Neuro Diseases Flashcards
(184 cards)
1
Q
What 3 regions of the brain are responsible for coma?
A
Reticular activating system #1, Thalamus, and Cortex
2
Q
What are 3 things that can cause coma?
A
disease, injury, drug induced
3
Q
What are the two subtypes of causes of coma?
A
Structural lesions, Diffuse disorders
4
Q
What are some structural lesions that can cause coma?
A
tumor, stroke, intracranial bleed
5
Q
What are the diffuse disorders that can cause coma?
A
hypothermia, hypoglycemia, drugs, postictal states, encephalopathy
6
Q
What are the eye opening Glasgow coma scale scores for: to pain spontaneously no response to speech
A
to pain 2
spontaneously 4
no response 1
to speech 3
7
Q
What are the verbal response Glasgow coma scale scores for: Oriented no response inappropriate words confused incomprehensible sounds
A
Oriented 5 no response 1 inappropriate words 3 confused 4 incomprehensible sounds 2
8
Q
What are the motor response Glasgow coma scale scores for: flexion withdraw to pain no response moves to localized pain abnormal flexion (decorticate) obeys commands abnormal extension (decorticate)
A
flexion withdraw to pain 4 no response 1 moves to localized pain 5 abnormal flexion (decorticate) 3 obeys commands 6 abnormal extension (decorticate) 2
9
Q
What GCS score is consistent with a comatose patient?
A
8 or less
10
Q
What should be included in a basic neuro exam?
A
pupil response to light, extra ocular muscle reflexes, extremity gross motor response
11
Q
What are normal pupil diameter?
A
3-4 mm
12
Q
What is anascoria? Is is normal?
A
1mm difference in normal pupil diameter (one eye may be bigger or smaller)
13
Q
Opioid or organophosphate intoxication, a focal pontine lesion or neurosyphilis is characterized by this pupil size?
A
Pinpoint 1mm
14
Q
Diencephalon compression leads to which type of pupils?
A
small 2mm, but reactive to light
15
Q
unresponsive midsize (5mm) pupils usually indicates what?
A
brainstem compression
16
Q
Compression of this brain area leads to unresponsive midsize (5mm) pupils?
A
midbrain
17
Q
Oculomotor nerve compression is indicated by which type of pupils?
A
fixed and dilated (7mm)
18
Q
Besides oculomotor nerve compression, fixed and dilated (7mm) pupils may indicate what 2 things?
A
anticholinergic or sympathomimetic drug intoxication
19
Q
Which cranial nerves can be assessed by extra ocular muscle function?
A
3, 4, 6
20
Q
What is a normal oculocephalic reflex?
A
eyes deviate opposite the side the head is turned
21
Q
What is oculocephalic reflex response would be expected in a comatose patient?
A
eyes follow head movement or stay midline
22
Q
What is a normal oculovestibular reflex (cold caloric testing)?
A
Eyes move toward the ear the cold saline is injected into
23
Q
What is a oculovestibular reflex (cold caloric testing)response would be expected in a comatose patient?
A
Eyes stay midline
24
Q
Mild to moderate diffuse brain dysfunction above the diencephalon usually leaves the patient with what reactions to painful stimuli?
A
intact or semi purposeful reaction
25
What does a unilateral reaction to painful stimuli indicate?
one sided tumor or stroke
26
Does Diencephalon dysfunction lead to decorticate or decerebrate posturing?
decorticate
27
What patient movements are consistent with decorticate posturing?
flexion at the elbow, adduction of shoulder, extension of the knee, plantar flexion
28
Does more severe brain dysfunction lead to decorticate or decerebrate posturing?
decerebrate
29
What patient movements are consistent with decerebrate posturing?
elbow extension, internal rotation (pronation) of forearm, leg extension, plantar flexion
30
What type of posturing does pontine or medullary lesion result in?
no response to pain.
