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47 Cards in this Set
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The most common cause of severe TBI in infants is ______. a. Child abuse b. Falling down stairs c. Penetrating injuries d. Vehicle collisions |
A. Child abuse. in infants, child abuse and falls account for the majority of brain injuries. Injuries from falling down the stairs can occur but not as frequently as abuse. Penetrating injuries are rare in infants. As children grow older the incidence rates of TBI from vehicle crashes steadily increases |
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Persistent cognitive complaints >3 months post uncomplicated mild TBI are _____.
a. Sufficient to change the diagnosis to complicated mild TBI. b. A reason to follow up with specialized neuroimaging c. Typically representative of factors other than TBI on functioning d. Almost never seen outside of malingering for financial or other gain |
c. Typically representative of factors other than TBI on functioning.
the injury severity is based on the history and medical records, not the course of recovery. While secondary gain and lititgation must be considered in individuals with persistent complaints this is certainly not the only plausible explatation for continued problems. Specialized neuroimaging is contraindicated and if done may sometimes inadvertently reinforce the patient’s erroneous belief that their brain injury is more serious than it actually is |
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In the management of severe TBI in the ICU, the goal is typically to keep ____. a. ICP up and cerebral perfusion down b. Cerebral perfusion up and ICP down c. Both ICP and cerebral perfusion up d. Both cerebral perfusion and ICP down |
B. Cerebral perfusion up and cup down.
cerebral perfusion pressure is calculated by subtracting the ICP from mean arterial pressure (CPP=MAP-ICP). In acute care management the goal is to lower ICP and keep ICP at or around 60-70 Hg to optimize the rate of blood flow to the brain |
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What is true about CTE? a. It often develops in mid to late adulthood when a person has had >2 concussions. b. The build of p-tau in the subcortical areas is fueled by impaired glucose metabolism c. Not all persons with CTE pathology demonstrate a progressive neurodegenerative process d. It is a disease, not a syndrome, and it is unique to those who played violent contact sports |
c. Not all persons with CTE pathology demonstrate a progressive process.
the number or severity of concussions that are definitely sufficient to cause CTE has not been established. Glucose metabolism is unrelated to p-tau distribution. The neuropathology described in CTE is neither universal in those who have played contact sports, nor is it unique to those with such a history. Even when the neuropathology of CTE is present, it may to be clinically progressive in a substantial proportion of persons |
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What is the primary role of neuroimaging in the acute phase following moderate to severe TBI? a. Determine prognosis b. Determine injury severity c. Identify diffuse axonal injury d. Neurosurgical planning |
d. Neurosurgical planning. neuroimaging provides valuable information but its primary role in the acute phase is determining whether neurosurgical intervention is required (eg, epidural or subdural hematoma causing significant midline shift). Initial neuroimaging is sometimes normal in patients who have clearly sustained moderate to severe tbi. Thus, neuroimaging is not used to determine or classify injury severity like GCS, TFC, and PTA. Neuroimaging cannot definitely identify DAI although certain findings are associated with a higher probability of DAI (eg, gliding contusions at the gray-white matter junction, hemorrhages in the corpus callous). At the very severe end of the TBI spectrum certain neuroimaging findings can predict grim prognosis (eg, obliteration of the basal cisterns, large midlife shift with uncle herniation), but this does not apply in most cases |
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Low stimulation protocols are commonly implemented during the acute phases of recovery following moderate to severe TBI primarily to ______. a. Reduce the cerebral metabolic rate b. Lower ICP c. reduce the risk of infection d. Prevent post traumatic seizures |
a. Reduce the cerebral metabolic rate.
even when severly injured the brain will expend energy when exposed to extra stimulation (e.g., noise, bright light, tactile stimuli). Critical care specialists sometimes pharmacologically induce a coma to reduce ICP, achieve a burst-suppression EEG pattern, and reduce cerebral metabolic rate. Low stimulation protocols also result in less sensory processing demands on the individual and thus are priarmily employed to reduce the cerebral metabolic rate |
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Which of the following is most likely to be affected after a moderate to severe TBI in a pre-teen? a. Single word reading b. Oral vocabulary c. Math calculation d. Classroom performance |
d. Classroom performance. answers a, b, c all represent academic skills or abilities that are over-learned in older school-aged children and are thus often more resilient following TBI. In contrast, studies have suggested that declines are frequently seen in classroom functioning, in part because every day school performance is more reliant on abilities that are known to be affected by TBI such as attention, executive control, processing speed, and new learning/memory |
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Following mild tbi in children and adults, PCS persisting beyond a month have been found to benefit most from interventions aimed at: a. diet b. Physical exercise c. School/work scheduling d. Medications |
b. Physical exercise. studies in both children and adults with prolonged symptoms after mild tbi have found that physical exercise that does not worsen symptoms reduce post concussion symptoms in “active rehabilitation” models. Although the other interventions listed may be helpful, exercise has been shown to be the most beneficial |
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Which combination of factors would generally have the most impact on long-term outcomes following TBI in a pediatric patient? a. Injury severity and injury location b. Injury age and injury location c. Injury lateralization and injury age d. Injury severity and psychosocial support |
d. Injury severity and psychosocial support.
