Clinical Aspects of Cerebral Perfusion and ICP

Question 1

What does GCS stand for?

Answer 1

Glasgow coma scale

Question 2

What does the GCS look at?

Answer 2

Eye response
Verbal response
Motor response

Question 3

What is the scoring of the GCS?

Answer 3

Best eye response
- open spontaneously - 4
- open to verbal command - 3
- open to pain - 2
- does not open eyes - 1
Best verbal response
- orientated - 5 
- confused speech - 4
- inappropriate words - 3
- incomprehensible sounds - 2
- no speech - 1
Best motor response
- obeys commands - 6
- localises to pain - 5
- Normal flexion to pain - 4
- abnormal flexion to pain - 3
- Extension to pain - 2
- no movement

Question 4

What is the total score of the GCS?

Answer 4

15

Question 5

What is the eye response of the GCS marked out of?

Answer 5

4

Question 6

What is the verbal response of the GCS marked out of?

Answer 6

5

Question 7

What is the motor response of the GCS marked out of?

Answer 7

6

Question 8

What does disruption of the BBB lead to?

Answer 8

Increased ECF (vasogenic oedema)
Membrane failure
- influx of Ca - cellular swelling (cytotoxic oedema)
Influx of inflammatory mediators

Question 9

What does BBB stand for?

Answer 9

Blood brain barrier

Question 10

What are the secondary effects of raised ICP?

Answer 10

Anatomical - herniation syndromes

Cellular - decreased cerebral perfusion

Question 11

What % of CO does the adult brain receive?

Answer 11

15%

Question 12

Does the brain have a high O2 consumption?

Answer 12

Yes

Question 13

What regulates cerebral blood flow?

Answer 13

Autoregulation (myogenic)
Cerebral metabolism
CO2 and O2
Neurohumoral factors

Question 14

Examples of herniation syndromes

Answer 14

Subfalcine herniation
Uncal herniation
Foramen magnum herniation

Question 15

What does a subfalcine herniation affect?

Answer 15

Medial motor cortex

Question 16

What does uncal herniation affect?

Answer 16

IIIrd CN

Ipsilateral corticospinal tracts

Question 17

What does a foramen magnum herniation affect?

Answer 17

Brain stem centres

Question 18

On intubation, what does the anesthetist briefly do to help the patient control his ICP?

Answer 18

Hyperventilate them

Question 19

What is normal PaO2?

Answer 19

80 - 100mmHg

Question 20

What is normal PaCO2?

Answer 20

35 - 45mmHg

Question 21

What interventions can neurosurgeons use to reduce ICP?

Answer 21

Craniotomy and evacuation of clot
External ventricular drainage
Decompressive craniotomy

Question 22

What does the Munro-Kellie Doctrine consist of?

Answer 22

Fixed volume; Brain/CSF/Blood

V(CSF) + V(blood) + V(brain) + V(other) = V(intracranial space) = constant

Question 23

What is the normal MAP?

Answer 23

90mmHg

Question 24

What is the normal ICP?

Answer 24

5 - 15 mmHg

Question 25

What does the CPP =?

Answer 25

MAP - ICP

Question 26

What does MAP =?

Answer 26

Diastolic BP + 1/3 pulse pressure

Question 27

What is the normal CPP value?

Answer 27

80mmHg

Question 28

What medical management can be used in ITU to reduce ICP?

Answer 28

``` Head position - 30 degrees head up Nothing to impede venous drainage CO2 maintained in a low normal range Intermittent boluses of mannitol when ICP raised Fully sedated and paralysed ```

Question 29

What can ICP be eventually controlled by after everything else?

Answer 29

Deep sedation with thopentone

Question 30

Treatment of neuroepileptic malignant syndrome

Answer 30

Bromocriptine (dopamine agonist)

Question 31

When assessing the GCS, what must be done?

Answer 31

The BEST response from both sides

Question 32

Pneumonic to remember the features of wernickes encephalopathy

Answer 32

``` CAN OPEN Confusion Ataxia Nystagmus Opthalmoplegia Peripheral neuropathy ```

Question 33

Cause of wernickes encephalopathy

Answer 33

Thiamine (Vit B12) deficiency

Question 34

Who is wernickes encephalopathy commonly seen in?

Answer 34

Alcoholics

Question 35

Causes of wernickes encephalopathy

Answer 35

Alcoholics Persistent vomiting Stomach cancer Dietary deficiency

Question 36

Classic triad of wernickes

Answer 36

1. Opthlamoplegia/nystagmus 2. Ataxia 3. Confusion

Question 37

Features of wernickes

Answer 37

``` Opthalmoplegia Nystagmus Ataxia Confusion - altered GCS Peripheral sensory neuropathy ```

Question 38

Investigations of wernickes encephalopathy

Answer 38

Decreased red cell transketolase | MRI

Question 39

Treatment of wernickes

Answer 39

Urgent replacement of thiamine

Question 40

What may develop if don't treat wernickes?

Answer 40

Korasskofs syndrome

Question 41

Features of korasskofs

Answer 41

Confabulation | Amnesia (anterograde and retrograde)

Question 42

Definition of confabulation

Answer 42

Make up stories in compensation for lost memories