Principles and Initial Assessment

Abstract

In this chapter, the questions and answers are intended to cover the following topics in relation to cranial neurotrauma: epidemiology, types of head injury, raised intracranial pressure, cerebral edema, initial assessment, and examination. It will also present key facts on coma, diffuse axonal injury, concussion, herniation syndromes, the systemic response to traumatic brain injury (TBI), and brain death.

• 1. Posttraumatic cerebral edema.

  The FALSE answer is:

  • A. Cytotoxic edema is due to injury of neurons or glia cells.

  • B. Cytotoxic edema occurs across a disrupted blood–brain barrier.

  • C. Vasogenic edema responds to corticosteroids.

  • D. A combination of cytotoxic and vasogenic edema is common.

  • E. The onset of edema is within hours of TBI.

FormalPara Answer B

• Cytotoxic edema occurs across an intact blood–brain barrier and is related to osmotic forces.

• 2. Malignant cerebral edema.

  The FALSE answer is:

  • A. Could follow a gradual course from several days to a week

  • B. Increased cerebral blood volume

  • C. Loss of cerebrovascular autoregulation

  • D. Up to 100% mortality

  • E. More common in adults

FormalPara Answer E

• Malignant cerebral edema is more common in children.

• 3. Posttraumatic cytotoxic cerebral edema.

  The FALSE answer is:

  • A. Water is driven across an intact blood–brain barrier

  • B. Common in brain tumors

  • C. Occurs at gray and white matter

  • D. Steroids are not effective

  • E. Diuretics are transiently effective

FormalPara Answer B

• Cytotoxic cerebral edema does not occur in tumors. Other etiologies include cerebral infarction, meningitis, diabetic ketoacidosis (DKA), and water intoxication.

• 4. Posttraumatic vasogenic cerebral edema.

  The FALSE answer is:

  • A. Blood–brain barrier malfunction

  • B. Common in brain tumors

  • C. Occurs at white matter

  • D. Steroids are not effective

  • E. Diuretics are transiently effective

FormalPara Answer D

• Corticosteroids are effective in vasogenic cerebral edema. vasogenic cerebral edema is also frequently seen in brain tumors, abscesses, infarction, and TBI.

• 5. Cerebral herniation syndromes

  Cushing response. The FALSE answer is:

  • A. Associated with central herniation

  • B. Arterial hypotension

  • C. Bradycardia

  • D. Respiratory irregularity

  • E. Occurs in 33% of cases of intracranial hypertension

FormalPara Answer B

• Cushing’s triad is arterial hypertension, bradycardia, and respiratory irregularity.

• 6. Cerebral herniation syndromes

  Central herniation. The FALSE answer is:

  • A. Downward shift of the brainstem toward the foramen magnum

  • B. Compresses perforating branches of basilar artery

  • C. Compromises the reticular formation in the midbrain and pons

  • D. Associated with Duret hemorrhage in the corpus callosum

  • E. May be associated with Parinaud syndrome

FormalPara Answer D

• Central (axial) herniation causes Duret hemorrhage in the brainstem.

• Duret hemorrhage is a small hemorrhage (or multiple hemorrhages) seen in the medulla or pons of patients with rapidly developping brain herniation rapidly developing brain herniation, especially central herniation. Durent hemorrhage is most commonly seen in patients with severe herniation 12–24 hours prior to death.

• Parinaud syndrome, also known as the dorsal midbrain syndrome, is a supranuclear vertical gaze disturbance caused by compression of the superior tectal plate. Parinaud syndrome is characterized by a classic triad of findings: upward gaze palsy, pupillary light-near dissociation, and convergence-retraction nystagmus.

• 7. Cerebral herniation syndromes

  Subfalcine herniation. The FALSE answer is:

  • A. Herniation of the cingulate gyrus under the falx cerebri

  • B. The most common herniation syndrome

  • C. May result in upper limb monoparesis

  • D. May result in paraparesis

  • E. Compresses pericallosal arteries

FormalPara Answer C

• Lower limb monoparesis. The lower extremity is the most commonly associated with anterior cerebral artery (ACA) syndrome or sometimes the deficit is hemiparesis of lower more than upper limb.

