Traumatic Brain Injury — MCQs

10 questions

First step in management of raised intracranial pressure-

In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

Signs of increased intracranial tension are all except:

Which of the following is false regarding cranial trauma?

Which of the following is not true about non-contrast CT scan in head injury?

Which one of the following is a secondary brain injury?

Neurological status is assessed under which step of ABCDE of trauma care?

A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

Q10

A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:

Traumatic Brain Injury Indian Medical PG Practice Questions and MCQs

Question 1: First step in management of raised intracranial pressure-

A. Breathing
B. mannitol
C. Loading dose of phenytoin
D. Airway maintenance (Correct Answer)

Explanation: ***Airway maintenance*** - Maintaining a **patent airway** is the absolute first step in managing any critically ill patient, including those with raised ICP, to ensure adequate **oxygenation and ventilation** [1]. - Without proper airway management, the brain will suffer from **hypoxia**, which can worsen cerebral edema and further increase ICP, leading to a poorer prognosis. *Breathing* - While essential in the **ABCs (Airway, Breathing, Circulation)**, ensuring adequate breathing (ventilation) comes immediately after securing the airway [1]. - An obstructed airway will prevent effective breathing, making airway maintenance the priority. *mannitol* - **Mannitol** is an osmotic diuretic used to reduce ICP by drawing fluid from the brain into the vasculature, but it is a **pharmacological intervention** that follows initial stabilization of the ABCs. - Administering mannitol without first securing the airway and ensuring ventilation could be detrimental if the patient is hypoxic. *Loading dose of phenytoin* - Administering a **loading dose of phenytoin** is primarily for seizure prophylaxis or treatment, which may be necessary in some cases of elevated ICP, but it is not the **immediate first step** in managing acute ICP elevation. - Seizure control is important, but airway, breathing, and circulation take precedence in the initial stabilization phase.

Question 2: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :

A. 20% Mannitol (Correct Answer)
B. Lasix
C. Glycine
D. Steroids

Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.

Question 3: Signs of increased intracranial tension are all except:

A. Headache
B. Seizures
C. Papilledema
D. Tachycardia (Correct Answer)

Explanation: ***Tachycardia*** - **Tachycardia** is generally *not* a sign of increased intracranial pressure (ICP); rather, **bradycardia** (Cushing's reflex) is a classic finding. - While other systemic responses may occur, a direct, consistent increase in heart rate due to elevated ICP is uncommon. *Papilledema* - **Papilledema** is a swelling of the **optic disc** due to increased ICP, a critical diagnostic sign [1]. - The increased pressure impedes venous return from the retina, causing the optic nerve head to bulge. *Headache* - **Headache** is a common and often early symptom of increased ICP due to the stretching of pain-sensitive meningeal and vascular structures [1]. - It is typically described as a dull, throbbing pain, often worse in the morning or with straining. *Seizures* - **Seizures** can result from increased ICP as the pressure on brain tissue can lead to electrical instability and abnormal neuronal discharge [2]. - This symptom indicates significant cortical irritation or dysfunction caused by the elevated pressure.

Question 4: Which of the following is false regarding cranial trauma?

A. Depressed skull is associated with brain injury at the immediate area of impact
B. Raccoon eyes seen in subgaleal hemorrhage (Correct Answer)
C. Carotid-cavernous fistula occur in base skull
D. Post traumatic epilepsy seen in 15%

Explanation: ***Raccoon eyes seen in subgaleal hemorrhage*** - **Raccoon eyes** (periorbital ecchymosis) are typically seen with **anterior cranial fossa fractures**, not subgaleal hemorrhage. - Subgaleal hemorrhage is a collection of blood between the galea aponeurotica and the periosteum, usually causing diffuse **scalp swelling**. *Depressed skull is associated with brain injury at the immediate area of impact* - A depressed skull fracture means a portion of the skull is pushed inward, directly impacting the underlying **brain tissue**. - This can lead to localized **contusions**, **lacerations**, or **hematomas** at the site of impact. *Carotid-cavernous fistula occur in base skull* - **Carotid-cavernous fistulas** (CCF) commonly result from **traumatic rupture** of the internal carotid artery within the **cavernous sinus**. - This type of injury is often associated with **severe skull base fractures**, particularly those involving the sphenoid bone. *Post traumatic epilepsy seen in 15%* - The incidence of **post-traumatic epilepsy** (PTE) after severe head injury ranges from 5% to 15%, making 15% a plausible, though upper-end, estimate. - Risk factors for PTE include **depressed skull fractures**, **intracranial hematomas**, and **early seizures**.