increasing severity of tbi is associated with progressively lower probablility of good functional outcomes. Additionally, the degree of psychosocial support available also has a significant influence on long term recovery, especially in children. With some exceptions, injury location is not predictive of long term recovery |
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Compared to acceleration-deceleration brain injury, penetrating brain injury carries a higher risk for ____. a. Edema and infection b. Seizure and infection. c. Seizure and subarachnoid hemorrhage d. Infection and subarachnoid hemmoragte |
b. Seizure and infection. penetrating head trauma typically results in blood-brain barrier compromise and the introduction of foreign matter into brain parenchyma (eg., bullet fragments, bone shards, hair). These factors significantly increase the risk for infection and seizure relative to nonpentrating injuries. |
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What is the brain reserve hypothesis? |
BRH (also called cerebral reserve hypothesis) maintains that there is variability across individuals with regard to resilience and susceptibility to brain injury and/or poor outcomes. Individuals who have a prior history of neurologic illness or injury are at higher risk for complicated outcome following TBI. |
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What is the cognitive reserve hypothesis? |
This is similar to BRH but emphasizes the potentially protective factors of higher premorbid intelligence and better quality of education prior to injury. |
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What is epidural (extradural) hematoma (EDH)? |
Caused by rupture of arteries between the skull and dura. Because of the high pressure in arteries, bleeding into the epidural space can result in a rapidly expanding hematoma that causes compression of brain tissue, which in turn can lead to tensorial herniation and death. Outcome with EDH has a somewhat binomial distribution, with some patients recovering similar to mild tBI if the EDH is evacuated quickly versus high morbidity and mortality if the patient does not receive timely neurosurgical management *blood collects between dura and bone, the result of tearing arteries, particularly the middle meningeal artery, which lies outside the dura and forms a groove in the cranial bone |
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What is considered a severe injury on GCS? |
GCS ranges from 3 to 15. Scores of 8 or less indicate severe injury and scores over 13 are associated with mild injuries. It is common to use the term “complicated mild” with GCS over 13 in the context of positive acute neuroimaging findings. In severe tbi, lower GCS (3 to 5) is clearly associated with increased mortality. |
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Is the GCS good at predicting longterm outcome in TBI? |
No. This is in part because it can be affected by non-brain injury related factors such as intoxication, intubation, patient age, iatrogenic medication, and poly trauma |
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What is the base rate of seizures following non penetrating TBI? |
about 5% and more frequent in children than adults. |
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What are the types of post traumatic seizures? |
1. Immediate occur within 24 hours 2. Early occur within 1-7 days 3. Late occur more than 1 week following injury -regardless, seizures in the first week following non penetrating TBI are not predictive of longterm risk for epilepsy and thus continued anticonvulsant prophylaxis is not typically recommended. |
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What is a significant risk factor for seizure (30-50%)? |
pentrating brain injury and direct injury to the cortex |
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What is a subarachnoid hemorrhage (SAH)? |
Caused by multiple sources including brain injury, cerebral aneurysm, arteriovenous malformation, and high blood pressure, SAH is often associated with poorer longterm outcome in moderate to severe TBI. Generally, when blood directly contacts brain tissue, there are higher risk for complications and worsening secondary injury effects *usually the results of leakage of an aneurysm in the region of Willis |
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What is a subdural hematoma (SDH)? |
caused by rupture of bridging veins between sulci on the upper surface of the brain. In high speed injuries, hematomas are commonly found in the frontal and aneterior temporal lobes due to the skull and brain’s anatomical arrangement. Elderly and pediatric patients are often at higher risk for SDH although for different reasons (ie, widening of the sulk in the elderly versus unique anatomical features of the head, brain, and neck in young children)
*results from tearing the bridging veins that connect the brain and dural sinuses |
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What is time to follow commands? |
refers to amount of time following TBI in which the patient is unable to follow simple motor commands and is unable to maintain arousal or awareness. Also referred to as length of coma but this is problematic for multiple reasons. The assessment of TFC can be challenging because it must take into account the impact of sedation and paralytics. Emergence from a minimally responsive state corresponds to a score of 6 on the motor sub scale of the GCS |
