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Neuro Assessment Flashcards

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1
Q

incidence of stroke

A

<0.1% in non-neurosurgical and non-cardiac cases

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2
Q

mortality of stroke for non-cardiac surgery and cardiac surgery

A

non-cardiac = eight-fold increase

cardiac = as high as 38%

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3
Q

risk factors for stroke

A

history of previous stroke/TIA
advanced age
renal disease

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4
Q

what type of surgery carries the highest risk?

A

cardiac (and valve surgery within that)

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5
Q

moyamoya syndrome

A

cerebrovascular disease characterized by narrowing of distal internal carotid arteries and its proximal branches

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6
Q

what other diseases is moyamoya syndrome associated with

A

sickle-cell

Neurofibromatosis

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7
Q

how do you treat moyamoya syndrome

A

antiplatelets and revascularization

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8
Q

anesthetic eval for stroke patients

A

cause/timing/symptoms/residual effects
echocardiogram is warranted
auscultate and palpate carotid arteries for bruits

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9
Q

anesthetic considerations for stroke patients

A 
antiplatelet therapy = bleeding risk (cesstion of therapy with or without bridging)
aka risk of thromboembolism must be weighed against bleeding risk

also if patient has been largely immobile - sux is contraindicated

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10
Q

what are increased risk factors for stroke patients undergoing anesthesia

A

stroke/TIA or thromboembolism in the last 3 months
genetic predisposition
CHA2DS2VASC score >2

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11
Q

asymptomatic patients presenting with what problem puts them at great risk for periop stroke

A

carotid stenosis

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12
Q

anesthetic implications of carotid bruit

A

large hemodynamic instability
surgery requires significant head/neck manipulation - watch the tube
positioning compromises blood flow

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13
Q

what is the gold standard for diagnosing carotid bruit and what is the acceptable first-line study

A

carotid arteriography = gold standard

carotid duplex is ok too

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14
Q

dementia

A

neurocognitive disorder characterized by a decline/change in memory, language, problem solving, and cognitive skills

commonly caused by alzheimer, vascular dementia, parkinsons

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15
Q

incidence of alzheimer

A 
>65 = 1/9
>85 = 1/3
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16
Q

perioperative screening for dementia

A

montreal cognitive assessment

mini-cog (3 min)

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17
Q

anesthetic considerations of dementia - meds

A

cholinesterase inhibitors may prolong effects of Succ and increase risk of pulm complications

NMDA antagonist and SSRIs may interact with anesthetics

Gingko can caused increased risk for bleeding

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18
Q

anesthetic considerations of dementia (not meds)

A

KNOW BASELINE
reduce periop risks like post-op delirium
avoid benzos and antihistamines
variable BP can be detrimental to patients with a predisposition for dementia
consider regional when appropriate

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19
Q

Parkinson’s

A

loss of dopamine-containing neurons from the pars compacta of the substantia nigra with intracytoplasmic inclusion “Lewy bodies” is the hallmark finding

results in unopposed action of ach in extrapyramidal motor system

  • bradykinesia
  • rigidity
  • tremor
  • postural instability
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20
Q

what are two major symptoms of parkinsons that put patient at high risk while undergoing anesthesia

A

dysphagia

respiratory dysfunction

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21
Q

anesthetic considerations for patient with Parkinsons

A

continue home meds
avoid meperidine and dopa agonists
bipolar cautery is preferred in patients with deep brain stimulators and keep ground pad as far from possible
NDMBs have little impact

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22
Q

Myasthenia gravis

A

autoimmune disease where antibodies attack the postsynaptic Ach receptor
present with proximal muscle weakness that is exacerbated with activity and relieved with rest

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23
Q

treatment for MG

A 
pyridostigmine - increased circulating Ach
glucocorticoids
immunosuppressives - infection risk
IV immunoglobin
thymectomy - infection risk
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24
Q

how do you differentiate between myasthenic and cholinergic crisis

A

edrophonium administration

this increases Ach so if you give it and they get better its myasthenic crisis and if they get worse its cholinergic crisis