• 8. Cerebral herniation syndromes

  Uncal (trans-tentorial) herniation. The FALSE answer is:

  • A. Uncal and hippocampal herniation into the ambient and crural cisterns

  • B. Caused by mass lesions in the lateral middle fossa

  • C. Causes contralateral hemiparesis

  • D. Causes contralateral oculomotor nerve palsy

  • E. May cause Kernohan’s notch phenomena

FormalPara Answer D

• Uncal herniation causes ipsilateral oculomotor nerve palsy, contralateral paresis, and coma.

• Kernohan’s notch phenomenon is an imaging finding resulting from extensive midline shift due a mass effect, resulting in the indentation in the contralateral cerebral crus by the tentorium cerebelli. Causes hemiparesis that is ipsilateral to the expanding mass which is a false localizing sign.

• 9. Cerebral herniation syndromes

  Tonsillar herniation. The FALSE answer is:

  • A. Prolapse of the cerebellar tonsils through the foramen magnum

  • B. Compresses the midbrain

  • C. Causes hypertension

  • D. Causes bradypnea

  • E. Causes cardiorespiratory arrest and death

FormalPara Answer B

• Tonsillar herniation compresses the medulla oblongata and, in some cases, the upper cervical cord.

• 10. Cerebral herniation syndromes

  Ascending trans-tentorial herniation. The FALSE answer is:

  • A. Also known as reverse herniation

  • B. Cerebellar tonsils ascend through the tentorial hiatus

  • C. Compress the midbrain

  • D. Compress superior cerebellar arteries

  • E. Occurs in posterior fossa masses and exacerbated by ventriculostomy

FormalPara Answer B

• Ascending tenstentorial herniation is the herniation of cerebellar vermis upward through tentorial hiatus.

• 11. Neurological examination in TBI

  Pupils. The FALSE answer is:

  • A. Pons lesion: bilateral pinpoint pupils

  • B. Midbrain lesion: bilateral fixed and dilated pupils

  • C. Medulla lesion: bilateral fixed and dilated pupils

  • D. Occipital lobe lesion: Bilateral fixed and dilated pupil

  • E. Brain death: bilateral fixed and dilated pupils

FormalPara Answer D

• Occipital lobe lesions result in unilateral fixed dilated pupil.

• 12. Neurological examination in TBI

  Horner syndrome. The FALSE answer is:

  • A. Involves the sympathetic pathway

  • B. Indicates carotid dissection

  • C. Represents a postganglionic injury

  • D. Anhidrosis may be absent

  • E. The miotic pupil is the normal one

FormalPara Answer E

• In Horner syndrome, the miotic (smaller) pupil is the abnormal one. Posttraumatic Horner syndrome represents a third-order neuron disorder with injury to the postganglionic neurons at the level of the internal carotid artery. Anhidrosis is usually limited or absent. The Paredrine test helps to localize the cause of the miosis. If the third-order neuron is intact, then the amphetamine causes neurotransmitter vesicle release, thus releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected pupil. If the lesion itself is of the third-order neuron, then the amphetamine will have no effect and the pupil will remain constricted.

• 13. Neurological examination in TBI

  Gaze deviation. The FALSE answer is:

  • A. Irritative frontal lesion: deviation away from the lesion

  • B. Irritative pontine lesion: deviation away from lesion

  • C. Midbrain pretectal lesion: upward gaze palsy

  • D. Medial thalamic hemorrhage: the “wrong way gaze”

  • E. Oculomotor nerve palsy: deviation down and out

FormalPara Answer B

• An irritative pontine lesion will result in eye deviation toward the side of the lesion.

• In supratentorial (frontal lobe) lesions, the deviation is towards the side of a destructive lesion and away from that of an irritative lesion.