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Depression following moderate to severe TBI in adults is not associated with ____. a. Increased cognitive impairment b. Poor functional outcome c. alcohol use disorders d. Greater initial injury severity |
d. Greater initial injury severity
depression is the most common psychological problem following tbi and occurs in 20-40% of individuals during the first year and up to 50% of the individuals in some stage. Depression can occur at all levels of severity and the prevalence rate does not increase along with injury severity. Risk factors for post TBI depression include minority status, unemployment, low income, low education, and alcohol abuse. Post tbi depression has been linked to the development of increased cognitive impairment, reduced psychomotor speed, and less favorable functional outcome |
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A patient sustains a severe TBI in a high speed motor vehicle collision. At the scene, she is unable to open her eyes, is completely flaccid, and displays no vocalization. The most likely GCS is ____. a. 0 b. 1 c. 3 d. 5 |
c. 3 gcs is a system for determining the degree of impairment in patients through the assessment of eye opening, verbal response, and motor response. In this example, the patient would get a score of 1 in each domain resulting in a gas of 3 (lowest possible score) |
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A patient 3 years post severe TBI completes NP testing. All scores are low average to average. However, collaterals report changes in impulse control, social skills, and disinhibition. Assuming these problems are due to tbi, where might the neuropsychologist reasonably speculate that persistent dysfunction is present? a. Dorsolateral system and its connections b. Prefrontal system and its connections c. Orbitofrontal system and its connections d. Medial frontal system and its connections |
c. Orbitofrontal systems and its connections severe tbi can result in personality, behavioral, and affective changes. However, in the absence of identifiable cognitive impairment the most reasonable conclusion would be orbitofrontal system dysfunction. If there was significant persistent dysfunction in prefrontal, dorsolateral, or medial frontal lobe systems one would expect to identify some level of cognitive impairment as well |
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A teenage patient continues to struggle with school 2 years following moderate TBI. Testing reveals moderate to severe memory impairment but average to low average EF, PS, and VSP. What combination of interventions would have the best chance of resulting in functional gains? a. Restorative skill training and processing efficiency strategies b. Error free learning and compensatory memory strategies c. Self regulation training and compensatory memory strategies d.self regulation training and time management strategies |
b. Error free learning and compensatory memory strategies. compensatory memory strategies, study skill training, and error free learning are all potential approaches with this type of patient. Individuals with moderate to severe tbi often respond more favorably to compensatory memory strategies and error free learning. Restorative therapist have very limited if any value in memory rehabilitation |
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Following TBI problems with initiation are most likely related to damage to the _____. a. DLPFC b. OFC c. Supplemental motor cortex d. Anterior cingulate cortex |
d. Anterior cingulate cortex. the cingulate gyrus is a medial structure that surrounds the corpus callous. Damage to the anterior portion has been associated with mutism, akinesia, and impaired initiation |
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Which of the following represents the most common physical complaints following moderate to severe TBI in adults? a. Dizziness and tinnitus b. Fatigue and sleep disturbance c. Headaches and back pain d. Visual disturbances |
b. Fatigue and sleep disturbances. these 2 symptoms are quite common following tbi at all levels of injury severity. Dizziness, tinnitus, headaches, pain, and visual disturbances also occur but with less frequency |
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What combination of deficits and problems 2 years following severe TBI would most likely predict the poorest community reentry outcome in an adult? a. VSP and moderate PS impairments b. Personality changes and behavioral problems with mild memory impairments c. Moderate attention, verbal memory, and PS impairments d. Moderate language and memory impairments, and moderate depression |
b. Personality changes and behavioral problem with mild memory impairments. although any of these issues would impact community reentry, emotional and behavioral issues following severe TBI tend to result in the poorest outcomes. These problems are often related to impairments in EF. |
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In addition to attention and concentration, direct retraining techniques will most likely generalize to real world tasks in which of the following domains? a. Verbal memory b. Nonverbal memory c. visual scanning d. Language processing |
c. Visual scanning. most direct retraining techniques do not have sufficient evidence to support real world generalization. Possible exceptions include process specific approaches that address cognitive functions such as attention/concentration (in the acute phase of recovery), visual scanning, and spatial organization. The true effects of cog rehab are sometimes uncertain when factoring in natural recovery |
