الأقوى
Causes of Head injury
- Road traffic accidents
- Blast injury
- Birth injury
- Falling
Diffuse axonal injury (shortnots)
Caused by Shearing Forces that occur when The head is rapidly accelerated.
Can Cause Persistant impairment of Consciousness In the absence of visible brain injuries.
Extra dural Hematoma
Source of bleeding: Middle meningeal artery and vein
Site: Temporal 75%
Clinical Presentation:
Slowly accumulating:
- Stage of concussion
- Lucid interval
- Compression
Rapidly accumulating:
- Compression
- ICP ↑
- Vomiting
- Loss of consciousness
- Lateralization
(Head trauma and spinal)
Indication of observation of depressed Fructus:
- Depression ICH
- Dilated fixed Pupil
- Infection
- Intracranial Hematoma
- Cosmetic deformity
- Frontal sinus involvement
Classification of skull base fructures
Ant. Cranial Fossa Fructure
- CSF rhinorrhea
- CIP Epistaxis + CSF
- Olfactory nerve affection
- Racoon's eye
Mid Cranial Fossa Fructure
- CLP Bleeding Per ear (Otorhea)
- Affection of 7, 8 CN
Post. Cranial Fossa Fructure
- Battle sign
- Brain stem affection
- Ipsilateral conjugate eye deviation
- Hemi Paresis
- Reflex +ve Babinski
In Complete spinal cord injuries
Ant Cord syndrom
- Motor Weakness below level
- Loss Pain & temp sensation
- Preserved deep sensation
Central Cord syndrom
- Lesion in central fibers
- Weakness in UL > LL
Brown-Séquard syndrom
- Spinal Cord Hemisection
- Ipsilateral motor weakness
- Ipsilateral deep sensation loss
- Contralateral loss of Pain & Temp. Sensation
Post. Cord syndrom
- Rare
- Pain in upper C-spine
Mech. spinal injury
- Flexion (most serious)
- Flexion-Rotation
- Flexion-Extension
- Distraction
- Direct-indirect
Management of spinal injuries
- History (Symptom, Pain or any deformity)
- Clinical assessment by ASIA scoring
- General management ABCD
- Immobilization and stabilization
- Radiological investigation CT, MRI
- Conservative
MED ZAGAZIG
مقياس درجة GLASGOW الغيبوبه COMA SCALE
"عباره عن مقياس لدرجه وعي المريض وبيبقي من 15 درجه"
"بنشوف التلت استجابات بتوع المريض ونديله درجه على كل استجابه ونجمعهم"
إصابة خفيفة Mild
13-15
إصابة متوسطة Moderate
9-12
إصابة شديدة Severe/Comatose
<=8
استجابه العين (Visual Response)
- أربع درجات: عينه مفتوحة عادى ع طول (Spontaneously)
- ثلاث درجات: يفتح عينه لما تكلمه (To speech)
- درجتين: يفتح عينه للألم (To pain)
- درجة واحدة: مبيفتحش عينه خالص (No response)
استجابه الكلام (Verbal Response)
- خمس درجات: بيتكلم عادي (Oriented to time, place and person)
- أربع درجات: بيتكلم بسيط ومش عارف هو فين ولا انت مين ولا بيعمل اي هنا (Confused)
- ثلاث درجات: بيقول كلمات مش راكبه ع بعضها مش مترابطه (Inappropriate words)
- درجتين: مبيتكلمش ولكن بيطلع اصوات مش مفهومه (Incomprehensible sounds)
- درجة واحدة: ولا بيتكلم ولا بيطلع صوت (No response)
استجابه الحركه (Motor Response)
- ستة درجات: بيستجيب مع كل حاجه عادي (Obeys commands)
- خمس درجات: بيقدر يحدد مكان الالم (Moves to localized pain)
- أربع درجات: بيبعد عن الالم (Flexion withdrawal from pain)
- ثلاث درجات: بيضم جسمه لما يحس بالوجع (Abnormal flexion decorticate)
- درجتين: بيمدد جسمه لما بيحس بالوجع (Abnormal extension decerebrate)
- درجة واحدة: مبيتحركش خالص (No response)
الأقمن
C/P of Brain tumors
General: ICP ↑ - Headache - vomiting...
Regional:
Frontal lobe tumor
- Contra lateral arm-face Weakness
- Personality Change
- Expressive dysphasia
Parietal lobe tumors
- Disturbed Cortical sensation (Tactile localization, stereognosis)
- Visual Field defect (lower Homonymous Hemianopia)
- Gerstmann's syndrom (Dominant): Acalculia-Agraphia
- Non-dominant hemisphere: sensory or motor neglect.
Temporal lobe tumor
- Epilepsy
- Dysphasia (Receptive)
- Visual defect (upper Homonymous Hemianopia)
Occipital lobe tumors
- Visual defect and hallucination
- Cortical blindness
Suprasellar (Pituitary adenoma)
- Bitemporal Hemianopia
- Hormonal dysfunction
Cerebellar Pontine angle
- Trigeminal: Facial hypesthesia
- Facial: Facial Palsy
- Vestibulocochlear: Tinnitus, Hearing loss and vertigo
Types of Brain Tumors
Gliomas (50% of adult Intra Cranial tumors, Neuro ectodermal origin)
- Astrocytoma
- Oligodendroglioma
- Ependymoma
- Mixed
Meningioma (Most Common benign tumor, arise from arachnoid Cap Cells, Extra-axial tumor, Mostly Solitary)
Pituitary tumors (arise From Ant. Pituitary gland)
Types according to size:
- Microadenoma (<1cm)
- Macroadenoma (>1cm)
Types according to endocrinal Function:
- Hormone secreting
- Non-hormone secreting
Enumerate hormone secreting adenomas:
- GH secreting adenoma
- Prolactinoma
- ACTH Secreting adenoma
- TSH
Medulloblastoma (Most common malignant Pediatric tumor, Primitive neuroectodermal (PNET), Usually arises From Roof of 4th ventricle)
C/P:
- Cerebellar dysfunction
- ICP, Hydrocephalus
- Leptomeningeal dissemination
Nerve sheath tumours (Originate From Schwann cell of the eighth nerve [Most common])
C/P: Hearing loss and vertigo symptoms.