• In infratentorial (pontine) lesions, the deviation is toward irritative lesions and away from destructive lesions.

• In median thalamic hemorrhage, the eyes will deviate away from the side of the lesion (wrong gaze palsy).

• Abducens nerve plasy will cause the ipsilateral eye to deviate inwards.

• Midbrain (pre-tectal lesions) are associated with an upward gaze plasy (Parinaud’s syndrome).

• 14. Neurological examination in TBI

  Parinaud’s syndrome etiologies. The FALSE answer is:

  • A. Thalamic lesion

  • B. Midbrain pretectal lesion

  • C. Barbiturates coma

  • D. Seizures

  • E. Tumors of pons

FormalPara Answer E

• Pineal tumors NOT pons.

• 15. Answer A: Respiratory patterns in coma.

  The FALSE answer is:

  • A. Bilateral hemispheric: Cheyne-Stokes

  • B. Thalamus: Kussmaul

  • C. Midbrain: Hyperventilation

  • D. Pons: Apneustic

  • E. Medullary: Ataxic

FormalPara Answer B

• Kussmaul’s breathing is nonspecific and occurs in severe acidosis, as in alcohol ingestion, uremia, and DKA.

• 16. Neurological examination in coma

  The FALSE answer is:

  • A. Arms extend and legs flaccid in decorticate posturing

  • B. Decorticate posturing occurs in large cortical lesions

  • C. Decerebrate posturing occurs in lesions below the lower midbrain

  • D. Arms flexed and legs flaccid in pontine tegmentum lesions

  • E. Decerebrate has a worse prognosis than decorticate posturing

FormalPara Answer A

• Arms flex and legs extend in decorticate posturing.

• 17. Brain death

  The FALSE answer is:

  • A. Absent gag reflex

  • B. Dilated fixed pupils

  • C. Positive occulocephalic reflex

  • D. Absent corneal reflex

  • E. Absent cough reflex

FormalPara Answer C

• Negative (absence) occulocephalic reflex is a sign of brainstem death.

• 18. Caloric testing (oculovestibular reflex)

  The FALSE answer is:

  • A. Records the function of each labyrinth separately

  • B. Can be done with water or air

  • C. Differentiates central from peripheral lesions

  • D. Normal test: eyes deviate toward the cold stimulus

  • E. Abnormal test: eyes deviate away from the warm stimulus

FormalPara Answer D

• Remember COWS (Cold-Opposite, Warm-Same) which represents normal testing. The caloric test will be abnormal in brain death, that is, Cold-Same, Warm-Opposite. The test can be made with ice or warm water which is irrigated inside the external auditory canal. In the absence of tympanic lesions, with the head of bed elevated to 30 degrees.

• 19. The oculocephalic reflex

  The FALSE answer is:

  • A. An application of the vestibular-ocular reflex

  • B. Contraindicated in suspected C-spine injury

  • C. Eyes rotate opposite to head direction: abnormal brainstem function

  • D. Eyes rotate opposite to head direction: normal brainstem function

  • E. A similar examination is performable for vertical eye movements

FormalPara Answer C

• In brain death, there will be loss of brainstem function, meaning that the eyes will move to the same side of head movement.

• 20. Indications for head CT scan within the first hour following TBI.

  The FALSE answer is:

  • A. GCS < 13 on initial assessment

  • B. Posttraumatic seizure

  • C. Suspected depressed skull fracture

  • D. Head injury in patients on warfarin

  • E. Large scalp laceration

• 21. Indications for head CT scan within 8 hours of TBI

  The FALSE answer is:

  • A. Loss of consciousness

  • B. Above 65 years

  • C. History of bleeding disorder

  • D. Dangerous mechanism of injury

  • E. Less than 30 min of retrograde amnesia

FormalPara Answer E

• No criteria for a head CT scan after a brief retrograde amnesia in isolation.