Question 5: Which of the following is not true about non-contrast CT scan in head injury?

A. Extradural hematomas are usually lens-shaped
B. Acute subdural hematoma appears as crescent shadow of increased density
C. Subdural hematoma increases in density on serial CT scans over weeks (Correct Answer)
D. Subarachnoid hemorrhage appears as areas of increased density in basilar cisterns

Explanation: ***Subdural hematoma increases in density on serial CT scans over weeks*** - A **subdural hematoma (SDH)** typically **decreases in density** over weeks due to clot lysis and absorption of its proteinaceous components, transitioning from hyperdense (acute) to isodense (subacute) and then hypodense (chronic). - An increase in density on serial CT scans would imply continued bleeding or re-hemorrhage, which is not the typical natural progression of an acute SDH. *Extradural hematomas are usually lens-shaped* - **Extradural hematomas (EDH)** are typically **biconvex** or **lens-shaped** because they accumulate in the epidural space and are limited by cranial sutures where the dura is tightly adhered to the skull. - This characteristic shape helps distinguish them from subdural hematomas. *Acute subdural hematoma appears as crescent shadow of increased density* - An **acute subdural hematoma (SDH)** appears as a **crescent or crescent-shaped shadow** of increased density (hyperdense) on a non-contrast CT scan because it spreads along the inner surface of the dura, conforming to the brain's convexity. - This indicates active bleeding that is relatively fresh, usually within the first 3-7 days. *Subarachnoid hemorrhage appears as areas of increased density in basilar cisterns* - **Subarachnoid hemorrhage (SAH)** manifests as areas of **increased density (hyperdensity)** within the **basilar cisterns**, Sylvian fissures, or sulci, due to blood filling these cerebrospinal fluid (CSF)-containing spaces. - This finding is a key indicator of SAH on non-contrast CT.

Question 6: Which one of the following is a secondary brain injury?

A. Intracerebral haematoma with raised intracranial pressure (Correct Answer)
B. Diffuse axonal injury
C. Cortical lacerations
D. Brainstem and hemispheric contusions

Explanation: ***Intracerebral haematoma with raised intracranial pressure*** - **Intracerebral haematoma** is a potentially treatable, secondary injury directly contributing to **raised intracranial pressure (ICP)**, leading to further brain damage if not managed. - **Secondary brain injuries** occur minutes to days after the initial impact, resulting from a cascade of events like ischaemia, oedema, and intracranial hypertension. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** is a **primary brain injury** caused by shearing forces at the moment of impact. - It is a direct consequence of the initial trauma, not a subsequent physiological process. *Cortical lacerations* - **Cortical lacerations** are **primary injuries**, representing a direct tearing or cutting of brain tissue due to the initial traumatic force. - These are immediately present at the time of injury and are not a consequence of subsequent physiological changes. *Brainstem and hemispheric contusions* - **Contusions** are localised areas of bruising on the brain, characteristic of a **primary brain injury**, occurring directly from the impact. - While contusions can evolve and contribute to secondary injury mechanisms like oedema, the contusion itself is a direct result of the initial trauma.

Question 7: Neurological status is assessed under which step of ABCDE of trauma care?

