L3_Cerebral Vascular Problems (2)_Cerebral Aneurysm AV Malformations_Moodle

Question 1

what is three components of Monro-Kellie hypothesis

Answer 1

caerebrospinal fluid 10%
intravascualr blood 12%
brain tissue 78%

Question 2

what is suggested by Monro-Kellie hypothesis

Answer 2

3 components must remain at a relatively constant volume within the closed skull.

Question 3

what if If the volume of any one of the 3 components increases within the cranial vault under Monro-Kellie hypothesis?

Answer 3

vault & the volume from another
component is displaced, the total volume will not changed.

Question 4

how can CSF volume be changed?

Answer 4

can be changed by altering CSF absorption or production, displacing
CSF into spinal subarachnoid space.

Question 5

how can intracranial blood volume be chnaged?

Answer 5

Changes in intracranial blood volume can occur through the collapse of cerebral veins & dural sinuses, regional cerebral vasoconstriction of dilation, changes in venous outflow.

Question 6

how can brain tissue volume be changed?

Answer 6

Brain tissue volume compensates through distention of the dura or
compression of brain tissue

Question 7

what is the range of MAP under normal function of autoregulation of cerebral blood flow?

Answer 7

MAP 70-150 mmHg

Question 8

what if MAP< 70 mmHg

Answer 8

CBF decreases and symptoms of cerebral ischemia, such as syncope and blurred vision occurs.

Question 9

what if MAP>150 mmHg

Answer 9

If MAP >150mmgHg, when this pressure exceeded, the vessels are maximally
constricted, & further vasoconstrictor response is lost.

Question 10

what is the normal range of ICP

Answer 10

5-15 mmHg

Question 11

what is the normal range of CPP

Answer 11

60-100 mmHg

Question 12

what is the relationship between CPP, MAP and ICP

Answer 12

CPP= MAP-ICP

Question 13

what is the relationship between MAP, DBP and SBP?

Answer 13

MAP= DBP+ 1/3 (SBP-DBP)

Question 14

what are associated with CPP< 50 mmHg (2)

Answer 14

CPP < 50 mmHg is associated with ischemia and neuronal death.

Question 15

what are associated with CPP< 30 mmHg?

Answer 15

ischemia and is incompatible with life

Question 16

complications of increased ICP (3)

Answer 16

1. brain herniation (occurs late in the course of ↑ICP) and
2. Compression of the brainstem lead to respiratory arrest
3. brain death (occurs when cerebral blood
   flow stops)

Question 17

LOC under increased ICP

Answer 17

decreased, progresses to coma and no response to painful stimuli

Question 18

motor function under increased motor function

Answer 18

Weakness in one
extremity or side
progressing to
hemiplegia opposite the brain injury side
–> Decorticate or
decerebrate posturing

Question 19

3 components of Cushing’s traid

Answer 19

increased systolic BP
widening pulse pressure
bradycardia

Question 20

why have bradycardia and increased SBP under increased ICP

Answer 20

if patient have increased ICP because of hematoma, we want CPP to be constant. Therefore, MAP increases. therefore we have hypertension. we also have parasympathetic nervous system. it notices high BP and reduces HR, leading to bradycardia

Question 21

other symptoms under increased ICP

Answer 21

headache worse on rising in the morning and with position changes, projectile vomiting

Question 22

unilateral fixed dilated pupil

Answer 22

pressure on ipsilateral cranial nerve III (oculomotor nerve)

Question 23

bilateral fixed and dilated pupils

Answer 23

severe brain anoxia and ischemia, bilateral CNIII compression

Question 24

pinpoint pupils

Answer 24

brain stem hemorrhage

Question 25

pinpoint, nonreactive pupils

Answer 25

pons damage

Question 26

bilateral fixed dilated pupils

Answer 26

brain herniation

Question 27

small, equal, reactive pupils

Answer 27

bilateral diencephalic damage affecting sympathetic innervation originating from hypothalamus

Question 28

nonreactive, midpositioned pupils

Answer 28

midbrain damage

Question 29

instillation of mydriatics (atropine, scopolamine) and orbital injuries may cause

Answer 29

unilateral fixed and dilated pupil

Question 30

medication such as dopamine, amphetamine and atropine may cause

Answer 30

bilateral fixed and dilated pupils

Question 31

miotic agents and opiates overdose may lead to

Answer 31

pinpoint, nonreactive pupils

Question 32

metabolic dysfunction may lead to

Answer 32

small, equal, reactive pupils

Question 33

describe cheyne-stokes respirations

Answer 33

Regular cycles of respirations that gradually increase in depth to hyperpnea and then decrease in depth to periods of apnea

