NEURO

Question 1

BP Goals in Stroke

1. Ischemic (a,b,c)
2. Hemorrhagic
3. SAH

Answer 1

1a. <220/120
1b. (to give TPA) <185/110
1c. (after TPA) <180/105

2. <160 (maybe <140, maybe <200, ICP can help guide)
3. <160

Question 2

Contraindication to Lytic (Absolute)

Answer 2

• > 3h (AAN says 3, Europe says 4.5 ECASS III)
• Head trauma or prior stroke within 3mos
• SAH
• Arterial puncture and noncompressible site within 7d
• previous ICH (ever)
• intracranial neoplasm, AVM, aneurysm
• recent intracranial/spinal surgery
• BP >185/110
• Active internal bleed or bleeding diathesis
  
  • Plt <100k, PTT > ULN, INR >1.7
• use of DTI or factor Xa inhibitor
• Glucose <50
• multilobar infarction >1/3 hemisphere

Question 3

Relative contraindication to lytic

Answer 3

• Clearing spontaneously
• Pregnancy
• Major surgery/trauma within 14d
• GI or urinary tract hemorrhage within 21d
• acute MI within 3mos

Question 4

When to consider surgical intervention in posterior hemorrhagic stroke (4)

Answer 4

• posterior fossa hemorrhage >3cm
• brainstem compression
• rupture 3rd ventricle
• hydrocephalus

Question 5

In TBI goal MAP-ICP

Answer 5

> 60mmHg

Question 6

Sustained IC >20…

Answer 6

Withdraw CSF

Question 7

Invasive ICP monitoring indicated if:

Answer 7

1. GCS <8 and abnormality on CTh

2. 2 or more: SBP <90, motor posturing, age >40

Question 8

When to consider Thrombectomy:

Answer 8

1. Prestroke modified Ranksin scale 0-1 (normal to minimal disability)
   
   2. Causative occlusion is ICA or proximal MCA
   3. Age >18
   4. NIHSS score >6
   5. CT score (small area with hypodensity)
      Procedure initiated within 6h of symptom onset

Question 9

Prereq for brain death exam

Answer 9

1. Cause of coma known and reversible
   
   2. No evidence of CNS-depressing drugs
   3. Electrical nerve stimulation to prove not paralyzed if NM blockade has been used
   4. No severe acid-base, electrolyte, or endocrine abnml
   5. Core Body Temp > or = 36C
   6. SBP > or = to 100
      No spontaneous breaths on the vent

Question 10

Time course for lytic, intervention in ischemic stroke

Answer 10

1. TPA by 4.5h LKN
2. TPA by 3h if >80
3. Thrombectomy up to 24h if not resolving, Glu OK, and CTh perfusion shows large area involved in stroke but not infarcted, with large vessel infovlement– NNT of 3 for recovery to independence

Question 11

CAM-ICU (4)

Answer 11

1. RASS score -3 and higher AND
2. Acute change (from baseline) or fluctuation in mental status (fluc within 24h) AND
3. Inattention (C-A-S-A-B-L-A-N-C-A) AND either
   4a. Disorganized thinking (series of questions, commands) OR
   4b. alterred level of consciousness (RASS no 0)

Question 12

Seizure ppx after head bleed: key point

Answer 12

1. Not indicated in spontanoues bleed

2. Clear benefit in TBI/hemorrhage for 7d (abnormal CT, GCS <20, seizure at presentation)

Question 13

Abrupt Paralysis DDx

Answer 13

Botulism
GBS (including Miller-Fisher variant)
MG/Eaton-Lambert
Tick-related paralysis

Question 14

SAH: First need to know…

Answer 14

If aneurysmal as very high risk to rebleed. Much higher acuity and poorer outcomes. [85% ruptured Berry aneurysm]

Question 15

VTE ppx after ischemic stroke

Answer 15

lovenox better

start after second day

Question 16

Time course for lytic, intervention in ischemic stroke

Answer 16

1. TPA by 4.5h LKN
2. TPA by 3h if >80
3. Thrombectomy up to 24h if not resolving, Glu OK, and CTh perfusion shows large area involved in stroke but not infarcted

Question 17

OK to start anticoag in embolic strokes after:

Answer 17

48h

Question 18

Therapies that work and don’t work in traumatic brain injury

Answer 18

1. Tranexamic acid within 3h decreased mortality in moderate TBI
2. Prophylactic hypervent- worse outcomes
3. Cooling- worse outcomes
4. methylpred- incr mort and disability

Question 19

Best agent for reversal of warfarin

Answer 19

PCC (4 factor)- Kcentra

Question 20

SAH: First need to know…

Answer 20

If aneurysmal as very high risk to rebleed. Much higher acuity and poorer outcomes.

Question 21

Main complication after SAH:

Management

Answer 21

Vasospasm, DCI
Nimodipine
“HHH” hypervolemia, HTN, hemodilution- not clear but making them dry is definitely NOT good

Question 22

Key difference SIADH and cerebral salt wasting

Answer 22

Cerebral salt waste- volume down, natriuesis and diuresis

Question 23

Overview treat SAH:
1.
2.

