhage in the basal cisterns.

Basal Cisterns at the Midbrain Level

Compressed or absent basal cisterns indicate a threefold risk of raised intracranial pressure and the status of the basal cisterns is related to outcome. The degree of mass effect is evaluated at the level of the midbrain. Cerebrospinal fluid cisterns around the midbrain are divided into three limbs, one posterior and two laterally (Fig. 1). Each limb can be assessed separately as to whether or not it is open or compressed. Basal cisterns can be:

Open (all limbs open).

Partially closed (one or two limbs obliterated).

Completely closed (all limbs obliterated).

Midline Shift at the Foramen of Monro

The presence of midline shift is inversely related to prognosis. However, interaction exists with the presence of intracranial lesions and other CT parameters1. Midline shift at the level of the foramen of Monro should be determined by first measuring the width of the intracranial space to determine the midline ("A"). Next, the distance from the bone to the septum pellucidum is measured ("B") (Fig. 2). The midline shift can be determined by calculating:

Midline shift = (A/2) - B

Traumatic Subarachnoid Hemorrhage

Traumatic subarachnoid hemorrhage occurs in between 26 and 53% of all patients with severe traumatic brain injury. Mortality is increased twofold in the presence of traumatic subarachnoid hemorrhage. The presence of subarachnoid hemorrhage in the basal cisterns carries a positive predictive value of unfavorable outcome of approximately 70%.

Diffuse Axonal Injury

Adams Neuropathological Grading / Classification of DAI Grade I : Axonal Injury of Parasagittal white matter of cerebral hemisphere

Grade II : Grade I + Focal Lesion in Corpus Callosum

Grade III : Grade II + Focal Lesion in Cerebral Peduncle

Diffuse Axonal Injury Radiological GradingCT Finding Grade IGrade IIGrade III (Swelling)Grade IV

Diagnostic CriteriaHematoma > 25 mlNoNoNoNo

Any AbnormalitiesNoYesYesYes

Compression of Brain Stem CisternsNoNoYesYes

Midline Shift > 5 mmNoNoNoYes

Incidence (Overall 56 %)7 %24 %21 %4 %

Mortality Rate (Overall 24 %)10 %14 %34 %56 %

Traumatic Loss of Consciousness < 6 hours : Concussion 6 to 24 hours : Mild DAI Coma > 24 hours without decerebration : Moderate DAI Coma > 24 hours with decerebration or flaccidity : Severe DAI 50 % Mortality

Grading Systems

Cantu and Colorado Head Injury Grading Systems

GradeCantuColorado

Grade ImildNo LOC

PTA < 30 minNo LOC

Confusion w/o amnesia

Grade 2moderateLOC < 5 min

PTA > 30 minNo LOC

Confusion with amnesia

Grade 3severeLOC > 5 min

PTA > 24 hrsLOC

Cantu's Guidelines for Return to Play after ConcussionGradeFirst ConcussionSecond ConcussionThird Concussion

Grade ImildMay return to play if asymptomatic for 1 weekMay return to play in 2 weeks if asymptomatic for 1 weekTerminate season, although patient may return to play next season if asymptomatic

Grade 2moderateMay return to play after asymptomatic for 1 weekMinimum of 1 month out of competition, may return to play then if asymptomatic for 1 week and consider termination of season dependent on symptomsSame as above

Grade 3severeMinimum of 1 month, may return to play if asymptomatic for 1 weekTerminate season, although may return to play next season if asymptomatic

When to Return to PlayColorado Medical Society GuidelinesGrade of Concussion:Return to play only after being asymptomatic with normal neurologic assessment at rest with exercise:

Grade 1 concussion15 minutes or less

Multiple Grade 1 concussions1 week

Grade 2 concussion1 week

Multiple Grade 2 concussions2 weeks

Grade 3brief loss of consciousness (seconds)1 week

Grade 3prolonged loss of consciousness (minutes)2 weeks

Multiple Grade 3 concussions1 month or longer, based on decision of evaluating physician

