TCP Week 5 - Head and Spine Trauma

What are the two broad mechanisms of traumatic brain injury (TBI)?

Blunt trauma and penetrating trauma.

Why is traumatic brain injury clinically important?

TBI is a significant cause of morbidity and mortality, especially in young adults.

In what settings are head injuries frequently encountered?

Polytrauma; high-velocity injuries; falls from height; and falls in older adults.

Approximately what proportion of head injuries are mild?

More than 80% of head injuries are mild.

What are the two phases of traumatic brain injury described in the lecture?

Primary traumatic brain injury and secondary traumatic brain injury.

What is the central assessment principle in a brain-injured trauma patient?

Use the Glasgow Coma Scale together with a systematic neurologic assessment.

What GCS score is classified as severe head injury on the main lecture slide?

GCS 8 or less.

What GCS score is classified as moderate head injury on the main lecture slide?

GCS 9-13.

What GCS score is classified as mild head injury on the main lecture slide?

GCS 14-15.

What alternate GCS severity ranges appear on the GCS table in the presentation?

Minor brain injury 13-15; moderate brain injury 9-12; severe brain injury 3-8.

What does GCS-P add to the traditional Glasgow Coma Scale?

It incorporates pupillary changes to add information about severity and prognosis.

What does the letter T indicate when documenting the verbal component of GCS?

The patient is intubated or has a tracheostomy, so the verbal response cannot be normally assessed.

What are the three components of the Glasgow Coma Scale?

Eye opening, verbal response, and motor response.

What is the maximum possible Glasgow Coma Scale score?

15.

What is the minimum possible Glasgow Coma Scale score?

3.

What GCS eye-opening score is given for spontaneous eye opening?

4 points.

What GCS eye-opening score is given when the eyes open to verbal command, speech, or shouting?

3 points.

What GCS eye-opening score is given when the eyes open to pain?

2 points.

What GCS eye-opening score is given when there is no eye opening?

1 point.

What GCS verbal score is given for an oriented patient?

5 points.

What GCS verbal score is given for confused conversation with the ability to answer questions?

4 points.

What GCS verbal score is given for inappropriate but discernible words?

3 points.

What GCS verbal score is given for incomprehensible sounds or speech?

2 points.

What GCS verbal score is given for no verbal response?

1 point.

What GCS motor score is given when the patient obeys commands for movement?

6 points.

What GCS motor score is given for purposeful movement or localization to a painful stimulus?

5 points.

What GCS motor score is given for withdrawal from pain?

4 points.

What GCS motor score is given for abnormal flexion or decorticate posturing?

3 points.

What GCS motor score is given for extensor or decerebrate posturing?

2 points.

What GCS motor score is given for no motor response?

1 point.

How should the neurologic examination progress in a trauma patient?

Use a systematic approach beginning with higher functions and progressing to simpler functions such as reflexes.

What musculoskeletal or neurologic abnormalities should be identified during the trauma neurologic examination?

Tenderness, edema, bruising, spasm, clonus, weakness, tone abnormalities, sensory deficits, and abnormal reflexes.

What motor findings should be emphasized during a neurologic examination for head or spine trauma?

Strength testing of major extremity muscle groups and assessment of muscle tone.

What sensory modalities should be examined after head or spinal trauma?

Touch, pain, vibration, and proprioception, evaluated by dermatomes when appropriate.

What spinal cord localization findings should be sought during the neurologic examination?

A sensory level, lateralizing signs, abnormal or absent deep tendon reflexes, and altered rectal tone.

What head findings should be assessed during the HEENT trauma examination?

Bruising, lacerations, raccoon eyes, and bruising behind the ears.

What ear findings suggest significant head trauma or a skull-base injury?

Blood behind the tympanic membrane and CSF leakage.

What eye findings should be assessed after head trauma?

Pupil size, equality, reactivity, and fundoscopy for retinal hemorrhage.

What nasal findings should be assessed after head trauma?

CSF leakage and bleeding.

What is a traumatic subdural hematoma?

A traumatic collection of blood beneath the dura, described in the lecture as having a convex appearance.

What vessel type is classically injured in a traumatic subdural hematoma?

Bridging veins.

Which age groups are particularly associated with subdural hematoma in the lecture?

Infants and older adults.

What are the two temporal presentations of subdural hematoma?

Acute and chronic.

What are common symptoms of a subdural hematoma?

Progressive headache, weakness, seizure, and alteration in level of consciousness.

Why are antiepileptic drugs often used in acute subdural hematoma?

Acute subdural hematoma is highly epileptogenic.

What imaging findings may accompany a large traumatic subdural hematoma?

Intraparenchymal contusion, cerebral edema, mass effect, and midline shift.

What thickness threshold is a surgical indication for traumatic subdural hematoma in the lecture?

Greater than 1 cm in thickness.

What midline-shift threshold is a surgical indication for traumatic subdural hematoma?

Greater than 0.5 cm, or 5 mm, of midline shift.

What is the definitive surgical approach for a large acute traumatic subdural hematoma?

Craniotomy with evacuation of the hematoma.

What less invasive procedure is commonly used for chronic subdural hematoma?

Burr-hole drainage.

What factors influence the choice between burr holes and craniotomy for a subdural hematoma?

The surgical lesion, patient age and comorbidities, chronicity, and size of the hematoma.

How can an acute-on-chronic subdural hematoma appear clinically or radiographically?