Answer 23

1. Address rebleed- find if aneurysm and treat, BP contro, coag
2. address vasospasm (occurs in 70%), leads to delayed cerebral ischemia (DCI)

Question 24

Therapies that work and don’t work in traumatic brain injury

Answer 24

1. Tranexamic acid within 3h decreased mortality in moderate TBI
2. hypervent ppx- worse outcomes
3. Cooling- worse outcomes
4. methylpred- incr mort and disability

Question 25

To control increased ICP

Answer 25

1. Lower JVP 2. Hypervent to PCO2 25-35 3. Osmotic agent (mannitol or HTS), Na goal 150 4. Sedation (WITHOUT hypotension) 5. Keep PEEP 3-7 6. Drain CSF if ICP consistently >20 7. Decompressive hemicraniectomy- possibly improve mortality if <60 8. Methylpred if assoc with neoplasm - Cooling not work - albumin- worse outcomes

Question 26

Most Important Aspect of Management of increased ICP

Answer 26

AVOID HYPOTENSION, SBP >100

Question 27

Brain Death Prerequisites

Answer 27

1. Cause of coma known 2. Not cold (temp >36) 3. No profound acid/base, endocrine, or electrolyte abnml 4. hemodynamically stable (SBP >100) 5. No CNS depressing drugs 6. Electrical nerve stim to prove not paralyzed if NM blockade used 7. No spon breaths on vent

Question 28

DDx Abrupt Paralysis

Answer 28

1. GBS- ascending flaccid paralysis, begins with sensory. Tx: IVIG, PLEX 2. Botulism poisoning- descending flaccid paralysis; Antitoxin 3. MG (Eaton Lambert)- proximal muscles, abx to avoid 4. Tick borne paralysis- flaccid paralysis

Question 29

Overview treat SAH: 1. 2.

Answer 29

1. Address rebleed- find if aneurysm and treat, coag | 2. address vasospasm

Question 30

Spontaneous ICH: 1. Poorer prognosis 2. Treatment

Answer 30

1. Brainstem, involve ventricle | 2. may be subset of pt who benefit, but aggressive BP control does not seem to improve mort or function

Question 31

Hemicraniectomy 1. when/who 2. when to avoid

Answer 31

1. within 48h, <60yo malignant MCA with large area stroke, shown to improve mortality with acceptable functional outcomes 2. -Did not show benefit in trauma patients. - Older patients >60, improved mortality but no more likely to achieve functional independence

Question 32

Most Important in Management of intracranial hypertension:

Answer 32

Avoid Hypotension- Keep SBP >100, MAP-ICP >70

Question 33

Effect of TPA:

Answer 33

1. Does not change mortality 2. Does increase likelihood of recovery to independence. 3. Higher risk of hemorrhage, but taken as a whole, improved chances of recovery

Question 34

GCS

Answer 34

Motor (6). 1. No response 2. Extension 3. Flexions 4. Withdraws 5. Localizes 6. Follows commands Verbal (5) 1. No response 2. Incomprehensible Speech 3. Disoriented, inappropriate 4. Confused, appropriate 5. Oriented, alert Eyes (4) 1. No response 2. Eyes open to pain 3. Eyes open to voice 4. Eyes open spontaneously

Question 35

Mild TBI

Answer 35

aka concussion, GCS 13-15 | -often brief loss of consciousness, confusion, amnesia

Question 36

Moderate TBI

Answer 36

GCS 9-13 - Prolonged LOC - abnormal neuroimaging, neuro deficits - necessitates hospitalization

Question 37

Severe TBI

Answer 37

GCS 8 or less - frequently with skull fracture, ICH, or contusion - also often have SDH, EDH, and SAH

Question 38

Neurogenic shock with

Answer 38

High T spine or c-spine injury

Question 39

Autonomic dysrrelexia typically if injury above

Answer 39

complete spinal cord injury above T6 level

Question 40

RASS +4

Answer 40

Combative

Question 41

RASS +3

Answer 41

Very agitated

Question 42

RASS +2

Answer 42

Agitated

Question 43

RASS +1

Answer 43

Restless

Question 44

RASS 0

Answer 44

Alert and clam

Question 45

RASS -1

Answer 45

Drowsy, not fully alert, but has sustained awakening with eye contact to voice

Question 46

RASS -2

Answer 46

Light sedation, <10sec awakens with eye contact to voice

Question 47

RASS -3

Answer 47

Moderate sedation, any movement to voice

Question 48

RASS -4

Answer 48

Deep Sedation, No response to voice, movement to physical stimuli

Question 49

RASS -5

Answer 49

No response to voice or physical stimuli

Question 50

Outline TTM

Answer 50

TTM- 32-34C 12-24h TTM for out of hospital VT/VF arrest and unresponsive -Improved neurological outcomes -Exact best method not established -Passive rewarming -S/E: Coag, immune suppression, electrolyte, diuresis, CV dysfunction -Avoid in trauma, sepsis

Question 51

Drugs that worsen MG

Answer 51

aminoglycoside, quinolones, macrolide, Li, CCB, betablocker

Question 52

TPA within (time)

Answer 52

4.5 hours!

Question 53

Class 1A for Endarterectomy (CEA)

Answer 53

``` 70-99% and symptomatic Symptomatic and 50-69% class 1B ```

Question 54

Class IIA for CEA

Answer 54

Asx and 70-99%