Page 771 - TNFlipTest

Toronto Notes 2019 Neuro-Oncology
Investigations
• neurologicalexamtoidentifyfocalneurologicdeficits • neurocognitiveassessment
■ simple orientation questions are inadequate to detect cognitive changes ■ initial assessment of severity is determined by Glasgow Coma Scale
◆ mild: 13-15, moderate: 9-12, severe: 3-8
■ sideline evaluation: Standardized Assessment of Concussion, Westmead Post-Traumatic Amnesia
Scale, Sport Concussion Assessment Tool • neuroimaging
■ x-ray of skull: not indicated for routine evaluation of mild TBI
■ CT head as indicated by Canadian CT Head Rules
■ MRI not indicated in initial evaluation – indicated in presence of continued or worsening symptoms
despite normal CT
Treatment
• observationforfirst24haftermildTBIinallpatientsbecauseofriskofintracranialcomplications • emergencydepartmentforassessmentifanylossofconsciousnessorpersistentsymptoms
• hospitalizationwithnormalCTifGCS<15,seizures,orbleedingdiathesis;orabnormalCTscan
• earlyrehabilitationtomaximizeoutcomes
■ OT, PT, SLP, vestibular therapy, driving, therapeutic recreation • pharmacologicalmanagementofheadaches,pain,depression
• CBT,relaxationtherapy
• followReturntoPlayguidelines(www.thinkfirst.ca)
Prognosis
• mostrecoverfrommildTBIwithminimaltreatment,butsomeexperiencelong-termconsequences
• patientswithapreviousconcussionareatincreasedriskofsubsequentconcussionandcumulative
brain injury
• repeatTBIcanleadtolifethreateningcerebraledema(controversiallyknownassecondimpact
syndrome) or permanent impairment
• sequelaeinclude:
■ post-concussion syndrome: dizziness, headache, neuropsychiatric symptoms, cognitive impairment (usually resolves within weeks to months)
■ post-traumatic headaches: begin within 7 d of injury
■ post-traumatic epilepsy: approximately 2% risk of epilepsy post-mild TBI, prophylactic
anticonvulsants not effective
■ post-traumatic vertigo
Neuro-Oncology
Paraneoplastic Syndromes
• seeEndocrinology,E49
Tumours of the Nervous System
• seeNeurosurgery,NS11
Movement Disorders
Function of the Basal Ganglia
• thecerebralcortexinitiatesmovementviaexcitatory(glutamatergic)projectionstothestriatum,which then activate two pathways: direct and indirect
■ direct: cortex activates the thalamus allowing movement
■ indirect: inhibits the thalamus and ultimately prevents movement
Neurology N29
Canadian CT Head Rule
Lancet 2001;357:1391-96
CT Head is only required for patients with minor HI with any one of the following High Risk (for neurological intervention)
• GCS score <15 at 2 h after injury
• Suspected open or depressed skull fracture • Any sign of basal skull fracture
(hemotympanum, “raccoon” eyes, CSF
otorrhea/rhinorrhea, Battle’s sign) • Vomiting ≥2 episodes
• Age ≥65 yr
Medium Risk (for brain injury on CT)
• Amnesia before impact >30 min (i.e.
cannot recall events just before impact)
• Dangerous mechanism (pedestrian struck by MVC, occupant ejected from motor
vehicle, fall from height >3 ft or five stairs) Minor HI is defined as witnessed loss
of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15.
NB: Canadian CT Head Rule does not apply for non- trauma cases, for GCS<13, age <16, for patients
on Coumadin® and/or having a bleeding disorder, or having an obvious open skull fracture.