What is another name for growing skull fractures ?
leptomeningeal cysts
Iw growing skull fractures, the radiological marker of dural laceration is diastasis of the edges of the fracture of
4 mm
Which symptomatic hormone deficiency is most common after pediatric moderate-to-severe traumatic brain injury?
The most common symptomatic hormone deficiency after pediatric moderate-to-severe TBI is growth hormone deficiency (GHD). Reviews of post-traumatic hypopituitarism consistently identify GH deficiency as the commonest pituitary hormone deficit in children and adolescents after TBI.
A useful nuance for exams: in the acute phase, the most immediately dangerous endocrine problems are ACTH/cortisol deficiency and diabetes insipidus, but the most common symptomatic chronic deficiency is GH deficiency.
So the best single answer is: Growth hormone deficiency.
Which cranial nerve injury is most likely to be associated with transvenous embolization of a cavernous-carotid fistula?
abducens CN 6
What is the most likely appearance of a chronic subdural hematoma on MRI?
Hyperintense on both T1 and T2
A 40 year old male develops left facial droop and left hemiparesis 48 hours after a motor vehicle accident despite initially being neurologically intact after the accident. A non-contrast head CT at the time of deterioration is negative. The most appropriate next diagnostic evaluation is:
CT angiogram of the cervical spine.
A 23-year-old male involved in motor vehicle accident exhibits neurological decline from an initial GCS of 15 to 8, with a neurological exam notable for left hemiparesis and right dilated pupil. What is the most appropriate initial step in management of this patient?
Hypertonic (3%) saline 250 mL bolus.
Intubation and HyperventilationCorrect
Fosphenytoin 15-18 mg/kg IV rapid infusion
Right temporal burr hole placement
Mannitol 1 mg/kg IV bolus.
Intubation and HyperventilationCorrect
A patient initially presents after closed head injury with a GCS of 14. Head CT demonstrates a small amount of pneumocephalus. Two hours later, the patient becomes unresponsive (GCS 4). A repeat head CT is obtained (Fig. 1). What is the most appropriate next step in management?
Lumbar puncture to rule out meningitis.
Treatment with high flow oxygen.
Surgical evacuation of pneumocephalus.
Repeat head CT with fine cuts to identify a basal skull fracture.
Administer 1g/kg of mannitol.
Surgical evacuation of pneumocephalus.
Gas absorption can be facilitated by high flow oxygen but is not appropriate in the setting of acute neurological deterioration. Mannitol and lumbar puncture could exacerbate the scenario.
Decompressive craniectomy has been shown to have what effect in adult patients with severe traumatic brain injury and elevated intracranial pressure (ICP) values that are refractory to first-tier therapies?
Decrease rates of vegetative state Increase mortality Increase number of days in the ICU stay Improved the rate of good outcome as assessed by the Extended Glasgow Outcome Scale at 6 months Reduce ICP
Reduce ICP
There have been two randomized controlled trials assessing decompressive craniectomy in adult patients with severe traumatic brain injury, DECRA1 and RESCUEicp2. The median ICP was found to be decreased in both trials after craniectomy. ICU stay was decreased or similar to medical management with decompressive craniectomy in both trials. In the DECRA study, decompressive craniectomy decreased the numbers of days in the ICU from 18 days to 13 days. In the RESCUEicp trial, there was no evidence of a difference between the groups in the median values of time to ICU death or discharge. Vegatative state rates were increased or similar to medical management with decompressive craniectomy in both trials. In the DECRA trial, the percentage of patients in a vegetative state was increased with 12% in the craniectomy group and 2% in the standard-care group. In the RESCUEicp trial, there was also an increase in the craniectomy group with 6.2% being vegetative vs. 1.7 in the medical group. Mortality rates were found to be similar or decreased with decompressive craniectomy. In the DECRA trial, mortality rates at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%). In the RESCUEicp trial, mortality rates were found to be decreased with 26.9% death among 201 patients in the surgical group versus 48.9% death among 188 patients in the medical group. In the DECRA trial, decompressive craniectomy was associated with a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). In the RESCUEicp trial, the rate of good recovery was 4.0% in the surgical group and 6.9% in the medical group
A 25 year old male is brought to the emergency department after a motor vehicle crash. His blood pressure is low, requiring pressors. His Glasgow Coma Scale score is 5. A ventriculostomy is inserted and his intracranial pressure is found to be 35 mm Hg. What is the most appropriate immediate treatment for lowering his ICP?