Germ Cell Tumor (occur in the midline especially in Pineal region, Respond to Radio Therapy)
Types:
- Germinoma
- Teratoma
- Embryonal Cell Carcinoma
Investigation of Brain tumors
MRI: golden tool (structure, vascularity, bony detail)
CT: (for bony detail)
Angiography: (For vascularity)
PET/SPECT: (study function)
Lab: Hormones, Markers
Biopsy: Stereotactic Biopsy
Treatment of Brain Tumors
- Surgical excision
- Stereotactic Radiosurgery
- Conventional radiotherapy
- Proton Beam Therapy
- Chemotherapy
- Medical Therapy (e.g., for hormonal dysfunction, neurological deficits)
الأقمى
Degenerative spinal disorder
Cervical disc Prolapse
Commonly affect (C5-C6 & C6-C7)
- If Prolapse Central → Myelopathy
- If Prolapse Posterolateral → Radiculopathy
- If Prolapse Large → Radiculomyelopathy
C/P (Symptoms):
- Neck Pain + brachialgia aggravated by neck motion
- Motor weakness + Parathesia
Signs (of Radiculopathy):
Level
Root Compressed / Sensory Loss / Motor deficit / Reflex Post
C3-C4
C4 / Shoulder tip / Dome / -
C5-C6
C6 / Lateral forearm, thumb, index / Biceps, Brachioradialis / Biceps and Brachioradialis
C6-C7
C7 / Middle finger / Triceps / Triceps
Manifestation of Myelopathy (Cord compression):
- Spastic Quadriparesis
- Hyperreflexia below level of compression
- Clumsiness and ataxia
- Sphincteric disturbance
Lumbar disc Prolapse
Commonly affect (L4-L5 & L5-S1)
- Posterolateral → Radiculopathy
- Central and large → Cauda equina syndrome
C/P (Symptoms):
- Back Pain + Pain relief by flexion of Knee
- Motor weakness + Parathesia
- Bladder symptom
Signs (Sign of Radiculopathy):
Level
Root Compressed / Motor deficit / Sensory Loss / Reflex lost
L3-L4
L4 root / Quadriceps / Medial part of the leg, medial malleolus and medial foot / Impaired Knee Jerk
L4-L5
L5 root / Dorsiflexors of the foot / Lateral part of the leg, Dorsum of the foot & big toe / -
L5-S1
S1 root / Plantarflexors of the foot / Posterior part of the leg, lateral malleolus, lateral foot & sole / Impaired Ankle Jerk
Clinical tests:
- Pain
- Restricted Spinal movement
- Straight leg raising test (if less than 60 degrees)
- Femoral stretch Test
- Tenderness (Paravertebral ms spasm)
Investigation (Cervical + Lumbar)
- MRI: Best diagnostic
- CT: Better in Bony details
- Plain X-Ray: Loss of lordosis, Narrowing of disc space, osteophytes, Instability
Management (Cervical + Lumbar)
Conservative:
- Rest
- Analgesic
- Muscle Relaxant
Indication of surgery:
- Radiculopathic Pain (severe, persistent)
- Progressive neurological deficit
- Signs of Myelopathy/Cauda Equina
Cauda Equina syndrome
Signs of Cauda Equina:
- Pain in back and lower extremity
- Numbness and saddle area hypesthesia
- Weakness and hyporeflexia in lower extremity
- Bowel and urinary incontinence (Late sign)
- Sexual dysfunction
Lumbar spondylolisthesis
Def: Forward Sliding of one vertebrae over the other. (L4-L5 / L5-S1)
This leads to Cord Compression.
Treatment:
Conservative:
- Wt reduction
- Analgesics
Surgical:
- Decompression
- Bony fusion with screws
DR/Mohamed Hossam
الأقمى
Brain abscess
Sources of infection
Direct:
- Infection after Penetrating Cranial injury
- Spread of infection From nearby Structure (Otitis media, Mastoiditis)
Hematogenous:
- Most common site is (Chest)
Common Predisposing factor
- Pulmonary abnormalities (AV Fistula)
- Congenital cyanotic heart disease
Stages of brain abscess formation
Stage
Histologic characteristics
Early cerebritis (days 1-3)
Early infection & inflammation, poorly demarcated from surrounding brain, toxic changes in neurons, perivascular infiltrates
Late cerebritis (days 4-9)
Reticular matrix (collagen precursor) & developing necrotic center
Early capsule (days 10-13)
Neovascularity, necrotic center, reticular network surrounds (less well developed along the side-facing ventricles)
Late capsule (> day 14)
Collagen capsule, necrotic center, gliosis around capsule
C/P of brain abscess
- ICP ↑
- Coma
- In newborn: Cranial enlargement
- Focal neurological deficit
- Meningeal irritation
- Seizures
- Failure to thrive
- Systemic feature of infection (fever, lab infection marker)
Investigation
- Blood Culture
- MRI with contrast (gold standard)
- CT with Contrast (Confirm diagnosis)
Management
- Is a medical emergency
- Drainage or excision of abscess
- Antibiotic (long term IV)
Complication
Neurological deficits, Epilepsy, Recurrence
N.B.: abscess is the only process in the brain that leaves a collagen scar, all other scars are glial scars.
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