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While playing football without a helmet, a 17 year old is hit on the side of the head. He experiences a brief LOC but recovers in minutes with no residual symptoms. Approximately 30 minutes later, he becomes increasingly confused and lethargic. He is taken to the ED. upon examination, he presents with mild left sided weakness, and a slightly larger, non responsive right pupil. What is the most likely cause of his symptoms? a. Hemorrhagic contusion b. Epidural hematoma c. DAI d. Evolving ischemic infarct |
b. Epidural hematoma. a right sided epidural hematoma is most likely developing resulting in lethargy, confusion, and compression of the 3rd cranial nerve which would cause an enlarged pupil on the ipsilateral side. |
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A neuropsychologist has been referred a patient who reportedly sustained a TBI 12 months ago. Which combination of information would be most helpful in determining the injury severity? a. GCS, PTA, TFC b. LOC, length of PTA, brain CT c. GCS, length of PTA, first hospital MMSE score d. Brain MRI, length of PTA, extended mental status exam 1 month post injury |
A. GCS, PTA, TFC. injury severity is best determined by GCS, PTA, and TFC not necessarily the initial CT scan or MMSE because CT can be negative in moderate to severe TBI and acute mental status can be affected by multiple non brain injury related issues. Additionally, cognitive and functional outcome from moderate to severe TBI is variable and can be influenced by multiple factors. Thus, test scores do not always directly correlate with the severity of injury. It should also be noted that GCS and TFC can be negatively affected by a variety of non-TBI related factors and thus length of PTA tends to be a better overall indicator with regard to injury severity. Radiologic studies are central in differentiating between complicated and uncomplicated mild TBI. |
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A 25 year old presents with aphasia 8 months after a severe TBI. The most likely mechanism of injury was a ____. a. Slip and fall b. Bicycle crash c. Gunshot wound d. Sports collision |
c. Gunshot wound. language disorders can occur in the acute stage of recovery following TBI due to acceleration-deceleration type injury but they rarely continue long term. On the other hand, penetrating injuries often result in focal or more circumscribed impairments. |
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Which of the following is an uncommon emotional-behavioral complication following moderate to severe TBI in children? a. depression b. ADHD c. Mania d. Anxiety |
c. mania. both mania and psychosis are fairly uncommon complications following tbi |
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On the Wechsler intelligence tests the index score that is most likely to show decline following TBI is _____. a. Verbal comprehension b. Perceptual reasoning c. Working memory d. Processing speed |
d. Processing speed. tests that tap processing speed tend to be among the most sensitive to changes following TBI. Although verbal comprehension and perceptual reasoning scores might decline due to focal injuries causing aphasia or visuospatial impairment it is much more common to observe declines in processing speed and the executive aspects of attention due to diffuse impact of TBI |
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Following moderate to severe TBI, the release of which of the following would be considered excitotoxic? a. glutamate b. GABA c. dopamine d. Cortisol |
a. Glutamate. this one is the only potential tbi related excitotoxic agent listed. |
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After examining a 28 year old male 4 years post moderate TBI, the neuropsychologist notes that scores for story and visual memory are average but list learning scores are consistently very low. Assuming adequate test engagement, the most likely explanation for this finding is that the patient _____. a. Has more intact right posterior hemisphere function b. Is experiencing organizational difficulties that affect memory c. Suffers from left sided medial temporal lobe dysfunction d. Is experiencing mild diffuse subcortical dysfunction |
b. Is experiencing organizational difficulties that affect memory. relative to story learning, list learning tasks tend to be more sensitive to the presence of memory dysfunction following tbi. Research suggests that list learning tasks have more organizational requirements which can identify the impact of frontal dysfunction on memory. An individual with medial temporal lobe dysfunction would be expected to display impairments on both list learning and story memory tasks. |
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What can be said with regard to cognitive restituion/restorative training methods following TBI? a. They outperform compensatory strategy training in all phases following injury b. They have lasting benefits primarily in the recovery of simple attention skills c. They have limited empirical support at any phase and typically do not generalize d. They are typically only efficacious in addressing prospective memory skills |
c. They have limited empirical support at any phase and typically do not generalize. cognitive restitution training methods have limited empirical support, especially as the time since injury increases |
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Brain injury during which of the following school years confers the most risk for a poor outcome? a. preschool b. Elementary school c. Middle school d. High school |