A. C - Circulation with haemorrhage control
B. E - Exposure: completely undress the patient and assess for other injuries
C. B - Breathing and ventilation
D. D - Disability: neurological status (Correct Answer)

Explanation: ***D - Disability: neurological status*** - The "D" in ABCDE trauma assessment specifically stands for **Disability**, which involves a rapid assessment of the patient's **neurological status**. - This step typically includes evaluating **level of consciousness** using tools like the AVPU scale (Alert, Voice, Pain, Unresponsive) or the Glasgow Coma Scale (GCS), assessing pupillary response, and identifying any gross motor deficits. *C - Circulation with haemorrhage control* - This step focuses on assessing and managing **blood flow**, including evaluating heart rate, blood pressure, capillary refill, and controlling any sources of external hemorrhage. - While neurological issues can result from poor circulation, the primary assessment of the nervous system itself is not performed here. *E - Exposure: completely undress the patient and assess for other injuries* - This final step involves a thorough **inspection of the entire body** to identify hidden injuries, such as bruising, lacerations, or deformities, while simultaneously ensuring temperature regulation. - It is for overall physical assessment, not for initial neurological evaluation. *B - Breathing and ventilation* - This step involves assessing the patient's **respiratory effort**, checking for symmetrical chest rise, listening to breath sounds, and intervening to ensure adequate oxygenation and ventilation. - While critical for brain function, this step focuses on the respiratory system, not the direct assessment of neurological function.

Question 8: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

A. MRI
B. CECT
C. NCCT (Correct Answer)
D. X-ray

Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.

Question 9: A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

A. EDH
B. SDH (Correct Answer)
C. Contusion
D. Diffuse axonal injury

Explanation: ***SDH*** - The image shows a **crescent-shaped collection** of hemorrhage with a concave inner margin, consistent with a **subdural hematoma** (SDH). - SDHs result from the tearing of **bridging veins** and typically conform to the brain's surface, crossing suture lines but not limited by bony sutures. *EDH* - An **epidural hematoma (EDH)** characteristically appears as a **lenticular** or **biconvex** shape on CT, not crescent-shaped. - EDHs are typically caused by arterial bleeding, often from the **middle meningeal artery**, and are limited by cranial sutures. *Contusion* - A **contusion** is brain tissue bruising that appears as **heterogeneous areas** of hemorrhage and edema within the brain parenchyma itself. - It would not manifest as a distinct extra-axial collection with a smooth, concave margin. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** involves widespread microscopic damage to axons, often at the gray-white matter junction. - It may appear as *punctate hemorrhages* or **small lesions** at these junctions on CT, but often the CT can be normal, and it would not present as a large extra-axial collection.

Question 10: A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:

A. Analgesia and sedation
B. Hypothermia
C. Controlled mechanical ventilation
D. IV mannitol (Correct Answer)

Explanation: ***IV mannitol*** - While **intravenous mannitol** is used in the management of head injury to reduce **intracranial pressure (ICP)**, it is **not a first-line treatment**. - It is a **second-line therapy** reserved for documented or suspected elevated ICP despite initial supportive measures. - First-line management focuses on maintaining adequate oxygenation, ventilation, and cerebral perfusion, while mannitol is used for specific ICP management when needed. *Analgesia and sedation* - **Analgesia and sedation** are essential **first-line treatments** to reduce pain, anxiety, and agitation, which can increase **intracranial pressure (ICP)**. - These therapies ensure patient comfort, decrease metabolic demand, facilitate mechanical ventilation, and prevent secondary brain injury. *Hypothermia* - **Therapeutic hypothermia** is **NOT routinely recommended** as a first-line treatment in pediatric traumatic brain injury. - Current evidence (including the Cool Kids trial) has not demonstrated benefit, and it may be associated with adverse effects. - It is considered **investigational** and not part of standard first-line management protocols. - **Note**: While this is also not first-line, the question specifically tests knowledge that mannitol is second-line therapy for ICP management. *Controlled mechanical ventilation* - **Controlled mechanical ventilation** is a fundamental **first-line treatment** for severe head injury to secure the airway and ensure adequate oxygenation and ventilation. - Prevents secondary brain injury from **hypoxia** and **hypercapnia**, which can worsen outcomes. - Maintaining appropriate **PaCO2 levels** is critical to control cerebral blood flow and intracranial pressure.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free