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25
what is MG associated with
RA thyroiditis autoimmune hematologic disorders cardiac involvement
26
anesthetic considerations of MG: elective vs emergency surgery
elective: safe in stable patients with well-controlled or mild disease emergency: optimize with plasma exchange
27
MG considerations for muscle relaxants
NDMRs - effect is increased due to diminished number of ACh receptors succ - effect is reduced, however block can be prolonged due to therapeutic cholinesterase inhibitors
28
anesthetic considerations for MG
may require post-op ventilation administration of glucocorticoids preop aspiration prophylaxis
29
scoring system to predict post op vent support needs
MG >/= 6 years (12 pt) history of chronic resp disease (10 pt) pyridostigmine dose > 750 mg/day (8 pt) vital capacity < 2.9 L (4 pt)
30
multiple sclerosis
rare autoimmune demyelinating disease of the brain and spinal cord with varied symptoms that progress toward fixed deficits
31
multiple sclerosis treatments
supportive: corticosteroids and immunosuppresant drugs
32
multiple sclerosis anesthesia implications
review chart for chronic pain meds upregulation of Ach - so no succ aspiration risk GA: risk for post op resp failure and cardiac dysfunction and hypotension RA: poor response to fluids or pressors and also it can be difficult to assess return to baseline with blocks because these patients often have parasthesias at baseline maintain normothermia
33
muscular dystrophy
group of inherited disorder presenting with muscle wasting and weakness recessive mutation in the dystrophin gene on the x chromosome
34
what are the most common types of muscular dystrophy
duchenne and becker
35
periop complications of muscular dystrophy include
``` rhabdo hyperkalemia malignant hyperthermia cardiac arrest dilated cardiomyopathy (duchenne's) ```
36
preop considerations of muscular dystrophy
all patients with duchenne will develop dilated cardiomyopathy - 75% will have ECG abnormalities - need a preop ECG and echocardiography restrictive lung disease occurs - determine baseline O2 sat on room air - PFTs important (FVC<50% with ineffective cough requires training in NIPPV as well as cough assist)
37
lambert eaton syndrome
autoantibodies attack presynaptic calcium channels
38
treatment for lambert eaton
3,4 diaminopyridine, pyridostigmine plasmapheresis immune globulin
39
presenting symptom of lambert eaton
proximal weakness in pelvic and truncal areas | patient weakest in morning with improvement during day
40
anesthetic considerations of lambert eaton
comp history and exam (extent of weakness, stiff aching muscles, altered gait) assess for pharyngeal weakness spirometery and PFTs determine risk of postop resp complications - vital capacity < 2.9 may indicate need for post op vent continue meds avoid blocks if possible increased risk of post op pulm complications avoid hyperthermia
41
incidence of aneurysms
3.2 % and only 0.25% rupture (10% die pre-hospital)
42
sign of aneurysm
worst headache of their life
43
treatment goal of aneurysm
prevent subsequent hemorrhage microvascular clipping endo-vascular clipping
44
what disorders are aneurysms associated with
marfan, ehler danlos, autosomal dominant polycystic kidney disease, coarctation of the aorta, bicuspid aortic valve, pseudoxanthoma elasticum, pheo
45
arteriovenous malformation
triangle of abnormal vessels referred to as a nidus | presentation includes hemorrhage seizures and neuro deficits
46
treatment options for AVM
endovascular embolization stereotactic radiosurgery surgical removal
47
Fluid and electrolyte probs with aneurysm and AVM
hyponatremia caused by SIADH/CSW hypokalemia hypocalcemia hypomagnesemia intravascular volume deficit
48
cardiac considerations of aneurysm/avm
mycocardial dysfunction possible d/t catecholamine release = dysrhythmia, prolonged QT, T-wave abnormalities
49
Guillian Barre'
leading cause of acute autoimmune neuromuscular paralysis -2/3 of patients who develop GB had an infection within the prior 6 weeks (campylobacter jejuni, Epstien-Barr, mycoplasma pneumoniae, cytomegalovirus) characterized by general weakness that begins in lower extremities
