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Special Pops II > 2b. Intracranial Pressure & Spinal Cord Blood Supply > Flashcards

2b. Intracranial Pressure & Spinal Cord Blood Supply Flashcards

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1
Q

normal ICP

A

5-15 mm Hg in adults

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2
Q

intracranial HTN

A

sustained increase in ICP above 20-25 mm Hg

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3
Q

causes of intracranial HTN (4)

A
  • obstructed CSF absorption
  • brain edema
  • expanding mass
  • elevated CBF
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4
Q

one of the first signs of increasing ICP is?

A

nausea and vomiting

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5
Q

other s/s of inc ICP

A
  • changes in LOC
  • headache
  • seizures
  • eyes: impaired movement, papilledema, pupillary changes
  • changes in speech
  • posturing
  • changes in VS
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6
Q

cushing’s triad

A
  • increased SBP
  • decreased HR
  • irregular respiratory pattern
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7
Q

gold standard for ICP monitoring

A

intraventricular catheter- ventriculostomy

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8
Q

complication of ICP monitoring

A

infection

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9
Q

patients that need ICP monitoring

A

TBI
GCS <9
abnormal CT scan
Normal CT with two of the following:
- > 40 years old
- Uni or bilat posturing
- SBP<90 mm Hg

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10
Q

3 components of ICP waveform

A
  • heart pulse waves
  • respiratory waves
  • slow vasogenic waves
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11
Q

true or false: steroids are contraindicated in TBI

A

true

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12
Q

arterial blood delivered to spinal cord va:

A

75% anterior spinal artery
25% posterior spinal arteries

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13
Q

major source of blood to the lower 2/3 of the spinal cord is via the…

A

artery of adamkiewicz

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14
Q

interruption of blood flow through the artery of adamkiewicz can l/t…

A

paraplegia

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15
Q

what comprises cranial volume?

A

blood
brain
CSF

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16
Q

ICP may be decreased by reduction of any of the following…

A

CBF
CSF
cerebral edema
cerebral mass

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17
Q

how does PaCO2 affect CBF?

A

hyperventilation decreases PaCO2 which causes vasoconstriction, this decreases CBF and therefore ICP

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18
Q

PaCO2 30-35 causes…

A

vasoconstriction of cerebral vessels

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19
Q

PaCO2 < 30 …

A

danger zone

risk of cerebral ischemia

(b/c O2 offloading is reduced)

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20
Q

Rx that reduce CMRO2

A

Propofol, Thiopental

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21
Q

what happens when BP surpasses upper limit of autoregulation?

A

cerebral edema

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22
Q

ways to promote CBF reduction via venous drainage

A

HOB 30º
head and neck midline to avoid JV compression
Keep PEEP at physiologic levels

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23
Q

position to avoid to promote venous drainage

A

Trendelenburg

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24
Q

to promote CBF reduction, what agents to avoid?

