Traumatic Brain Injury 1

A 115 yo F is admitted to inpatient rehabilitation after TBI from an unhelmeted motor cycle accident. She was found to have widespread white matter lesions with focal findings within the corpus callosum on MRI. What is the most likely diagnosis?

• Diffuse axonal injury Grade I

• Subdural Hematoma

• Diffuse axonal injury Grade II

• Subarachnoid Hemorrhage

• Diffuse axonal injury Grade III

Answer explanation

Grade I has widespread white matter/axonal damage but no focal findings, Grade II has focal findings, Grade III has damage involving brainstem

What is true regarding penetrating traumatic brain injuries?

• Lower mortality rate compared to non-penetrating

• Greater risk of long-term post-traumatic epilepsy compared to non-penetrating

• Patients who are initially comatose have a favorable prognosis

• 50% of patients with through and through injuries survive

Answer explanation

Also have 15-20% risk of early seizures; 88% mortality rate for those initially comatose, 80% mortality instantly or within minutes for through and through injuries

The term diaschisis is described by which of the following?

• Healthy structures not previously used for a given function are repurposed to do functions for the lesioned area

• Intact axons in damaged areas establish synaptic connections through dendritic and axonal sprouting

• Techniques/new strategies are learned to compensate for deficits

• Lesions at one area of the CNS alter function at other distant areas of the brain where there are connections between the two sites

• Areas of the brain alter their properties in order to subserve a particular function

Answer explanation

The other answers describe unmasking, neuronal sprouting, functional/behavioral substitution, and vicariation

What disorder of consciousness is characterized by resumption of the sleep-wake cycle on EEG?

• Vegetative state

• Coma

• Minimally conscious state

• Full consciousness

Answer explanation

A patient with TBI shows wakefullness and is able to give a thumbs up on command about 30% of the time. What stage of consciousness is he in?

• Permanent vegetative state

• Persistent vegetative state

• Coma

• Conscious

• Minimally conscious state

Answer explanation

MCS = awake and aware but inconsistently reproducible awareness; VS = awake but not aware (verbal or auditory startle but no localization or tracking) persistent = 1 month, permanent - 12 month for TBI, Coma = neither awake nor aware (no spontaneous purposeful movement or ability to localize noxious stimuli)

Patient with MVA TBI presents to the ED but the preferred CT scanner is down. Which neuropsychological assessment would be the best for assessment of brain damage?

• Minnesota Multiphasic Personality Inventory

• Wechsler Adult Intelligence Scale - Revised

• Halstead-Reitan Neuropsychological Battery

• Token Test

Answer explanation

MMPI is for personality, WAISR for IQ, and Token for assessment of aphasias vs normal

Which of the following indicators of demographics and imaging indicate a worse outcome?

• Age < 45, right hemisphere lesion in right handed individual.

• Age >75, left sided lesion in right handed individual.

• Age <25, bi-hemispheric lesion.

• Age > 65, bi hemispheric lesion.

Comatose patient presents with GCS score of 6 is brought into the ED. Careful endotracheal intubation is done as patient may have cervical instability. What should his PO2 and PCO2 goals be in mmHg?

• PO2 100 to 120 & PCO2 28-32

• PO2 65 to 85 & PCO2 14 to 18

• PO2 160 to 180 & PCO2 40 to 44

Answer explanation

normal ABG PO2 80-120 & PCO2 35 to 45

An intubated TBI patient in the ICU starts to have more prolonged episodes of hypotension, bradycardia and bradypnea with apneic episodes. What is not a possible reason?

• The benzodiazepines used for agitation are scheduled too closely, resulting in increasing toxicity

• The patient's ICP is rising and thus causing herniation compressing the brainstem

• The propofol infusion is set too rapid, resulting in compounding adverse effects

What FIM level is associated with "cueing, coaxing, and prompting"?

• 4: Minimal Assist

• 5: Supervision

• 6: Modified Independent

• 7: Independent

Answer explanation

7: Complete Independence (timely, safe)

6: Modified Independence (Extra Time, devices)

5: Supervision (cueing, coaxing, prompting)

4: Minimal Assist (performs 75% or more of task)

3: Moderate Assist (performs 50% -74% of task)

2: Maximal Assist (performs 25%-49% of task)

1: Total Assist (performs <25% of task)