• 22. TBI. Rotterdam CT score

  The FALSE answer is:

  • A. Depressed skull fracture

  • B. Midline shift

  • C. Epidural mass lesion

  • D. Intraventricular hemorrhage

  • E. Subarachnoid hemorrhage

FormalPara Answer A

• Skull fractures are not included in the Rotterdam classification.

• 23. TBI. Rotterdam CT score

  The FALSE answer is:

  • A. Absent cisterns: 2 points

  • B. Normal cisterns: 0 points

  • C. Compressed cisterns: 1 point

  • D. Intraventricular hemorrhage present: 1 point

  • E. Epidural mass lesion present: 1 point

FormalPara Answer E

• The presence of epidural mass equals zero points, while their absence gives 1 point.

• Rotterdam score is aimed at improving prognostic evaluation of patients admitted with acute traumatic brain injuries.

Rotterdam score.

Predictor value	Score
Basal cistern
Normal	0
Compressed	1
Absent	2
Midline shift
No or <5 mm	0
Shift >5 mm	1
Epidural mass lesion
Present	0
Absent	1
Intraventricular blood or tSAH
Absent	0
Present	1
Sum score	+1
tSAH: Traumatic subarachnoid hemorrhage

• 24. TBI. Marshall CT classification

  The FALSE answer is:

  • A. Marshal I: No lesion

  • B. Marshal II: Diffuse injury

  • C. Marshal III: Diffuse injury with swelling

  • D. Marshal IV: Diffuse injury with shift

  • E. Marshal VI: Evacuated mass lesion

FormalPara Answer E

• Marshal V: Evacuated mass lesion. Marshal VI: Nonevacuated mass lesion.

• Marshal classification serves as an outcome prediction tool in TBI patients.

Marshall classification
Classification	Description	Mortality
I	No lesion in CT	6.4%
II - diffuse injury	MLS 0–5 mm Visible basal cisterns No high or mixed density lesions ≥ 25 cma	11%
III - diffuse injury swelling	MLS 0–5 mm Compressed/effaced basal cisterns No high or mixed density lesions ≥ 25 cma	29%
IV - diffuse injury Shift	MLS >5 mm No high or mixed density lesions ≥ 25 cma	44%
V - Evacuated mass lesion	Any lesion evacuated surgically	30%
VI - nonevacuated mass lesion	High or mixed density lesions ≥ 25 cm Not surgically evacuated lesion	34%

1. ^aEstimated volume, may include bone fragments and foreign bodies

• 25. TBI. Multimodality monitoring

  The FALSE answer is:

  • A. Central venous pressure

  • B. Jugular bulb venous oximetry

  • C. Intracranial pressure

  • D. Lactate/glucose ratio

  • E. Brain tissue oxygen tension

FormalPara Answer A

• Central venous pressure is NOT a method of multimodality monitoring in TBI.

• Multimodality neuromonitoring in traumatic brain injury (TBI) includes glycerol, glucose, lactate/pyruvate ratio, lactate/glucose ratio, glutamate, near-infrared spectroscopy, Jugular bulb venous oximetry, intracranial pressure (ICP) monitoring, brain tissue oxygen tension, cerebral perfusion pressure (CPP), pressure reactivity index, and other noninvasive ICP monitoring methods.

• 26. TBI. Multimodality neuromonitoring

  The FALSE answer is:

  • A. Pressure reactivity index: correlation between arterial blood pressure (ABP) and ICP

  • B. Cerebral ischemia in severe TBI decreases the lactate/pyruvate (L/P) ratio

  • C. Jugular bulb venous oximetry: global cerebral oxygenation and metabolism

  • D. Brain tissue oxygen tension: availability of oxygen for oxidative energy metabolism

  • E. CPP is calculated by subtracting mean ICP from mean ABP.

FormalPara Answer B

• Cerebral ischemia and increased anaerobic respiration increase the L/P ratio and relate to poor neurologic outcomes.