A

strong vasodilating agents: NTG, SNP

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25
PaO2 below what increases CBF?
50
26
what is used for chronic treatment of CSF reduction?
VP or ventriculoatrial shunt
27
Rx to reduce CSF and treat idiopathic intracranial hypertension
Acetazolamide & furosemide
28
mainstays of cerebral edema treatment (3):
- diuretics (loop + osmotic) - corticosteroids - hypertonic saline (not common) *be mindful of hypovolemia
29
why are corticosteroids contraindicated in TBI?
cause elevated serum glucose, which can produce poor outcomes when cerebral ischemia is present
30
what are ways to reduce cerebral mass?
- surgical debulking of cerebral tumors - mass reduced when cellular water is reduced with osmotic diuretics
31
intracranial aneursym
focal protrusion arising from weakened arterial walls at major bifurcations of the arteries at the base of the brain
32
how are aneurysms most commonly treated
endovascular coiling (>50%) or microsurgical clip ligation
33
what is the most common cause of SAH
aneurysm rupture into the subarachnoid space
34
explain T = P x r
T = circumferential wall tension P = transmural pressure r = mean vessel radius increased blood pressure > increased tension stress > progressive vessel dilatation + weakening of vessel wall > enlargement of aneurysm
35
which law defines enlargement of aneurysms until rupture?
Law of Laplace: wall tension is proportional to vessel radius
36
when does aneurysm rupture occur?
when mechanical stress on wall exceeds strength of wall tissue
37
what scale is used for prognostic clinical outcome for SAH?
Hunt-Hess Grading System
38
Hunt-Hess score 0
unruptured, asymptomatic aneurysm
39
Hunt-Hess score 1
ruptured aneurysm minimal headache no neurologic deficits
40
Hunt-Hess score 2
moderate to severe headache no deficit other than cranial nerve palsy
41
Hunt-Hess score 3
drowsiness, confusion mild focal motor deficit
42
Hunt-Hess score 4
stupor, significant hemiparesis early decerebration
43
Hunt-Hess score 5
deep coma decerebrate rigidity
44
what Hunt-Hess scores require intubation?
4 and 5
45
s/s SAH
worst HA of my life LOC (50%) nausea and vomiting fever photophobia
46
morbidity from SAH results from...
vasospasm!!! rebleeding obstructive hydrocephalus (if bleeding blocks outflow of CSF)
47
leading cause of morbidity and mortality following SAH
vasospasm may lead to cerebral infarct
48
amount of bleeding in SAH is directly proportional to...
incidence of vasospasm
49
vasospasm occurs how many days after SAH?
4-9
50
why is it important to maintain CPP during vasospasm?
ischemic areas depend on pressure to receive blood flow
51
triple H therapy for vasospasm
Hypertensive (higher CPP; use pressors) Hypervolemic (crystalloids, colloids) Hemodilution (Hct 27-32%; blood less viscous)
52
what can be used for daily monitoring of vasospasm?
transcranial doppler
53
Rx for vasospasm
nimodipine
54
how does nimodipine treat cerebral vasospasm compared to other CCBs?
Nimodipine primarily targets L-type calcium channels in cerebral arteries, which are associated with vasospasm after subarachnoid hemorrhage (SAH). Unlike other calcium channel blockers, nimodipine has a more selective effect on cerebral vessels, making it suitable for preventing and treating cerebral vasospasm.
55
what is the gold standard for detection of intracranial aneurysms?
digital subtraction angiography
56
23% of patients with intracranial aneurysm have...
neurogenic pulmonary edema
57
EKG changes with intracranial aneurysm
PVCs T wave inversion ST depression
58
induction for craniotomy for intracranial aneurysm
- goal = smooth induction - decrease CBF by inducing cerebral vasoconstriction - pressors (CPP) i.e. phenylephrine during and after induction - pts may benefit from moderate hyperventilation during induction
59
anesthetic maintenance for craniotomy for intracranial aneurysm
Iso or Sevo 0.5 MAC (if EP monitoring) Avoid N2O Propofol gtt (↓ CMRO2)
60
other maintenance for craniotomy for intracranial aneurysm
BP control (aline preop) Substantial HTN = rebleeding, rupture, permanent neuro deficits or death Substantial hypoTN = cerebral ischemia and infarct
61
emergence for craniotomy for intracranial aneurysm: Hunt-Hess I-III
extubate titrate BBlockers and vasodilators
62
emergence for craniotomy for intracranial aneurysm: Hunt-Hess IV-V
remain intubated + sedated postop avoid coughing HOB elevated 30º on transport
63
Intra-op Concerns for AVM intubation
fiberoptic awake (if arrives with stereotactic frame)
64
Intra-op Concerns for AVM: complication
VAE place central line
65
Intra-op Concerns for AVM: msc
Aline mild hypothermia brain relaxation
66
strategies for brain relaxation
↓ PaCO2 (dec cerebral vascular volume) mannitol/furosemide (monitor K+ and Na+)
67
mild hypothermia at what ºC can ↓ CMRO2 and to ↓ susceptibility to ischemia?
Mild hypothermia (33–34°C) (CMRO2 decreases ~30% @ 33°C)
68
effective and safe induction agents for AVM
Barbiturates, propofol, and etomidate
69
methods to blunt stimulation of laryngoscopy & Mayfield placement
+Deepen with VAA +Esmolol +Lido +Short acting opioids +Dexmedetomidine
70
NMBs for AVM induction
non-depolarizing agents, avoid sux
71
emergence for AVM
close regulation of BP = key suppress cough = lidocaine IV HOB elevated 20-30º
72
treat increases in BP for AVM
B-blockers or vasodilators
73
monitors for tumor craniotomy when sitting or beach chair position and why?
precordial doppler, CVP monitoring, or TEE on standby d/t risk of VAE
74
induction for tumor craniotomy
DEEP anesthesia complete skeletal muscle paralysis to avoid ↑ICP
75
anesthesia maintenance for tumor craniotomy
maintain CPP maintain euvolemia and eucapnia (consider mannitol) consider mild hyperventilation HOB 20-30 degrees may require CSF drain
76
tumor craniotomy emergence
goal = rapid awakening avoid bucking, coughing (lidocaine) treat BP w/ BBs and vasodilators
77
what MAP may a surgeon require to test hemostasis after tumor is resected during craniotomy?
transient increase to 90-100 mm Hg
78
awake craniotomy indications
epilepsy tumors involving motor or speech (eloquent cortex) patients with full understanding only
79
induction for awake crani
LMA Mayfield headrest cranium removal patient positioning
80
awake crani premapping
mannitol slow infusion Precedex scalp block aline foley
81
preop management for ventricular shunt
assess for cushing's triad HA w/ ICP > 15 mm Hg no preop med required
82
goals for ventricular shunt
normocarbia and normovolemia
83
how does hyperventilation and hypocarbia affect ventricular shunt maintenance
makes cannulation of vessel difficult maintain PeCO2 35-40 mm Hg
84
how does seizure activity during GA manifest?
abrupt changes in HR and BP increased CO2 production
85
termination of seizures
propofol, barbiturates, benzos other: surgeon may apply cold saline to brain surface
86

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