Calcium Channel Blocker Hyperventilation CSF Drainage Mannitol Barbiturate Coma
CSF drainage
A 25 year-old man presents after assault with bilateral contusions and subarachnoid hemorrhage. His admission GCS is 4T, and an ICP monitor is placed. ICP steadily increases despite sedation, CSF diversion, hyperosmolar therapy, and hypothermia. What additional non-surgical intervention is most appropriate?
Increase PEEP > 10 mmHg
Acetazolamide
Maintain CPP > 60mmHg
10mg IV dexamethasone
Hyperventilate with goal PCO2 <30mmHg
Maintain CPP > 60mmHg
A 56 year old male suffered severe TBI after a MVA. Has refractory ICP and the decision was made to induce a pentobarbital coma. Which of the following is a potential mechanism of neuropotection from pentobarbital coma?
Decreased cerebral blood volume and decreased cerebral metabolic rate (CMRO2)
Increased intracerebral calcium
Decreased in intracerebral glucose energy store
Free radical scavenging
Increased nitrogen excretion
Decreased cerebral blood volume and decreased cerebral metabolic rate (CMRO2)
1) decrease in cerebral metabolic rate (CMRO2), from decrease in synaptic transmission; 2) decrease in CBV and ICP, due to increase in cerebrovascular resistance; 3) promote or induce hypothermia; 4) increase in intracerebral glucose, glucagon, and phosphocreatine energy store; 5) decrease in nitrogen excretion; 6) shunt blood from regions of normal perfusion to those of reduced CBF; 7) endogenous anticonvulsant function; 8) stabilization of lysosomal membranes; 9) decrease in excitatory neurotransmitters and intracerebral calcium; 10) free radical scavenging (thiopental only
An 18 year old man who was involved in a motor vehicle accident is admitted to the ICU and intubated and sedated on high dose continuous propofol infusion (4mg/kg/h). Ten days later, he is following command in all four extremities. Suddenly, on hospital day 12, he becomes acutely altered. CT head is stable from admission. Laboratory studies reveal a markedly profound hypertriglyceridemia, metabolic acidosis and rhabdomyolysis. Which one of the following is the next step in management?
Propofol infusion syndrome is a rare but potentially fatal complication associated with continuous propofol infusion. The symptoms altered mental status, hyperkalemia, hepatomegaly, lipemia, rhabdomyolysis, hypertriglyceridemia, metabolic acidosis, and kidney failure. If untreated, it can lead to cardiac failure and even death. Although it is first discovered in pediatric population, it can occur in any age. It is associated with high dose and long term propofol infusion use (> 4mg/kg/h over 24 hrs). Treatment is mainly supportive. Early recognition is the key as discontinuing propofol infusion can lead to significant reduction of mobility and mortality. In this scenario, while hemodialysis, CT- angio of chest, and 12 lead EKG with troponin may be possible answers, given that this patient had been on high dose propofol for prolonged time, propofol infusion syndrome should be the top of differential list and therefore propofol infusion should be stopped immediately. The patient has no signs of possible stroke.
A 56 year-old woman presents with diffuse traumatic subarachnoid hemorrhage on CT after a motor vehicle accident. On exam, she is flexor posturing, and initial ICP is 15mmHg. Her CPP is 50mmHg. What management strategy is recommended by the Brain Trauma Foundation Guidelines?
Maintain PCO2 less than 30 mm Hg
Maintain systolic blood pressure above 90mmHg
Maintain a minimum CPP of 60 mmHg
Monitor brain tissue oxygenation
Maintain ICP less than 20 mm Hg
The current Brain Trauma Foundation Guidelines recommends a CPP greater than 60mmHg.
Artificial elevation of CPP to greater than 70mmHg should be avoided due to the risk of ARDS.
ICP should be maintained less than 22mmHg.
Hypotension should be avoided as this may worsen neurological outcome, with more recent guidelines recommending maintaining systolic greater than 100 to 110mmHg depending on the patient’s age.
Hyperventilation to PCO2 to less than 30 mm Hg is not recommended due to risk of cerebral ischemia.
Multimodality monitoring and individualized CPP goals based on the autoregulatory status of the patient is a reasonable approach, but there is currently no formal guideline recommendation.
A 30-year-old male is brought to the emergency department after a motor vehicle crash. His Glasgow Coma Scale score is 13. He begins to have seizure activity in the emergency department and the seizure is continuing after several minutes. What is the pharmacologic treatment of choice for the seizure?
Lorazepam
An open, comminuted, and depressed skull fracture over what region of the dural venous sinus system has the lowest risk of venous infarct?
Posterior 1/3 of the superior sagittal sinus
Right sigmoid sinus
Anterior 1/3 of the superior sagittal sinus
Left transverse sinus
Middle 1/3 of the superior sagittal sinus
Which of the following is the most effective sedative for pediatric trauma with severe traumatic brain injury and increased intracranial pressure?