COMA

Breathing Patterns

Different abnormal respiratory patterns are associated with pathologic lesions (shaded areas) at various levels of the brain. Tracings by chest-abdomen pneumography, inspiration reads up. (A) Cheyne-Stokes respiration is seen with metabolic encephalopathies and with lesions that impair forebrain or diencephalic function. (B) Central neurogenic hyperventilation is most commonly seen in metabolic encephalopathies, but may rarely be seen in cases of high brainstem tumors. (C) Apneusis, consisting of inspiratory pauses, may be seen in patients with bilateral pontine lesions. (D) Cluster breathing and ataxic breathing are seen with lesions at the pontomedullary junction. (E) Apnea occurs when lesions encroach on the ventral respiratory group in the ventrolateral medulla bilaterally.

(From Saper, C. Brain stem modulation of sensation, movement, and consciousness. Chapter 45 in: Kandel, ER, Schwartz, JH, Jessel, TM. Principles of Neural Science. 4th ed. McGraw-Hill, New York, 2000, pp. 871909. By permission of McGraw-Hill.)

Pupils

(From Saper, C. Brain stemmodulation of sensation,movement, and consciousness. Chapter 45 in: Kandel, ER, Schwartz, JH, Jessel, TM. Principles of Neural Science. 4th ed. McGraw-Hill, New York, 2000, pp. 871909. By permission of McGraw-Hill.)

ICPCompliance and Elastance

Types of Edema

Vicious Cycle of ICP

ICP Waves

Abnormal Waves

IIH

The modified Dandy criteria suggested by Wall

1. Signs and symptoms of increased intracranial pressure

2. Absence of localizing neurological findings (Note: abducens paresis is nonlocalizing and, thus, allowed)

3. Absence of deformity, displacement, and obstruction of the ventricular system and otherwise normal results on neurodiagnostic studies, with the exception of an increase in cerebrospinal fluid pressure (greater than 25 cm H2O; pressures between 20 and 25 cm H2O provide less certainty).

4. Wakefulness and alertness

5. No other cause of increased intracranial pressure presentKey Online Resources for MedicosJust point your Mobile / Tablet on this QR Code and you can reach the online resource. (No need to remember lengthy addresses). If QR Reader is not inbuilt in your handheld device, you can download an app for freeGroupSite and URLQR Code

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Multiple ring-enhancing lesions of the brainCauses of multiple ring-enhancing lesions of the brain

Differential diagnosis of multiple enhancing lesions of the brain according to the size of the lesions

Modified diagnostic criteria for neurocysticercosis

Methods used for establishing the diagnosis in patients with multiple enhancing lesions of the brain

Algorithm for the differential diagnosis in an immunocompetent patient with multiple enhancing lesions of the brain

Algorithm for the differential diagnosis in a human deficiency virus infected patient with multiple enhancing lesions of the brain

Brain Abscess - Stages

EndoscopyEntry Points and Tumour LocationLESION LOCATION USUAL ENTRY POINT SUITABILITY FOR ENDOSCOPIC BIOPSY

Anterior third ventricle 1 cm posterior to the coronal suture 2-3 cm lateral to the midline+++

Floor of the third ventricle 1 cm anterior to the coronal suture 2-3 cm lateral to the midline+++

Posterior third ventricle 7 cm posterior to the nasion 2 cm lateral to the midline+++

Anterior lateral ventricle 8 cm posterior to the nasion 4-6 cm lateral to the midline+++

Atrium of the lateral ventricle 8 cm posterior to the midline 1 cm lateral to the midline vs. the superior parietal lobule++

Temporal horn Superior parietal lobule +

Occipital horn 8 cm posterior to the midline 1 cm lateral to the midline+

Fourth ventricle 10 cm posterior to the nasion 2 cm lateral to the midline vs. suboccipital+/0

Radiation

The Four Rs of Radiobiology

CONCEPT RATIONALE

Reoxygenation Hypoxic cells or hypoxemic areas within tumors are relatively more resistant to a given dose of radiation. Dynamic biologic changes within the tumor suggest that cells that are hypoxic during one fraction may be less so during subsequent fractions, and fractionation will thus increase the chances of desired effect on the largest number of cells.

