Case 10 Summary - ILOs

Case 10 Summary
General ILOs:

- To demonstrate basic knowledge of recovery of movement in the lower limb after
brain injury (rehabilitation)
- To demonstrate basic knowledge of the effect of cerebral oedema and seizure on
the cerebral cortex
- To demonstrate basic knowledge of the treatment of fractures in this case

Recovery depends on the mechanism of damage:

 Concussion
o A reversible impairment of neurological function for minutes to hours
following head injury.
o Loss of consciousness, ‘seeing stars’, headache, dizziness, nausea and
vomiting are common symptoms
o Treatment is typically rest
 Contusion/Laceration
o Petechial haemorrhage, oedema and tissue destruction typically from
mechanical forces. This displaces and compresses the hemispheres of the brain
against the skull.
o Symptoms depends on the location of the contusion/laceration
o Recovery results in glial scarring and immune cell filtration. These can cause
haemosiderin-stained depressions in the cortex that can result in epilepsy
 Cerebral Oedema
o Vasogenic oedema – influx of fluid and solutes into the brain via an
incompetent BBB
o Cytotoxic Oedema – cellular swelling due to trauma or infarction
 Elevated ICP
o Presents with drowsiness and reduced consciousness with later signs of coma
and pupillary changes
o Treated by elevating the head to 30 degrees. Emergent treatment includes
intubation, hyperventilation high dose barbiturates, decompressive
hemicraniectomy and possibly hypothermia.
 Seizure
o Temporary loss of function of brain activity due to excessive neural activity
o Cortical scars from contusions may result in seizures
o Can be focal or generalised

Brain damage can occur due to trauma through a variety of mechanisms:

 Axonal shear injury – damage to the white matter
 Petechial haemorrhage – spots of blood in the white matter
 Intracranial heamorrhage – large spots of blood in the white matter
 Cerebral contusion
 Penetrating trauma
 Cerebral oedema



1
Guillaume Antem – MBChB Y2

, A craniotomy is a procedure that involves drilling a home in the skull, exposing the dura and
then elevating said dura to reduce ICP.

The GCS is a tool used to record the conscious state of the patient:

 Severe – GCS <8
 Moderate – GCS 9-12
 Minor – GCS >13

As a primary survey assessment for consciousness, the abbreviated coma scale can be used:

A  Alert

V  Vocal stimuli

P  Pain

U  Unresponsive

- To demonstrate basic knowledge of sleep and consciousness

The ascending arousal system increases arousal and facilitates consciousness by maintaining
a desynchronised EEG. This system consists of monoaminergic and cholinergic neurons in
the brainstem and hypothalamus which project into the thalamus and cortex:

 Cholinergic neurons in the pedunculopontine nucleus and basal nucleus of Meynert
are important in arousal
 These neurons project to the diencephalon and cortex

Sleep and wakefulness

Sleep-wake cycles are determined by the circadian rhythm. This system works as follows:

 The sleep-wake cycle is regulated by the suprachiasmatic nucleus (SCN)
 SNC cells produce CLOCK and BMAL1, which promotes PER and CRY gene
transcription
 PER and CRY proteins bind together, inhibiting their own gene transcription
 PER and CRY degrade, allowing CLOCK and BMAL1 to promote PER and CRY
transcription
 The whole process takes about 24hrs

The SCN uses light information to adjust the circadian rhythm via the retinohypothalamic
tract.

Stage of sleep

Sleep can be divided in non-REM (desynchronised) and REM (synchronised) stages:

 There are typically 4-6 cycles in 8hrs of sleep.
 80% of sleep is spent in non-REM sleep.

2
Guillaume Antem – MBChB Y2