Diagnostic Tool Indications of use of CT `Hounsfield number(Bone>>> lipid>air) `fisrt line in evaluation of a change in mental status `Test of choice for those with implantable devices `shows acute and sub acute blood(ICH/SAH,SDH) `Bony abnormalities,i.e Trauma or Fracture `Edema/mass effect `Abnormalities in size and shape of structures (brain atrophy,gyri effacement with swelling) `Hydrocephalus `Ischemic stroke
Diagnostic Tool Indications of use of MRI `Use with caution with people with claustrophobia,implantable devices or programmable shunts `Provide better soft tissue differentiation than CT `Tumor `Abscess `Edema/mass effect `Stroke `Hydrocephalus `Stereotactic surgical planning
How things appear on a CT Acute blood/Calcifications -White Chronic blood collection -Low density black to gray as increasing density CSF/Air-Black White matter- Less dense than gray matter Ischemia-lower density and therefore will be darker and may not appear for 12hours
Types of MRI Gadilinium enhancement(tumor/infection) T1/T2 Diffusion- can assess an acute infarct within the last 2 weeks MRV-Assess patency,stenosis or occlusion of the venous system MRA Flair/Echo gradient-Similar studies(Echo gradient may see a smaller bleed clearer Functional MRI-Asked to do sensory,motor and cognitive tasks. Shows increasing signals with cerebral activity
MRI overview (T1/T2) T1 CSF appears black White matter brighter than gray matter T2 CSF apperars white
Basal ganglia ICHThalamic ICH
Lt.F infarction(Broca area)
Lt.MCA infarctionSAH(Subarachnoid hemorrhage)
EDH c skull Fx.
T12 bursting Fx.
Brain death(Reversal sign)
Orbital wall Fx.
Spinal cord injury Methylprednisolone(Within 8hrs) 1.concentration:62.5mg/ml 2.bolus:30mg/kg initial bolus over 15minutes 3.followed by a 45 minutes pause 4.maintenance:then 5.4 mg/kg/hr if<3hrs:23hrs, >3~8hrs:47hrs
Spinal cord injury(Frankel Scale)Grade Description1(A) complete motor and sensory paralysis below lesion2(B) Complete motor paralysis,but some residual sensory perception below lesion3(C) Residual motor function,but of no practical use4(D) Useful but subnormal motor function below lesion5(E) normal
Glasgow coma scale(≥4yrs)Points Eye opening verbal motor 6 - - obeys 5 - oriented Localizes pain 4 Spontaneou Confused Withdrawals to pain s 3 To speech Inappropriate Flexion 2 To pain Incomprehesible Extenson 1 None None none
Glasgow coma scale(≤4yrs) Points Eye opening verbal motor 6 - - obeys 5 - Smile,interact Localizes pain s 4 Spontaneous Consolable , Withdrawals to inappropriate pain 3 To speech moaning Flexion 2 To pain Inconsolable, Extenson restless 1 None None none
Alteration in consciousness Alert Confusion Obtundation Drowsy(Lethargy) Stupor Coma
Vegetative state Preservation of autonomic function and primitive reflex. No meaingful interaction for external stimuli.
Locked in syndrome A state quadriplegia with preservation of cognition Consciousness,vertical eye movements,eyelid blinking Destructive lesions in the ventral pons or ventral midbrain Reemergence of horizontal movement (within 4weeks):Predictive of improved recovery
Facial weakness H-B(House-Brackmann grade)Grade Description1 Normal function in all areas2 Slight weakness on close inspection3 Obvious but not disfiguring4 Obvious weakness and/or disfiguring asymmetry5 Barely perceptible motion6 No movement
Acute medical management ofischemic stroke Effective therapy for stroke -Reduce degree of ischemic change -Minimize effect of reperfusion injury*penumbra:Target ofneuroprotective therapy
Thrombolytic agents Plasminogen to plasmin Degradation of fibrin Canal recanalization * t-PA:only drug approved by FDA
t- PA administration Inclusion -18yr older -Signs of measurable neurological deficit -Onset≤3hrs
t- PA administration Exclusion -Hemorrhage ICH,SAH,active internal bleeding Platelet count<100,000/mm 3 Heparin within48hrs,PT>15sec Recent lumbar or arterial puncture GI bleeding within 21 days
t- PA administration Exclusion -Minor or rapidly improving symptoms -Uncontrolled HTN (SBP>180,DBP<110) -abnormal blood glucose(<50 or >400) -Post myocardial infarction -Seizure at time stroke onset
t- PA administration Monitor BP every 15min for 2hrs Recommneded goal of BP -less than 185/100 Aggressive blood pressure reduction might precipitate further ischemic injury