• 27. TBI. Cerebral microdialysis

  The FALSE answer is:

  • A. Found after cell injury

  • B. Systemic lipolysis may affect its cerebral levels

  • C. Released from phospholipids following cell membrane degradation

  • D. Low extracellular glucose levels are associated with good outcome

  • E. Reduced CBF (ischemia) may decrease its extracellular concentration

FormalPara Answer D

• Reduced cerebral blood flow (CBF) (ischemia) or increased consumption of glucose may lead to a decrease in glycerol extracellular concentration. Low extracellular glucose levels are associated with poor outcome after TBI.

• 28. Jugular venous oxygen saturation SVJO2

  The FALSE answer is:

  • A. SjVO2 ≥ 55–75%: normal

  • B. SjVO2 < 50%: ischemia

  • C. Multiple desaturations: poor outcome

  • D. Sustained desaturations: evaluate for correctable causes

  • E. High SjVO2 > 75%: good outcome

FormalPara Answer E

• High SjVO2 > 75% may indicate hyperemia or infarcted tissue and is associated with poor outcomes. Other causes of desaturation include increased ICP, poor catheter position, CPP < 60 mmHg, surgical lesions, and PaCO2 < 28 mmHg

• 29. Arterial-jugular venous oxygen content difference (AVdO2).

  The FALSE answer is:

  • A. AVdO2 of 6.5 vol %: normal

  • B. AVdO2 > 9 ml/dl: global cerebral ischemia

  • C. AVdO2 > 4 ml/dl: cerebral hyperemia

  • D. AVdO2 is independent of CBF

  • E. AVdO2 < 4 ml/dl: luxury reperfusion

FormalPara Answer C

• AVdO2 < 4 ml/dl indicates cerebral hyperemia.

• 30. ICP measurement

  The FALSE answer is:

  • A. Mean arterial pressure (MAP) = diastolic pressure + 1/3 pulse pressure

  • B. Normal adult ICP: 7–15 mmHg

  • C. Normal adult CPP is >50 mmHg

  • D. Standing adult ICP of −10 is normal

  • E. CPP has to drop below 70 before CBF would be impaired

FormalPara Answer E

• Due to cerebral autoregulation, CPP has to drop below 40 before CBF if affected.

• 31. ICP monitoring: indications

  The FALSE answer is:

  • A. Severe TBI: GCS ≤ 8

  • B. Normal brain computerized tomography (CT) with drowsiness only

  • C. Multiple systems injury with altered consciousness

  • D. Post hematoma evacuation

  • E. Abnormal brain CT with cerebral edema

FormalPara Answer B

• Normal brain CT with ≥2 of the risk factors for intracranial hypertension (IC-HTN) is an indication of ICP monitoring. Add risk factors.

• Up to 50% of patients who subsequently develop increased ICP may have a normal admission head CT scan. In these patients, an ICP monitor is recommended if two or more of the following are present at admission: age >40 years, unilateral or bilateral motor posturing, or episodes of systolic blood pressure <90 millimeters of mercury (mmHg).

• 32. ICP monitoring devices

  The FALSE answer is:

  • A. Intraparenchymal monitor is the most accurate.

  • B. EVD allows CSF drainage.

  • C. EVD must be maintained at a fixed reference point.

  • D. In subarachnoid bolt, high ICP causes false low readings.

  • E. Open anterior fontanelle can be used in infants.

FormalPara Answer A

• Intraventricular catheter (IVC): also known as (AKA) external ventricular drain (EVD) is the most accurate device for ICP monitoring.

• 33. ICP monitoring devices: Intraventricular catheter (IVC)

  The FALSE answer is:

  • A. Can be used in children

  • B. Utilizes transducers tipped with fiber optic devices

  • C. Is the most accurate

  • D. Can not be recalibrated

  • E. Allows CSF drainage

FormalPara Answer D

• IVC has the lowest cost. It is the most accurate and can be recalibrated to minimize measurement drift.