a. Preschool. children who sustain tbi during infancy and early childhood have worse neuropsychological and functional outcomes than those injured in later childhood or the teenage years |
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The risk for decline in previously mastered daily living skills 5 years post every TBI is greatest in which of the following groups? a. Young children b. adolescents c. Young adults d. Middle aged adults |
d. Middle aged adults. although severe tbi would be expected to result in cognitive impairments in all 4 groups, children, adolescents, and young adults would be expected to experience some progressive functional improvements. Middle aged adults would be at higher risk for early onset dementia following severe tbi and thus functional decline |
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Following acceleration-deceleration TBI, neuroimaging is most likely to reveal lesions in ____. a. Temporal and parietal areas b. Frontal and subcortical areas c. Temporal and subcortical areas d. Frontal and temporal areas |
d. Frontal and temporal areas. fronttemporal subdural hematomas, subarachnoid hemorrhage, and focal contusions are much more common following acceleration-deceleration injuries |
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Rupture of bridging veins between sulk on the upper surface of the brain causes ____. a. Subarachnoid hemorrhage b. Intracerebral hemorrhage c. Epidural hematoma d. Subdural hematoma |
d. Subdural hematoma. rupture of bridging veins between sulk on the upper surface of the brain causes subdural hematoma. A subarachnoid hemorrhage occurs when there is a rupture in blood vessels between the arachnoid and pia. An intracerebral hemorrhage (also called intraparenchymal hemorrhage) lies within the brain parenchyma due to many potential causes. Epidural hematomas develop in the potential space between the dura and the skull |
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A 13 year old boy is accidentally hit on the head with a baseball bat. He is knocked unconscious and taken to the emergency room. Ct scan reveals a concave hyper density in the left frontal epidural space, with mild mass effect evidenced. Which of the following likely occurred? a. Tearing of the left uncinate fasciculus b. Rotational acceleration and deceleration injuries c. Impact of the brain over bony skull prominences d. Laceration of the middle meningeal artery |
d. Laceration of the middle meningeal artery. epidural hematomas develop I the potential space between the dura and the skull typically due to rupture of the meningeal artery following fracture of the temporal bone. |
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A 70 year old woman is referred for assessment 2 months following a fall down her basement steps. Injury parameters indicate mild injury (GCS-15, LOC-<1 min, PTA-1 hour). NP testing reveals moderate VSP impairments and evidence of mild left hemispatial inattention. Based on these findings, what type of pathology should be ruled out? a. Slowly developing subdural hematoma b. Local seizure activity in the right hemisphere c. Lacunar infarction in the right hemisphere d. Ocular disturbances impacting visual acuity |
a. Slowly developing subdural hematoma. in this case the clinician would want a ct of the brain to rule out the possibility of a right sided subdural hematoma. This occurs more frequently in the elderly population following tbi secondary to stretching of bridging veins, which are often a consequence of atrophy but older veins are also more prone to shearing effects or rupture. Another less likely possibility would be recent or remote right hemisphere stroke and ct scan would most likely identify this as well. Answer c is not a viable option as a remote lacunar infarct would have a low probability of resulting in this type of profile |
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What are primary and secondary injuries in TBI? |
primary injuries occurring immediately after the injury and secondary injuries occur days to weeks after injury |
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What are examples of primary and secondary injuries in TBI? |
primary - occur due to impact and results from linear and/or rotational forces. Ex: skull fracture, contusion, subarachnoid hemorrhage, and mechanical injury to axons and blood vessels. DAI tends to be most prominent at the gray-white matter junctions secondary - happens from cascade of events that occur after brain tissue is injured or from consequences of extra cerebral events. Ex: hypoxia, ischemia, swelling/edema, hypotension, mass lesions, ICP, poor cerebral perfusion pressure. Secondary injuries can be gradual or accelerate quickly if not properly managed |
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When is MRI more reliable than CT in identifying structural changes in TBI? |
>3 months. MRI also correlates better with longer term outcomes |
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When is it appropriate to administer a brief NP exam to establish baseline and assist with rehab treatment and discharge planning? |
When the patient demonstrates measureable level of continuous memory for 2-3 continuous days. Brief NP battery administered 1 month following complicated midl to severe TBI (regardless of PTA resolution) provides incremental value and is predictive of outcome above and beyond functional and injury severity variables |