A mixed-age collection with cerebral edema, marked mass effect, and significant midline shift.

What is traumatic subarachnoid hemorrhage (tSAH)?

Traumatic bleeding into the subarachnoid space, usually in the sulci or near the cortical surface adjacent to the traumatic insult.

How common is traumatic subarachnoid hemorrhage according to the lecture?

It is described as the most commonly seen TBI, with about 35% incidence and a reported range of 11%-60% of traumatic brain injuries.

What small vessels are commonly injured in traumatic subarachnoid hemorrhage?

Small capillaries and veins near the cortical surface.

How can a cerebral contusion cause traumatic subarachnoid hemorrhage?

Blood can directly extravasate from an adjacent cerebral contusion into the subarachnoid space.

What vascular mechanisms can produce traumatic subarachnoid hemorrhage?

Arterial dissection, direct damage to small veins or arteries, or sudden increased intravascular pressure causing rupture.

How does the clinical presentation of traumatic SAH compare with traumatic SDH?

It is similar to traumatic SDH but generally less severe.

How is most traumatic subarachnoid hemorrhage managed?

Nonsurgically.

Are antiepileptic drugs routinely required for traumatic SAH?

Often no; traumatic SAH is less epileptogenic than acute subdural hematoma.

What is the usual prognosis of isolated traumatic SAH in the lecture?

Good.

What should blood near the basal cisterns raise concern for?

A vascular event such as aneurysmal subarachnoid hemorrhage rather than a purely cortical traumatic bleed.

What is a traumatic epidural hematoma?

Bleeding outside the dura but trapped between the dura and the skull or suture lines.

What type of space contains an epidural hematoma?

A false or potential space between the skull and dura.

What is the typical imaging shape of an epidural hematoma?

Lens-shaped.

Why is an epidural hematoma constrained on imaging?

The collection is trapped by the skull and suture lines.

What fracture is commonly associated with an epidural hematoma?

An occult skull fracture.

Which age group is more commonly affected by epidural hematoma?

Younger patients more than older patients.

What is the usual source of bleeding in a traumatic epidural hematoma?

Arterial bleeding from rupture of the middle meningeal artery or one of its branches.

What is a lucid interval in epidural hematoma?

Temporary clinical improvement after trauma followed by rapid neurologic decline as the arterial hematoma expands.

Approximately what percentage of epidural hematoma patients have a lucid interval?

About 25%.

Why is untreated epidural hematoma particularly dangerous?

Although less common, it has high morbidity and mortality if not treated.

What antiseizure medication is listed as first-line for epidural hematoma?

Levetiracetam, or Keppra.

What is the definitive treatment for a clinically significant epidural hematoma?

Craniotomy and surgical evacuation.

What general mass-lesion criteria make an epidural or other traumatic hematoma surgical?

A lesion greater than 1 cm thick or producing more than 5 mm of midline shift.

What mechanism commonly produces traumatic skull fractures?

High-velocity head trauma.

How are many uncomplicated skull fractures treated?

Conservatively.

What does a basilar skull fracture imply about the mechanism?

It generally reflects a more severe mechanism of injury.

What is Battle sign?

Bruising over the mastoid or behind the ear associated with a mastoid or skull-base fracture.

What are raccoon eyes?

Periorbital ecchymoses associated with a basilar skull fracture.

What findings may suggest CSF leakage after a skull-base fracture?

Clear fluid from the ear or nose.

What is a depressed skull fracture?

A skull fracture in which a fragment is displaced below the inner table of the skull.

What depressed-skull-fracture threshold is listed on the dedicated fracture slides?

Greater than 1 cm depression of the inner table.

What alternate depressed-skull-fracture surgical threshold appears on the definitive-care slide?

More than 5 mm below the inner table.

What are the surgical indications for a depressed skull fracture listed in the lecture?

Greater than 1 cm depression; an open depressed fracture; or a foreign body causing brain irritation.

What is the definitive treatment for an operative depressed skull fracture?

Craniotomy with elevation of the skull fracture.

What imaging finding may accompany an open depressed skull fracture?

Intracranial air.

Where are traumatic brain contusions commonly located?

The frontal and anterior temporal lobes.

What is the typical pathologic appearance of a brain contusion?

Hemorrhage with surrounding cerebral edema.

What hemorrhage can develop from a brain contusion?

Traumatic subarachnoid hemorrhage.

What neurologic effect can a brain contusion produce?

A broad spectrum of neurologic dysfunction.

How can a brain contusion affect intracranial pressure?

The hemorrhage and surrounding edema may increase ICP.

What is traumatic intracerebral hemorrhage?

Traumatic hemorrhage within the brain parenchyma, often accompanied by edema and neurologic dysfunction.

What is a craniotomy?

Removal of a bone flap that is replaced after the intracranial lesion is treated.

What is a craniectomy?

Removal of a portion of skull that is not immediately replaced.

What is a focal craniotomy?

A smaller craniotomy centered directly over a focal hematoma.

What is a trauma flap?

A large, wide craniotomy used to expose and decompress the injured brain.

What occurs after completion of a trauma flap for EDH or SDH?

The dura may be opened with a durotomy and the mass lesion is removed.

What is definitive surgical care for a large acute traumatic intracranial hemorrhage?

Craniotomy with evacuation of the mass lesion.

What is definitive surgical care commonly used for chronic subdural hematoma?

Burr holes.