31
What should you always know about your patient coma before taking care of them?
the cause of the coma
32
If the cause of your patients coma is a TBI what should be avoided?
steroids, no hyperventilation for 24 hours after insult
33
What medication should be avoided in TBI?
ketamine
34
What neuromuscular blocker increases ICP?
succ
35
What is permanent cessation of total brain function and must involve coma of an irreversible cause?
brain death
36
What are criteria to determine brain death?
lack of spontaneous movement
lack of cranial nerve reflexes and function
Positive apnea test
37
Along with lack of cranial nerve function, what other test must be done?
0.04mg/kg Atropine with failure of HR to increase by 5bpm
38
How is an apnea test performed?
PaCO2 35-45, and pH 7.35-7.45 first. Then ventilation with 100% FiO2 for 10 minutes. Stop ventilating, continue 100% FiO2 for 10 minutes. ABG after 5 and 10 minutes.
39
What does a positive apnea test mean?
No spontaneous respiratory effort is made during the apnea test.
40
What is a potent stimulus for ventilation?
hypercarbia
41
What are some "other" brain death tests?
isoelectric EEG, absence of CBF on doppler, angiography
42
During organ donation are we more concerned about the donor or recipient?
recipient
43
Neurogenic shock, DI, 3rd spacing, and pharmacologic management lead to what in the brain dead patient?
hypotension
44
How is HoTN in brain death patients preferably managed?
aggressive fluids and inotropes.
45
What are the preferred inotropes in managing HoTN in brain dead patients?
Dopamine and Dobutamine
46
What is third line treatment for HoTN for organ donation patients?
Epi
47
Why is Epi avoided in the patient is donating their heart??
causes catecholamine induced cardiomyopathy
48
Should dysrhythmias be shocked for the patient donating their organs?
No. Pace or treat with drugs.
49
What can PEEP lead to?
barotrauma, decreased CO, hypoxemia
50
Hypovolemia, hypotension, hyperosmolarity, and electrolyte abnormalities in brain dead patients is typically caused by what?
DI
51
What is the preferred treatment of DI in brain death patients?
Desmopressin 1-4mcg
| Vasopressin is another treatment
52
If vasopressin must be used to treat DI what other medication should be given to prevent end organ ischemia?
NTP
53
What is the rule of 100's for managing brain dead patients?
SBP > 100
Urine output > 100
PaO2 > 100
Hgb > 100 g/L
54
What type of stroke is most common?
ischemic
55
Stroke is most common in what gender? Up until which age then odds are the same/
Males
| Age 75
56
what tests are used to diagnose and determine monitoring in stroke?
noncontrast CT, angiography, doppler
57
What test is used to determine ischemic or hemorrhagic stroke?
noncontrast CT
58
What is a sudden vascular related focal neurological deficit that resolves within 24 hours.
TIA
59
What is the most significant risk factor for acute ischemic stroke?
systemic HTN
60
What medication is used as initial therapy and prevention of recurrent stoke?
ASA
61
The mass expanding effects of stroke peaks after how many days after onset and should be prevented?
two days
62
Large hemispheric stroke may be characterized by what?
middle cerebral artery syndrome
63
What is middle cerebral artery syndrome?
Edematous infarcted tissue compresses anterior & posterior cerebral arteries resulting in seconding infarctions
64
Infarction of which brain area results in basilar artery compression and brainstem ischemia?
cerebellum
65
What is the mortality rate with cerebellum and middle cerebral artery syndrome?
80%
66
what is the treatment of cerebellum and middle cerebral artery syndrome?
craniotomy and surgical decompression
67
Is ventilatory drive affected by ischemic stroke?
No
68
What causes ventilatory drive to be affected by ischemic stroke?
massive hemispheric or medulla infarction
69
What is common immediately post ischemic injury?
HTN
70
Immediately post ischemic injury what is the blood pressure goal?
maintain below 220/120
71
After revscularization of ischemic injury what is the blood pressure goal?
below 180/105
72
To maintain appropriate intravascular volume, cardiac output, and CPP what should be initiated after ischemic injury?
