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Concussion
Blunt head injury leading to a brief loss of consciousness (or 'dazed'). Sometimes followed by a transient basic amnesia syndrome that clears within min to hours
- Increased risk of permanent brain damage if further concussions occur in close temporal proximity
- - Post concussion syndrome:
- HA, dizziness, fatigue, sleep disturbance, nausea, vomiting, depression... improves over many months; all better by 1 year
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Cerebral contusion
- Bruise of the brain
- Neurological deterioration in first few days, then improvement. Maximal improvement in ~6 months
- - does NOT cause loss of consciousness-Mechanism: falls
- 1. Coup contusion - at the site of impact
- 2. Contrecoup contusion - remote from site of impact (Frontal lobes, Temporal lobesmost often; regardless of site of impact)
- - old contusions: yellow brown patches ("plaque jaune")
<img src="GFMedia/FE643C19-22E0-4370-8577-01F83336484D-2185-0000022E53DFA90B.png">
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Diffuse axonal injury
- "multifocal", may be microscopic, often asymmetric
- Pathophysiology: blunt head injury at high speed. Rotational velocity of gray/white matter is different --> shear forces on brain
- -gray-white junctions preferentially in Frontal and Temporal lobes, then in corpus callosum and finally dorsolateral midbrain
- Presentation:
Loss of consciousness for min to days; Maximal recovery within 1-2years- +/- hemorrhage
<img src="GFMedia/48B3D882-823B-46D9-BC0E-851AD607EDB0-2185-00000230DDE9020C.png">
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Epidural hematoma
- "classic" presentation: loss of consciousness, lucid interval, subsequentdeterioration, (death)
- - Mechanisms: Falls and assaults. (most often associated w/ temporal or parietalbone fracture that *lacerates the middle meningeal artery*)
Radiograph: "lens-shaped" mass that compresses underlying brain --> herniation
<img src="GFMedia/58DD76AFE27B-4465-8B7F-910BA24BA2F9-2185-00000235E2079289.png">
Tx: most need evacuation (surgery) to avoid expansion
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Glasgow Coma Scale (GCS)
neuro exam for pt w/traumatic brain injury
- GCS 3 - worst possible
- GCS 15 - highest, best possible
-BEST GCS score in first 24 hours provides good measurement of severity and prognosis oftraumatic brain injury IN PATIENTS WITH DIFFUSE AXONAL INJURY
- Other measures:
- - length of time pt is unconscious
- - extent of permanent retrograde amnesia
- - * post traumatic amnesia
- - ***(best) neurological and neuropsychological status after maximal recovery
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Subdural hematoma
- Chronic >> acute (acute acts like epidural hematoma)
- Presentation: mild impact to head... days or weeks later may develop neurological sx (headache, hemiparesis)
- Pathophys: tearing of the bridging veins (that drain to superficial cortical veins --> superiorsagittal sinus or other).
-expands in the subdural space between the dura and arachnoid: "crescent-like shape"
<img src="GFMedia/C57E2485-DA26-48B5-BD81-72B660B6CBC4-2185-00000239C8C8B240.png">
Risk factors: brain atrophy (more stretch of bridging veins); bleeding disorders
Tx: Most gradually regress, even those that do not often don't require treatment
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Traumatic subarachnoid hemorrhage
- - Blunt head injury (most common); ruptured saccular aneurysm (most feared)
- Clinical: asymptomatic, or sx of meningeal irritation (meningismus)
- -blood in subarachnoid space --> vasospasm (stroke risk in following days/week)
- -can lead to delayed complications: hydrocephalus (often normal pressure hydrocephalus)
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Normal pressure hydrocephalus (NPH)
- Presentation:
- -older individuals
- -large ventricles; NORMAL PRESSURE
- - Cognitive dysfunction
- - Gait disorder
- - urinary bladder dysfunction (later in natural history)
Tx: lumboperitoneal shunt
- problematic: older pts and Alzheimer's pts have enlarged ventricles, cognitive and gaitdisorders...