50
how do you diagnose GB
lumbar puncture
51
anesthetic considerations of GB
avoid NMBDs, ET intubation, and mechanical vent when possible - upregulated nAChRs, exaggerated response to surgical stim, GBS worsens after surgery - regional anesthesia is safer and LA reqs are often decreased
52
focal seizure
originates from one point in the cerebral hemisphere
53
generalized seixure
arises from both hemispheres
54
therapy for seizures
preferred monotherapy anti-epileptics also can use adrenal corticotropic hormone, corticosteroids, ketogenic diet
55
anesthetic considerations of seizures
get a good history seizures should be well-controlled and triggers limited prior to surgery benzos can help enhance sedative effects NS is preferred for patients on ketogenic diet antiepilileptic drugs should be continued
56
meningiomas
36% of intracranial tumors - arise from dura or arachnoid - most benign - more common in women
57
gliomas
24% of intracranial tumors - arrive from astrocyte anaplasia - numerous types (glioblastoma worst) - median survival 14 months following diagnosis
58
common features of tumors
``` mass effect with neuro deficit - may cause false localizing signs increase in ICP papilladema and headache unsteady gait seizures vomiting ```
59
anesthetic considerations of tumors
review history including symptoms and current/past therapies | preop study - electrolytes (glucose), CBC, blood type and cross, ECG
60
monroe kelly doctrine
skull is a closed vault containing tissue, blood, and CSF and if there is an increase in one the others have to decrease, or ICP will rise
61
what icp causes cerebral ischemia
50-60mmhg
62
cushings triad
hypertension, bradycardia, irregular breathing
63
anesthetic considerations of intracranial hypertenstion
``` detailed neuro history and determine etiology GCS < 8 intubate labs = CBC, osmolality (expect hyponatremia) get ECG (neurogenic myocardial ischemia) continue meds as indicated ```
64
TBI classified by
etiology severity location
65
TBI severity as rated by GCS
mild = 13-15 moderate = 9-12 severe < 8
66
anesthetic implications of TBI
are there concominant injuries? - aka spine? support BP, O2, and thermoreg (expect low BP, high temp, and low O2) monitor ICP and treat labs - CMP, CBC, PT/INR, toxicology
67
what is your ICP goal for TBI
ICP < 20 with CPP 50-70 | CPP = MAP - ICP
68
how to treat elevated ICP
elevate HOB 30-45 keep body midline hyperosmolar/hypertonic solution (mannitol/3-23% saline)
69
dosing for mannitol
initial bolus 1g/kg with repeat dosing every 6 hours 0.25 g/kg
70
lab goals for hypertonic saline infusion
maintain serum osmolality <360 and serum sodium <160 mg/dl
71
quick way to determine sodium from serum osmolality
half your serum osmo and it should be within 10 pt
72
autism
neurodevelopment disorder diagnosis 1 in 68 4x greater in males social communication deficits and social interaction deficits with repetitive patterns of behavior patients exhibit intellectual disability (IQ<70), anxiety, panic, oppositional defiant disorder, self-injury, attention deficit, fine and gross motor probs
73
anesthetic considerations of autism
continue preop meds because risk for withdrawal/psychosis assess routines simple language and use visual aids premed with benzos
74
protopathic
noxious sensation
75
epicritic
non-noxious sensation
76
nociception
the neural responses to traumatic or noxious stimuli (causes pain)
77
pain perceptions can be different d/t
gender (men>women) | age (decrease with age, infants unable to communicate)
78
how is pain classified
clinically (acute/chronic) patho (nociceptive vs neuropathic) etiology (what is causing it) location
79
evolution of chronic pain
failure of resolving pain despite tissue healing resulting in occult inflammation and unrecognized failure of tissue healing or when faced with persistent stimulation changes occur to afferent nervous system leading to allodynia
80
two aspects of perceptive pain
sensory discriminators in the dorsal horm to the thalamus and sensory cortex - causes perception of pain affective motivators from the dorsal to limbic system and prefrontal cortex - causes perception of repulse