• 34. Secondary Intracranial Hypertension: Causes

  The FALSE answer is:

  • A. Hyperventilation

  • B. Delayed hematoma formation

  • C. Cerebral vasospasm

  • D. Delayed edema formation

  • E. Hyponatremia

FormalPara Answer A

• Hyperventilation is not a cause of secondary IC-HTN. Hypoventilation can be a cause of secondary IC-HTN. A secondary increase in ICP is sometimes observed 3–10 days following the trauma.

• 35. ICP waveforms

  The FALSE answer is:

  • A. Can be used to predict raised ICP

  • B. Respiratory variations affect normal waveforms

  • C. Plateau waves: ICP elevations ≥30 mmHg for 5–20 minutes

  • D. Abnormal B wave lasts for 30 seconds–2 minutes

  • E. Low-amplitude C waves are sometimes normal

FormalPara Answer C

• Plateau waves occur when ICP is ≥50 mmHg for 5–20 minutes.

• 36. ICP waveforms

  The FALSE answer is:

  • A. Type A wave is synonymous with Traube–Hering waves.

  • B. Normal ICP waveforms are small pulsations transmitted from the systemic blood pressure into the intracranial cavity.

  • C. The large (1–2 mmHg) peak corresponds to the arterial systolic pressure wave, with a small dicrotic notch.

  • D. The central venous “A” wave is from the right atrium.

  • E. Expiration causes ICP elevation.

FormalPara Answer A

• Type C wave is also known as Traube–Hering waves.

• 37. ICP waveforms

  The FALSE answer is:

  • A. As ICP rises and cerebral compliance decreases, the arterial pulses become more pronounced.

  • B. In right atrial cardiac insufficiency, the CVP rises and the ICP waveform takes on a more “venous” appearance.

  • C. In right atrial cardiac insufficiency, the venous “A” wave begins to predominate.

  • D. Plateau waves are usually aborted at the onset by instituting treatments.

  • E. The Lundberg D wave is associated with higher morbidity rates.

FormalPara Answer E

Types of Lundberg waves:

• Lundberg A waves AKA plateau waves of Lundberg: ICP elevations ≥50 mmHg for 5–20 minutes. Usually accompanied by a simultaneous increase in MAP (it is debated whether the latter is cause or effect)

• Lundberg B waves AKA pressure pulses: amplitude of 10–20 mmHg is lower than A waves. Variation with types of periodic breathing. Lasts 30 seconds–2 minutes.

• Lundberg C waves: frequency of 4–8/minute. Low-amplitude C waves (AKA Traube–Hering waves) may sometimes be seen in the normal ICP waveform. High-amplitude C waves may be pre-terminal and may sometimes be seen on top of plateau waves.

• 38. TBI. Syndrome of inappropriate anti-diuretic hormone (SIADH)

  The FALSE answer is:

  • A. Hyponatremia

  • B. Hypovolemia

  • C. Serum osmolality <275 milliosmoles per kilogram (mOsm/kg)

  • D. High urinary osmolality

  • E. Normal renal function

FormalPara Answer B

• Syndrome of inappropriate anti-diuretic hormone (SIADH) is characterized by euvolemia (or hypervolemia). SIADH is caused by the release of anti-diuretic hormone (ADH) in the absence of physiologic (osmotic) stimuli. Diagnostic criteria include hyponatremia, inappropriately concentrated urine, and no evidence of renal or adrenal dysfunction.

• 39. TBI. Cerebral salt wasting syndrome (CSWS)

  The FALSE answer is:

  • A. Hyponatremia

  • B. Hypovolemia

  • C. High/normal serum K

  • D. High serum osmolality

  • E. Dehydration

FormalPara Answer D

• In CSW, the serum osmolarity is low.

• 40. TBI. CSWS

  The FALSE answer is:

  • A. Low central venous pressure (CVP)

  • B. Decreased serum potassium

  • C. Hyponatremia

  • D. Low pulmonary capillary wedge pressure (PCWP)

  • E. Low plasma volume

FormalPara Answer B

• CSWS is associated with normal-high serum potassium levels.