Reassortment A given dose of photons is most likely to irreversibly damage DNA if the cell is in mitosis and the DNA is condensed as chromosomes. Cells that are not in mitosis during one fraction may be so during subsequent fractions, so fractionation will increase the chances of desired effect on the largest number of cells.

Repair The time between fractions allows for repair of sublethally damaged cells before the next dose. This is an advantage for fractionation only if normal tissue in the treatment volume is more efficient at this process than tumor cells, which is usually the case.

Repopulation The time between fractions allows for replacement of lost cells before the next dose. This is an advantage for fractionation only if normal tissue in the treatment volume is more efficient at this process than tumor cells, which may or may not be the case for a given tumor type. Stroke

Cerebral Blood Flow Thresholds

Cerebral blood flow thresholds for critical functions.

(Adapted from Astrup J, Symon L, Branston NM, et al. Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke. 1977;8:51-57.)

Code Stroke Algorithm

Immediate Diagnostic Studies: Evaluation of a Patient with Suspected Acute Ischemic Stroke

Characteristics of Patients with Ischemic Stroke Who Could Be Treated with Tissue Plasminogen Activator

Developmental Milestones

Gross Motor MilestonesMilestonesDevelopmental Implications

Head steady in sitting 2.0Allows more visual interaction

Pull to sit, no head lag 3.0Muscle tone

Hands together in midline 3.0Selfdiscovery

Asymmetric tonic neck reflex gone 4.0Child can inspect hands in midline

Sits without support 6.0Increasing exploration

Rolls back to stomach 6.5Truncal flexion, risk of falls

Walks alone12.0Exploration, control of proximity to parents

Runs16.0Supervision more difficult

Fine Motor Milestones

MilestonesDevelopmental Implications

Grasps rattle 3.5Object use

Reaches for objects 4.0Visuomotor coordination

Palmar grasp gone 4.0Voluntary release

Transfers object hand to hand 5.5Comparison of objects

Thumbfinger grasp 8.0Able to explore small objects

Turns pages of book12.0Increasing autonomy during book time

Scribbles13.0Visuomotor coordination

Builds tower of two cubes15.0Uses objects in combination

Builds tower of six cubes22.0Requires visual, gross, and fine motor coordination

Communication and LanguageMilestonesDevelopmental Implications

Smiles in response to face, voice 1.5Child more active social participant

Monosyllabic babble 6.0Experimentation with sound, tactile sense

Inhibits to "no" 7.0Response to tone (nonverbal)

Follows onestep command with gesture 7.0Nonverbal communication

Follows onestep command without gesture (e.g., "Give it to me")10.0Verbal receptive language

Speaks first real word12.0Beginning of labeling

Speaks 4-6 words15.0Acquisition of object and personal names

Speaks 1015 words18.0Acquisition of object and personal names

Speaks twoword sentences (e.g.,"Mommy shoe")19.0Beginning grammaticization, corresponds with 50+ word vocabulary

Cognitive MilestonesMilestonesDevelopmental Implications

Stares momentarily at spot where object disappeared (e.g., yarn ball dropped) 2.0Lack of object permanence (out of sight, out of mind)

Stares at own hand 4.0Selfdiscovery, cause and effect

Bangs two cubes 8.0Active comparison of objects

Uncovers toy (after seeing it hidden) 8.0Object permanence

Egocentric pretend play (e.g., pretends to drink from cup)12.0Beginning symbolic thought

Uses stick to reach toy17.0Able to link actions to solve problems

Pretend play with doll (gives doll bottle)17.0Symbolic thought

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