81
neurologic pain
an infrequent symptom of a neuro disease including conditions such as trigeminal neuralgia, cluster headaches, shingles, sciatica
82
inflammation of the meninges S&S
complain of pain with neck flexion and extension
83
brudzinskis sign
pain with resistance to motion
84
kernigs sign
pain with resistance to knee extension
85
what is the other name for trigeminal neuralgia and how does it present
tic douloureux presents with jabbing pain lasting seconds in the maxillary and mandibular distributions of trigeminal nerve
86
components of a neuro assessment
``` general appearance mental status cranial nerves motor function reflexes sensory function cerebellar function ```
87
general appearance assessment includes
body symmetry and musculoskeletal assessment
88
mental status assessment includes
LOC (behavior and arousability) orientation describe in observational terms
89
motor function scale
``` 0= no muscle twitch with attempted movement 1= muscle twitch with no movement 2=movement along horizontal plane 3=movement against gravity 4=movement against slight resistance 5=movement against full resistance ```
90
reflexes occur through
activation of the stretch receptor that communicates with lower motor neurons in the anterior horn can be deep tendon or superficial
91
reflex scale
``` 0 - no response 1 - diminished response 2- normal 3 - increased 4 - clonus ```
92
hyporeflexia
indicates lower motor function neuron lesions myopathies and spinal cord (anterior) lesions
93
hyperreflexia
usually present in MS patients and neuro diseases corticospinal tract
94
jendrassiks manuever
in patients with decreased reflexes, isometric contraction of other muscles will increase reflex action
95
what reflexes do we test
``` biceps Triceps brachioradialis patellar achilles ```
96
testing reflex of biceps tendon
tests nerve c5-6 observe for contraction of biceps tendon (hammer hits in crease of AC over provider thumb)
97
testing brachioradilais reflex
tests nerve roots of c5-c6 observe for flexion at the elbow and simultaneous supination of forearm reflex hammer hits about 2-3cm above thumb on side of forearm (per pic)
98
testing of triceps tendon
test nerve roots c6-8 prompt contraction of the triceps tendon with extension of the elbow hammer hits just above elbow with patient arm bent
99
testing patellar reflex
test nerve roots L2-4 quadriceps contraction hammer hits on soft spot of knee with patient leg dangling and bent over table/chair (per pic)
100
testing achilles reflex
assess S1-2 plantar flexion of ankle provider support foot and hits achilles tendon on back of heel at about the same level as the lateral malleolus (per pic)
101
superficial reflex test - the babinski reflex
assess nerve roots L5-S2 if positive you sill see dorsiflexion of big toe with fanning of toes should be negative in adults
102
touch and pain are conducted where?
at representative dermatome levels
103
vibratory assessment is performed where
at distal joints, working proximally as deficiencies are identified
104
cerebellar function
brain GPS coordinates motor, vestibular, and sensory
105
how to test cerebellar function
finger to nose, heel to shin, romberg test
106
carotid artery atherosclerosis is a significant contributor to
ischemic brain attack and CVA
107
what puts you at an increase risk for significant carotid stenosis
cervical bruit, AAA, previous neuro event
108
carotid ultrasound
in transverse orientation you should see SCM above IJ (collapsable) and you should see the carotid artery and should be able to follow it up until it splits into the external and internal carotid artery in longitudinal view, at the bifurcation you should see the external carotid above your internal carotid cephalad and just the common carotid caudally
109
ICP ultrasound assessment of optic nerve
optic sheath is the most distal portion of the nerve with dura as ICP increases, CSF is distributed through the dura, dilating the sheath 3mm from vitreous humor (eyeball) you can measure the width of the optic nerve sheath <5mm = normal, >5mm = problem

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