Thiopental
Dexmedetomidine
Fentanyl
Propofol
Sevoflurane
Fentanyl is the most effective sedative in this patient population. In patients with a severe traumatic brain injury (TBI), inadequate sedation leads to an overactive sympathetic nervous system. This may result in significant increases in intracranial blood volume. After TBI, the brain’s ability to compensate for this increase in blood volume is impaired and the intracranial pressure will rise
A 35 year-old man was found down for an unknown period of time after a generalized seizure. In the emergency department, he complains of pain in his thighs, shoulders, and calves. On exam, he is GCS 14 with confusion, and his imaging shows a small left frontal subarachnoid hemorrhage. Rhabdomyolysis is suspected. What finding is most consistent with this diagnosis?
Myoglobinuria
Hematuria
Normal serum creatinine
Hypokalemia
Normal CPK level
What monitoring modality has the greatest sensitivity for detection of a venous air embolus?
EKG
Pulmonary artery pressure
Precordial Doppler
Pulse oximetry
Transvenous intracardiac echocardiography
The correct answer is transvenous intracardiac echocardiography. The detection sensitivities for venous air embolus (VAE) with transvenous intracardiac echocardiography is as low as 0.002ml/kg.
Furthermore with moderate (2, 5 and 10 ml) VAE, transvenous intracardiac echocardiography image-guided aspiration-catheter manipulation recovered significantly more (34.1% vs. 17.2%, P < 0.0001) intracardiac air than without catheter manipulation.
A patient with a severe closed head injury exhibits a decreasing serum sodium over a 48 hour period to 125 mEq/l. Serum osmolality is diminished, urine sodium is elevated. What parameter is critical to understand in the ensuing management of this patient?
Hematocrit
Urine Osmolality
Blood pressure
Serum potassium
Circulating blood volume
The key parameter used to differentiate between SIADH and cerebral salt wasting, both of whichpresent with hyponatremia and decreased serum osmolality,is** circulating blood volum**e. In SIADH, free water is recaptured in the kidneys via the action of ADH. Thus blood volume is expanded, serum sodium is diluted; urine is concentrated, elevating urine sodium. Treatment requires fluid restriction. Cerebral salt wasting involves the loss of excess sodium in the kidneys thus pulling free water out of the blood with it. Blood volume diminishes with the loss of free water and sodium.
Based on the Guidelines for the Acute Management of Severe Traumatic Brain Injury, in patients with severe head injury, what should the cerebral perfusion pressure (CPP, mmHg) should be maintained between?
10-30
90-110
50-70
70-90
30-50
CPP should be maintained between 50 and 70 mmHg. Normal adult cerebral perfusion pressure (CPP) is >50 mmHg, therefore CPP < 50 mmHg should be avoided.
After a fall, a 20 year old skateboarder is asymptomatic but is found to have a non-displaced fracture involving the petrous portion of the left temporal bone. What is the most appropriate management of this fracture?
Surgical repair.
Steroid therapy.
Conservative management.
Lumbar drainage.
Prophylactic antibiotics.
Asymptomatic basilar skull fractures can be treated conservatively.
A 23 year old male sustains a gunshot wound to the head. On examination, his GCS is 3T, his pupils are bilaterally fixed and dilated, he has a weak gag and cough reflex, and he intermittently draws a spontaneous respiration. His non-contrast head CT demonstrates a transventricular bullet tract and a 3 mm right subdural hematoma. What is the most appropriate management for this patient?
Ventriculostomy
Evacuation of subdural hematoma
Debridement of bullet tract
Decompressive hemicraniectomy
Expectant care
There is little chance for a meaningful survival of gunshot wound victims with this level of GCS, bihemispheric involvement, and transventricular bullet tracts. Expectant care is appropriate even if the patient is not clinically brain dead.
A 50 year old male is admitted to the ICU after a fall from a scaffolding with severe diffuse TBI. ICP and BtpO2 monitors are placed. Despite sedation, pain control and hyperosmolar therapy, ICP remains at 25 mmHg and BtpO2 is 22 mmHg. His PaCO2 is 38 mmHg. The trauma service would like to hyperventilate the patient with a goal PaCO2 30 mmHg. When is hyperventilation indicated?
Within the first 24 hours
When brain oxygen is low
Only in conjunction with barbiturate coma
As temporizing measure
Never
There is no level I evidence regarding the use of hyperventilation. According to the guidelines hyperventilation should only be used as a temporizing measure such as en route to OR or while awaiting other interventions however it should be avoided during the first 24hrs after injury as is can lead to further vasoconstriction and decrease of cerebral blood flow.
