Brain 3

Question 1

Anesthetic management for the patient with an ICP of 25 mmHg undergoing craniotomy for tumor resection includes (select 3):
a. PaCO2 30 mmHg
b. nitroprusside
c. D5LR
D. dexamethasone
E. phenylephrine
F. PEEP 10 cmH2O

Answer 1

a. PaCO2 30 mmHg
D. Dexamethasone
E. Phenylephrine

Question 2

What are the four strategies to reduce ICP?

Answer 2

reduce cerebral blood volume
reduce CSF
reduce cerebral edema
reduce cerebral mass

Question 3

How can we reduce cerebral edema?

Answer 3

administer diuretics and steroids (dexamethasone and methylprednisolone)

Question 4

How can we reduce cerebral mass?

Answer 4

surgical debulking or evacuation of a hematoma

Question 5

How can we reduce cerebrospinal fluid?

Answer 5

drain with an intraventricular catheter or VP shunt or
administer acetazolamide or furosemid

Question 6

How can we reduce cerebral blood volume?

Answer 6

provide mild hyperventilation
avoid hypoxemia
avoid vasodilators and employ cerebral vasoconstrictors
elevate head >30 degrees and avoid neck flexion
reduce intrathoracic pressure

Question 7

Steroids should NOT be used for

Answer 7

traumatic brain injury or a functional pituitary adenoma

Question 8

Corticosteroids cause ________ which in the setting of cerebral ischemia is associated with worse outcomes.

Answer 8

hyperglycemia

Question 9

Loop diuretics reduce cerebral edema by

Answer 9

inducing diuresis and decreasing the rate of CSF production

Question 10

Osmotic diuretics (i.e. mannitol) increase

Answer 10

serum osmolarity and “pull” water across the blood-brain barrier

Question 11

The high tonicity of 3% sodium chloride can also

Answer 11

reduce ICP by “pulling” water across the BBB

Question 12

If the BBB is disrupted and mannitol is given,

Answer 12

mannitol can enter the brain and increase cerebral edema

Question 13

The following drugs can reduce CSF production:

Answer 13

acetazolamide
furosemide

Question 14

Draining CSF is most useful when there’s an

Answer 14

obstruction to CSF flow such as in the case of hydrocephalus

Question 15

Describe how mild hyperventilation can decrease cerebral blood flow.

Answer 15

mild hyperventilation (PaCO2 30-35 mmHg) constricts the cerebral vessels–> increased cerebral vascular resistance–> decreased cerebral blood flow–> decreased ICP

Question 16

Lowering PaCO2 <30 mmHg increases the risk of

Answer 16

cerebral ischemia due to vasoconstriction and shifting the oxyhemoglobin dissociation curve to the left

Question 17

PaO2 <50-60 mmHg greatly increases

Answer 17

CBF and ICP

Question 18

_____ is a good choice to maintain cerebral perfusion pressure.

Answer 18

phenylephrine

Question 19

What positions should be avoided in the setting of increased ICP?

Answer 19

head <30 degrees- does not facilitate venous drainage from the brain
neck flexion or extension can compress the jugular veins and reduce outflow
the Trendelenburg position increases CBV and ICP

Question 20

The following vascular structures exist as pairs EXCEPT the:
a. posterior communicating artery
b. vertebral artery
c. basilar artery
d. middle cerebral artery

Answer 20

C. basilar artery

Question 21

The primary function of the circle of Willis is to provide

Answer 21

redundancy of blood flow in the brain

Question 22

What are the two cerebral circulations?

Answer 22

anterior and posterior circulations

Question 23

What supplies the anterior circulation?

Answer 23

internal carotid arteries

Question 24

What supplies the posterior circulation?

Answer 24

vertebral arteries
enter through the foramen magnum

Question 25

The cerebral venous circulation can be divided into

Answer 25

two separate circulations

Question 26

Venous blood from the cerebral cortex and cerebellum drain via the

Answer 26

superior sagittal sinus & the dural sinuses

Question 27

Venous blood from the basal brain structure drains via the

Answer 27

inferior sagittal sinus, the vein of Galen, and the straight sinuses

Question 28

All venous blood exits the brain via the

Answer 28

paired jugular veins

Question 29

Within how many hours can IV recombinant tissue plasminogen activator be given after a patient exhibits symptoms of an acute ischemic stroke?

Answer 29

4.5 hours

Question 30

_____ is the first therapy in patients with acute ischemic stroke

Answer 30

PO aspirin

Question 31

We can classify the type of CVA as

Answer 31

ischemic or hemorrhagic

Question 32

_______ strokes are more common

Answer 32

Ischemic

Question 33

A transient ischemic attack or “mini-stroke” is a

Answer 33

focal neurologic deficit that spontaneously resolves within 24 hours

Question 34

_____________ should be determined prior to treatment because

Answer 34

The type of CVA b/c a thrombolytic should not be given to a patient with a hemorrhagic stroke

Question 35

________ is common after ischemic CVA

Answer 35

Hypertension

Question 36

An elevated BP in the setting of ischemic stroke supports

Answer 36

CPP & cerebral oxygenation

Question 37

The blood pressure should be kept under ______ in the setting of an ischemic stroke

Answer 37

185/110 mmHg

Question 38

During cerebral hypoxia, glucose is converted to

Answer 38

lactic acid; cerebral acidosis destroys brain tissue and is associated with poor outcomes

Question 39

Risk factors for ischemic stroke include

Answer 39

Hypertension (most important)
smoking
DM
HLD
excessive alcohol intake
elevated homocysteine levels

Question 40

Since the etiology of CVA cannot be determined by clinical criteria alone, the patient should receive an

Answer 40

emergent non-contrast CT