- -test by large volume LP, see if gait improves
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Trigeminal neuralgia
(syndrome and disorder)
- syndrome: paroxysm (1-2 seconds) of SEVERE stabbing or lancinating pain most often in V2, V3distribution of CNV
- trigger point
- Pathophys: compression of trigeminal nerve near entry zone into the pons by small tortuousbranches of basilar artery
- -arterial pulsation --> demyelination --> cross talk --> syndrome
Tx: antiepileptic drugs carbamazepine and phenytoin (prolong inactivation stage of voltagegated Na channels); gabapentin, baclofen; surgical decompression
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Spinal cord contusion
~coup injury of the brainimpact may be transient or persistent, may be associated with a fracture or dislocation
Spinal shock! initially lasting (up to) weeks. can interfere with evaluation
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Myelopathy
- pathology of spinal cord...
- **most often presents as syndrome of "midline external compression"
chronic onset, side pain and decreased range of motion
increasing compression leads to worsening neurological dysfunction
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Midline external compression
- 1) Loss of proprioception/fine touch
- 2) UMN dysfxn (lower > upper)
- 3) Truncal ataxia
- 4) Neurogenic bladder (sometimes)
dorsal column and corticospinal tract affected due to midline compression from the ventral surface: slipped disc
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Radiculopathy
- nerve root (spinal nerve)
- presentation: shooting pain, somatosensory loss or abnormality (dermatome), lower motorneuron dysfunction (weakness) (myotome)
-herniation of the "x-y" disc compresses the "y" root (i.e. L4-L5 herniation usually compresses the L5 root)
-lumbosacral radicular pain often referred to as "sciatica" (misnomer)
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Lumbar spinal stenosis
Neurogenic claudications
at the level of cauda equina, can lead to syndrome "neurogenic claudications"
- Presentation: pain, numbness that arises **with walking, resolved with rest
- -peripheral pulses in feet are normal
- -sx MINIMIZED or gone when exercising with forward flexion at the hips
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Mononeuropathies
- 1. Carpal tunnel syndrome
- 2. Tardy ulnar palsy
- 3. Saturday night palsy
- 4. Peroneal palsy at fibular head
- 5. Meralgia paresthetica
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Carpal tunnel syndrome
chronic compression injury of the median nerve in the carpal tunnel
Pathophys: excessive repetitive movement with prolonged extension or flexion at the wrist
-Tinel's sign: tapping over the carpal tunnel causes neuropathic shooting pain
Dx: nerve conduction studies
Tx: steroid injections, surgical decompression
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Tardy ulnar palsy
- chronic compression injury of the ulnar nerve at or near the ulnar groove (posterior aspect of elbow)
- -nerve conduction studies are the gold standard for diagnosis
Tx: stop leaning on elbows, surgical efficacy is controversial
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Saturday night palsy
acute compression of the radial nerve in the spinal groove at the level of the mid-humerus
- Presentation: awaken from a sleep in which they were sedated (alcohol, drugs, etc.)
- -Weakness of all radial-innervated muscles DISTAL to the triceps
- -somatosensory loss in radial territory of the hand (dorsal hand, lateral to 4th digit, sparing the tips)
- "wrist drop"
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Chronic compression of the common peroneal nerve at fibular head
- Presentation: crossing legs, prolonged squatting and walking forward (strawberry pickers)
- -Neuropathic pain, sensory loss, weakness
- -"foot drop"
peroneal nerve = fibular nerve
somatosensory loss: dorsal aspect of the foot and anterolateral lower leg
weakness of tibialis anterior, peronei, extensor hallucis longus, and extensor digitorum brevis (inversion is OK, eversion is weak)
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Meralgia pareshtetica
chronic compression of the lateral femoral cutaneous nerve in the inguinal region
- **Pure somatosensory loss (anterolateral thigh from groin to knee)
- -often neuropathic pain
- **No weakness
- Risk factors: Excess fluid/tissue (obese, pregnant), tight garmets
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Post lumbar puncture headache
Spontaneous intracranial hypotension
- Up to 10% of all pts who have LP
- -headache comes on shortly after pt arises
- -resolves completely within moments of lying down.
- (headaches resolve within days to 2 weeks)
MRI shows diffuse enhancement of meninges (due to venous dilation)
Tx: conservative, blood patch: injection of blood into epidural site where the spinal tap was done
spontaneous: associated with straining or non-harmful fall
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