• 41. CSW versus SIADH

  The FALSE answer is:

  • A. The plasma volume is higher in CSWS.

  • B. The salt balance is normal in SIADH.

  • C. PCWP is low in CSWS.

  • D. CVP is low in CSWS.

  • E. Orthostatic hypotension occurs in both.

FormalPara Answer A

• The plasma volume is lower in CSWS.

• To compare between CSW and SIADH, the two most important differences are extracellular volume and salt balance. An elevated serum [K+] with hyponatremia is incompatible with the diagnosis of SIADH.

• 42. CSW versus SIADH

  The FALSE answer is:

  • A. High hematocrit in CSWS

  • B. Lower urinary salt CSWS

  • C. Serum potassium (K) is elevated in CSWS

  • D. Normal serum uric acid in CSWS

  • E. Normal serum uric acid in SIADH

FormalPara Answer B

• Urinary salt is two times higher in CSWS.

• 43. TBI. Diabetes insipidus

  The FALSE answer is:

  • A. Low ADH levels

  • B. Craving for water

  • C. High output of dilute urine

  • D. Normal or high serum Na

  • E. Adrenal insufficiency

FormalPara Answer E

• Normal adrenal function in DI as it cannot occur in primary adrenal insufficiency because a minimum of mineralocorticoid activity is needed for the kidney to make free water.

• 44. TBI. Diabetes insipidus (DI)

  The FALSE answer is:

  • A. Central DI: subnormal levels of ADH

  • B. Inability to concentrate urine to >300 mOsm/kg

  • C. Large doses of mannitol can mimic it

  • D. Low serum sodium

  • E. Normal adrenal function

FormalPara Answer D

• Central DI is characterized by normal or above-normal serum sodium.

• 45. Pediatric TBI

  The FALSE answer is:

  • A. Central nervous system (CNS) injuries are the most common cause of traumatic death

  • B. Subgaleal hematoma is usually soft, fluctuant

  • C. Subperiosteal hematoma extend over skull sutures

  • D. Growing skull fractures require a widely separated fracture and a dural tear

  • E. A ping pong fracture is seen only in the newborn

FormalPara Answer C

• Subperiosteal hematoma is limited by skull sutures.

• 46. Subgaleal hematoma in children

  The FALSE answer is:

  • A. Bleeding between the galea from periosteum

  • B. Limited by suture lines

  • C. Usually starts as a small localized hematoma

  • D. Under one year of age significant loss of circulating blood volume

  • E. Soft fluctuant mass

FormalPara Answer B

• Subgaleal hematoma may cross sutures.

• 47. Subperiosteal hematoma in children

  The FALSE answer is:

  • A. Commonly seen in newborns

  • B. Limited by sutures

  • C. Firmer than subgaleal hematoma

  • D. Scalp moves freely over the mass

  • E. Does not reabsorb

FormalPara Answer E

• 80% reabsorb, usually within 2–3 weeks. Occasionally may calcify.

• 48. Growing skull fractures (posttraumatic leptomeningeal cysts)

  The FALSE answer is:

  • A. Nondisplaced, linear skull fracture is typical

  • B. Requires a dural tear

  • C. Over 90% occur before 3 years

  • D. Parietal is the most common location

  • E. Surgery must involve dural repair

FormalPara Answer A

• Growing skull fractures are characterized by bone diastasis 3 mm or more.

• The most common age group is 3 months to 3 years.

• 49. Nonaccidental head injury in pediatrics

  The FALSE answer is:

  • A. Retinal hemorrhage

  • B. Ping pong fracture

  • C. Multiple injuries of different ages

  • D. Bilateral CSDH in a child <2 years of age

  • E. Significant neurological injury with minimal external trauma

FormalPara Answer B

• The “ping pong fracture” is not a factor of suspected child abuse. Unlike in accidental TBI in children, skull fractures are not typically located at the frontal bone in nonaccidental trauma.

