l*********0
发帖数: 85 | 1 Old man come to ER, after falling down his head to ground a few hours ago.
Presentation: Severely headache; shortly unconciousness, now awake; BP 159/
99 mmHg; respiratory 13/min; HR 66/min; right pupil dilation; mild left
hemiparesis.
CT will be
A subdual haemorrhage; B tonsil herniation; C cingulate herniation; D uncal
herniation; E SAH.
If you can correctly answer this within 1.5 min, you are almost ready in
your neurology part. |
l**********e
发帖数: 382 | 2 D. ipsilateral dilated pupil is usually the first sign. |
l*********0
发帖数: 85 | |
l*********0
发帖数: 85 | 4 REMEMBER
Subarachnoid blood can be detected on CT scanning in as many as 60% of
people with traumatic brain injury.
SAH can also show pupil dilation and paresis, unlike uncal herniation, it is
not necessary to be ipsilateral together
D is a big trap, ..., the answer from other sources also say 'D' which is
not correct according to the above links. |
c*******s
发帖数: 399 | 5 你的分析只能说SAH 是可能性之一， 根据你列的题目的关键词， fall， headcche，
pupil dilation， ，不能排除uncal herniation
是不是把原题在列一遍呢
is
【在 l*********0 的大作中提到】
: REMEMBER
: Subarachnoid blood can be detected on CT scanning in as many as 60% of
: people with traumatic brain injury.
: SAH can also show pupil dilation and paresis, unlike uncal herniation, it is
: not necessary to be ipsilateral together
: D is a big trap, ..., the answer from other sources also say 'D' which is
: not correct according to the above links.
|
l*********0
发帖数: 85 | 6 Ipsilateral pupil dilation and ipsilateral hemiparesis in UNCAL HERNIATION
This pateint has righ pupil dilation and left hemiparesis, against uncal
herniation.
If I am wrong, please correct me.
The following is pasted from wiki link
Uncal herniation
In uncal herniation, a common subtype of transtentorial herniation, the
innermost part of the temporal lobe, the uncus, can be squeezed so much that
it goes by the tentorium and puts pressure on the brainstem, most notably
the midbrain.[5] The tentor
【在 c*******s 的大作中提到】
: 你的分析只能说SAH 是可能性之一， 根据你列的题目的关键词， fall， headcche，
: pupil dilation， ，不能排除uncal herniation
: 是不是把原题在列一遍呢
:
: is
|
c*******s
发帖数: 399 | 7 you are right, did not pay attention to right pupil
very tricky question
that
the
【在 l*********0 的大作中提到】
: Ipsilateral pupil dilation and ipsilateral hemiparesis in UNCAL HERNIATION
: This pateint has righ pupil dilation and left hemiparesis, against uncal
: herniation.
: If I am wrong, please correct me.
: The following is pasted from wiki link
: Uncal herniation
: In uncal herniation, a common subtype of transtentorial herniation, the
: innermost part of the temporal lobe, the uncus, can be squeezed so much that
: it goes by the tentorium and puts pressure on the brainstem, most notably
: the midbrain.[5] The tentor
|
s******t
发帖数: 579 | 8 I would choose A (with Cushing triad):
1. "right pupil dilation; mild left hemiparesis" - Can BE induced by either epi
- or sub- dural hematoma.
2. The pt is old
3. the trauma was not very sever
I would not choose SAH. |
S******9
发帖数: 2837 | 9 A
old man spontaneous
fluctuating level of consciousness
herniation |
l*********0
发帖数: 85 | 10 Thanks for you explaination.
May be, you are right, we have to consider acute SDH.
Neurological findings associated with acute SDH may include the following:
Altered level of consciousness
A dilated or nonreactive pupil ipsilateral to the hematoma (or earlier: a
pupil with a more limited range of reaction)
Hemiparesis contralateral to the hematoma.
However, considering this: 'Subarachnoid blood can be detected on CT
scanning in as many as 60% of people with traumatic brain injury', the
possibili
【在 s******t 的大作中提到】
: I would choose A (with Cushing triad):
: 1. "right pupil dilation; mild left hemiparesis" - Can BE induced by either epi
: - or sub- dural hematoma.
: 2. The pt is old
: 3. the trauma was not very sever
: I would not choose SAH.
|
|
|
l*********0
发帖数: 85 | 11 Classical SDH would show slow onsite due to the slower bleeding speed of
vein than artery or arteriole, patient feel good until after several weeks
of injury (choronic SDH), that was probably told by FA or GJ
Frequency
Acute subdural hematomas (SDHs) have been reported to occur in 5-25% of
patients with severe head injuries, depending on the study. Chronic SDH has
been reported to be 1-5.3 cases per 100,000 people per year. More recent
studies have shown a higher incidence, probably because of b |
d******t
发帖数: 28 | 12 I will say the symptom of "pupil dilation and mild left hemiparesis"
probably is due to secondary effect of injury. The Q is not clear about the
pt's conscious level, ("awake" does not mean too much) if GCS score is
around 8, I will say most possibility should be uncal herniation induced by
secondary mass (epidural hematoma) effect. Acute subdural hemorrhage usually
has a very severe primary brain contusion and injury (more than epidural).
If this is the case (subdural), the pt's GCS probably is |
s******t
发帖数: 579 | 13 Thanks Drsheart and Sillymd for your correction and explanation. I though I
know something about neurology, now, I found that I need lots of work on it.
Let me summarize and go though the answers one by one. Please correct me if
I am wrong!
A - subdual haemorrhage
Acute subdural hemorrhage usually has a very severe primary brain contusion
and injury (MORE than epidural). If this is the case, the pt's GCS probably
is even lower and might keep in the unconsciousness, can not be awake again.
(Thank |
l*********0
发帖数: 85 | 14 Thanks all of you great explaination, Drsheat and Stardust made more clear.
May be, the following explaination will be helpful:
Examination:
1. Level of consciouness
- often depressed, either transiently or usually persisently
- important predictor of outcome / severity
- use GCS to grade (see WFNS grading below)
2. Pupils / Eyes:
- assess for oculomotor palsy (pupil fixed & dilated, ptosis,
ophthalmoplegia)
- can be due to early uncal herniation in comatose patient but more often (
in awake SAH |
l*********0
发帖数: 85 | 15 Some more need to be clear.
4. Meningismus:
- nuchal rigidity important sign in patient with suspected SAH but takes 6-
12 hours to develop (in this patient, injury hapens a few hours ago, most
possibly less than 6 hours, so meninges sign might be absent)
- irritation of meninges by blood breakdown products ("chemical meningitis")
- may be absent or hard to detect in deeply comatose patients
5. Systemic Features:
- may see fever (neurogenic often), hypertensive response (to mainatin
cerebral per |