Question 34

what does cheyne-stokes respirations indicate

Answer 34

Usually bilateral lesions deep within cerebral hemispheres, diencephalon, and basal ganglia

Question 35

describe central neurogenic hyperventilation

Answer 35

deep, rapid respiration

Question 36

where is affected if central neurogenic hyperventilation

Answer 36

midbrain, upper pons

Question 37

describe apneustic respirations

Answer 37

Prolonged inspirations followed by a 2 to 3 second pause; occasionally may alternate with an expiratory pause

Question 38

where is affected if apneustic respirations

Answer 38

lower pons

Question 39

describe cluster respirations

Answer 39

Clusters of irregular breaths followed by an apneic period lasting a variable amount of time

Question 40

where is affected if cluster respirations

Answer 40

lower pons and upper medulla

Question 41

describe ataxic respirations

Answer 41

Irregular, unpredictable pattern of shallow and deep respirations and pauses

Question 42

where is affected if ataxic respirations

Answer 42

medulla

Question 43

what is intracerebral hemorrhage

Answer 43

rupture of a vessel, usually in the basal ganglia

Question 44

what is the range of rate of 30 day mortality for intracerebral hemorrhage?

Answer 44

40-80%

Question 45

what is the portion of patients with intracerebral hemorrhage die within 48 hrs

Answer 45

half

Question 46

what is the most common cause of intracerebral hemorrhage

Answer 46

hypertension

Question 47

other cause of intracerebal hemorrhage (6)

Answer 47

* vascular malformations * coagulation disorders * anticoagulant and thrombolytic drugs * trauma * brain tumors * ruptured aneurysms.

Question 48

what is subarachnoid hemorrhage

Answer 48

bleeding into the subarachnoid space

Question 49

cause of subarachnoid hemorrhage

Answer 49

caused by rupture of a cerebral aneurysm or arteriovenous malformation

Question 50

range of mortality rate of subarachnoid hemorrhage

Answer 50

25-50%, most patient die on first day

Question 51

posttest of femoral artery site care after cerebral angiogram (5)

Answer 51

1. After the diagnostic catheters are removed from the femoral artery, pressure is applied to the femoral vessels until bleeding has stopped. 2. The patient remains flat for up to 6 hours to allow the femoral arterial puncture site to form a stable clot. 3. Check the groin area for bleeding or hematoma. 4. Monitor dorsal pedal and posterior tibial pulses hourly of affected limb. 5. Check the color, temperature, pain or paresthesia to detect early evidence of acute arterial occlusion.

Question 52

what is endovascular coiling

Answer 52

* a percutaneous transfemoral approach * the catheter is threaded up to the internal carotid artery. * Specially microcatheters are then manipulated into the area of the vascular anomaly, and embolic materials are placed endovascularly.

Question 53

what is surgical clipping

Answer 53

* Craniotomy to expose and isolate the area of aneurysm or AVM. * A clip is placed over the neck of the aneurysm to eliminate the area of weakness.

Question 54

how to monitor respiratory status (5)

Answer 54

* High priority to maintain patent airway for patient with stroke ! * Monitor RR * SpO2, keep > 90 -92% (to prevent hypoxia and worsening the brain injury) * Administer oxygen as ordered (no routine oxygen administration) * Seizure precaution by Positioning to side lying/recovery position * +/ -assist in intubation if severe pre pre-existing or acute pulmonary disease/acute aspiration/LOC with risk of aspiration

Question 55

how to monitor neurological status (5)

Answer 55

* Ensure prompt assessment of patient at least q1-2h for first 24 hr * Monitoring neurological signs (e.g. GCS/NIHSS) * detect any early S/S of new neurological deficits caused by cerebral edema or ↑ICP, decrease in limb powers, unequal pupil sizes * Observes for signs of increased ICP e.g. decreased LOC, headache ( more common with SAH), nausea, vomiting (more common with ICH), slurred speech, and Cushing's triad. * Elevate the head of the bed * Prepare for neurosurgery to evacuate intracerebral bleed or to repair vascular defect, as indicated.