• “Ping pong ball” fracture: A green-stick type of fracture → caving in of a focal area of the skull as in a crushed area of a ping pong ball. Usually is seen only in the newborn due to the plasticity of the skull. Retinal hemorrhages, subdural hematomas (bilateral in 80%), and/or subarachnoid hemorrhage (SAH) are frequently found in these cases.

• 50. Pediatric retinal hemorrhage

  The FALSE answer is:

  • A. Clears slower than preretinal hemorrhage

  • B. Inflicted versus accidental injury can be differentiated

  • C. Causes: acute high-altitude sickness

  • D. Causes: acute increase in ICP

  • E. Frequently associated with intracerebral hemorrhage (ICH)

FormalPara Answer A

• Retinal hemorrhage clears much faster than preretinal hemorrhage.

• In a traumatized child with multiple injuries and an inconsistent history, the presence of retinal hemorrhage is pathognomonic for child abuse.

• 51. Penetrating TBI

  The FALSE answer is:

  • A. Less prevalent than closed TBI

  • B. Mostly caused by low-velocity objects

  • C. Mechanisms include cavitation and shockwaves

  • D. Brain damage depends on the kinetic energy imparted

  • E. Velocity has greater influence than projectile mass

FormalPara Answer B

• In the civilian population, TBI is mostly caused by high-velocity objects.

• 52. Penetrating TBI. Factors associated with higher mortality

  The FALSE answer is:

  • A. Traverses the ventricles

  • B. High-velocity projectiles

  • C. Crosses the midline

  • D. Tangential injuries

  • E. Large missiles

FormalPara Answer D

• Tangential injuries are associated with lower mortality rates.

• 53. Blunt Cerebrovascular injury (BCVI): risk factors

  The FALSE answer is:

  • A. Basilar skull fracture involving the carotid canal

  • B. GCS < 6.

  • C. CSF rhinorrhea

  • D. Cervical vertebral body fracture

  • E. Fractures involving C1–3

FormalPara Answer C

• CSF rhinorrhea is a sign of skull base fracture and is not a risk factor for BCVI.

• Cervical fractures at any level, but specially C1 to C3 + transverse foramen fracture, subluxation, or ligamentous injury at any level and/or near hanging lesion with are all risk factors for BCVI

• 54. BCVI: signs and symptoms

  The FALSE answer is:

  • A. Nasal arterial hemorrhage

  • B. Cervical bruit in a patient <50 years old

  • C. Expanding cervical hematoma

  • D. Focal neurological deficits

  • E. Neurological deficit with head CT abnormalities

FormalPara Answer E

• Neurologic deficit without head CT alterations.

• 55. BCVI: Denver grading scale

  The FALSE answer is:

  • A. Luminal irregularity with <25% stenosis is Grade I.

  • B. ≥25% luminal stenosis is Grade II.

  • C. 16-slice multidetector CT angiography is equivalent to catheter angiography in BCVI diagnosis.

  • D. The Denver grade of the dissection correlates the risk of stroke from ICA dissection.

  • E. Intraluminal thrombus alone is Grade V.

FormalPara Answer E

• Intraluminal thrombus is Grade II, while transection with free extravasation is Grade V.

BCVI grading scale (“Denver grading scale”)
Grade	Description
I	luminal irregularity with <25% stenosis
II	≥25% luminal stenosis or intraluminal thrombus or raised intimal flap
III	pseudoaneurysm
IV	occlusion
V	transection with free extravasation

FormalPara Imaging recommendations for BVI Detection:

• 1. 16MD-CTA should be obtained as follows:

  • Emergently in patients with signs/symptoms of BCVI

  • Asymptomatic patients with risk factors

• 2. If the 16MD-CTA is equivocal or if it is negative but the clinical suspicion remains high: a catheter arteriogram should be done (otherwise, if negative: stop).