Question 56

how to monitor BP

Answer 56

* antihypertensive medications should be restarted at approximately 24 hours after stroke onset in patients with preexisting hypertension who are neurologically stable * intravenous labetalol and nicardipine as first first-line antihypertensive agents if pharmacologic therapy is necessary in the acute phase

Question 57

why we cannot drop BP rapidly

Answer 57

gradual BP reduction (5-15%) with 24 hrs. rapid BP lowering may lead to cerebral infarction (caused by sudden inadequate blood supply to brain due to sudden change in BP

Question 58

ischemic stroke BP management

Answer 58

allow Bp < SBP 220 mmHg and DBP < 120 mmHg UNLESS patient was treated with thrombolytic therapy

Question 59

hemorrhagic stroke

Answer 59

Bp < SBP 180 mmHg and DBP < 105 mmHg

Question 60

how to reduce risk of aspiration

Answer 60

1. Monitor level of consciousness, cough reflex. 2. A swallowing assessment should be performed as soon as possible after admission within first 24 hrs and before any oral intake. 3. Consult speech therapist if necessary and follow prescription if any, e.g. * Take smaller boluses of food * Puree diet * Use thickener as prescribed for liquid (water, juice) 4. Inform doctor if patient cannot tolerate oral feeding with choking and NG feeding may prescribed to ensure adequate nutrition

Question 61

3 teaspoons or table spoons thicken up in 100ml H20?

Answer 61

teaspoons

Question 62

how to manage impaired physical mobility

Answer 62

1. Collaborate with physiotherapist and occupational therapist in developing exercise program. 2. Encourage passive and active exercise 3. Apply splints to achieve stability of proximal joints involved with fine motor skills to prevent contractures. 4. Provide restful environment for patient after periods of exercise to facilitate recuperation.

Question 63

how to manage impaired verbal communication

Answer 63

1. Listen attentively to convey the importance of patient’s thoughts and promote a positive environment for learning. 2. Use simple words and short sentences to avoid overwhelming patient with verbal stmuli 3. Provide verbal prompts and reminders to help patient to express self (e.g. picture)

Question 64

unilateral neglect management

Answer 64

1. Monitor for abnormal responses * Inability to see objects on affected side * Leaving food on plate that correspond to affected side * Lack of sensation on affected side. 2. Instruct patient to scan from Lt to Rt to visualize the entire environment. 3. Rearrange the personal items within view on unaffected side to compensate for visual field deficits.

Question 65

how to maintain bladder function

Answer 65

* Encourage fluid intake, acidification of the urine to avoid urinary tract infection (UTI) * Bladder training Q2H --> possibility of establishing normal bladder function * Monitor I/O * Do not suggest insertion of an indwelling catheter in the rehabilitation period unless for those with skin complications!

Question 66

maintain bowel function

Answer 66

* Constipation is the most common problem! * Developed a bowel training program * Provide food that stimulates defecation (e.g. high fiber diet, roughage, prune juice) * Encourage fluid intake & exercise

Question 67

how to reduce risk for impaired skin integrity

Answer 67

1. Assess patient’s skin regularly especially on bony areas and dependent parts of the body. 2. The patient’s skin keep clean and dry. 3. Maintain a regular turning schedule with minimize shear and fiction forces 4. Apply pressure relieving devices (e.g. low air loss mattress, heel protector) 5. Maintain adequate nutrition.

Question 68

how to maintain motor function and prevent complications

Answer 68

* Frequent turning * Maintain good body alignment: correct positioning * provide appropriate support with pillows or cushions

Question 69

what is the correct positioning

Answer 69

* avoid pressure on shoulders, ulnar and peroneal nerve when turning and positioning * prevent shoulder adduction by placing a pillow in the axilla to keep arm away from chest when turning.

Question 70

eating devices

Answer 70

* Nonskid mates to stabilize plates * Plate guards to prevent food from being pushed off plate * Wide -grip utensils to accommodate a weak grasp

Question 71

bathing and grooming devices

Answer 71

* Long handled bath sponge * Grab bars, nonskid mats, handheld shower heads * Shower & tub seats, or on wheels

Question 72

toileting aids

Answer 72

* Raised toilet seat * Grab bars next to toilet

Question 73

dressing aids

Answer 73

* Long handled shoe horn * Velcro closures

Question 74

mobility aids

Answer 74

* canes * walkers * wheelchairs

Question 75

how to deal with low self-esteem of patient

Answer 75

1. Assess patient’s emotional state 2. Assist in setting realistic goals to achieve higher self self-esteem 3. Reward or praise patient’s progress toward reaching goals 4. Introduce relevant social resources (e.g. MSW, support group, respite service) 5. Introduce coping skill to patient and caregivers for managing stress, emotion and loss.

Question 76

what are the purpose of home visit before discharge

Answer 76

* Home modifications to help patient more independent * Ensure a safe home environment

Question 77

what community support can we give

Answer 77

* geriatric day center, meals on wheels * Respite care (relieve family from continuous 24 hours care)