HHH therapy: HTN, hypervolemia, hemodilution
73
During ischemic stroke abnormal glucose levels leads to what?
tissue acidosis and injury
74
What medication and dose is used to prevent DVTs following ischemic stroke?
heparin 5000 SQ
75
What is the preferred anesthetic for ischemic stroke diagnostic testing?
sedation, not general
76
Cardiac, neurologic, vascular, and radiologic procedures of heart/major arteries carry the highest risk of what?
perioperative stroke
77
Perioperative stroke has ___ times increase in 30 day mortality following surgery?
8
78
amputations, abdominal exploration, small bowel resection, increasing age, MI within 6 months, renal dysfunction, stroke/TIA hx, HTN, COPD, smoking, metoprolol use are risk factors for what?
perioperative stroke
79
Elective sx should be delayed how long following stroke to allow for return of autoregulation?
9 months
80
What should be suspected if mental status does not improve as expected following anesthesia?
Perioperative stroke
81
The hallmark of this disease is progressive stenosis of intracranial blood vessels with secondary development of anastomotic capillary network?
moyamoya
82
What disease can be characterized by a cluster of abnormal blood vessels?
moyamoya disease
83
How is moyamoya disease diagnosed?
angiography
84
Affected arteries of moyamoya disease have a ___ intima and a ____ media.
thick intima
| thin media
85
Patients with moyamoya disease have increased incidence of what?
cerebral aneurysms
86
What are common initial findings of moyamoya disease in children?
symptoms of ischemia
87
What are common initial findings of moyamoya disease in adults?
hemorrhagic complications
88
What medications are common in treating moyamoya disease?
anticoagulants and vasodilators
89
What treatment of moyamoya disease is not super effective but it is treatment option?
Bypass by direct anastamosis of superficial temporal artery to middle cerebral artery
90
What medication should you ensure is discontinued before taking a patient with moyamoya disease back to the OR?
anticoagulants
91
What ventilatory dynamic should be avoided in moyamoya disease?
hypocapnia
92
What should be avoided during induction of a patient with moyamoya disease?
HoTN or HTN
93
What is a necessary monitor for moyamoya disease?
A-line
94
In a patient with moyamoya disease, avoided factors that cause cerebral vaso______?
vasoconstriction
95
How is HoTN in moyamoya disease best treated?
dopamine or ephedrine
96
What is a congenital displacement of the cerebellum, four types, treated with surgical decompression and enlargement of foramen magnum?
Chiari malformation
97
Which type of chiari malformation is characterized by cerebellar tonsils over cervical spinal cord?
1
98
Which type of chiari malformation is characterized by downward displacement of vermis?
2
99
Which type of chiari malformation is characterized by cerebellum into an occipital encephalocele?
3
100
Which type of chiari malformation is characterized by cerebellar hypoplasia without displacement?
4
101
People with type 2 chiari malformations typically have this intraoperative complication?
significant blood loss
102
Signs of what are present in 50% of people with chiari malformations?
syringomyelia
103
What are benign lesions occurring throughout the body including the brain?
Tuberous sclerosis
104
What are complications of tuberous sclerosis?
intellectual disability, seizures, and facial angiofibromas
105
What is the most common cardiac dysrhythmia caused by tuberous sclerosis lesions?
WPW
106
What is a familial disease characterized by benign retinal angiomas, hemangioblastomas, visceral tumors, and CNS tumors?
Von hippel-lindau disease
107
Where does Von-Hippel Lindau typically occur?
Cerebellum
108
What is a common complication of Von-Hippel Lindau disease?
Pheochromocytoma
109
What type of anesthesia should be avoided in Von-Hippel Lindau disease? why?
Neuraxial, spinal lesions
110
What is a condition involving tumors that grow in the nervous system primarily of Schwann cell?
Neurofibromatosis
111
What are the three types of neurofibromatosis?
Nf 1, NF 2, schwannomatosis
112
What type of neurofibromatosis consist of neurons, fibroblasts and collagen?
neurofibromas
113
What type of neurofibromatosis consist almost entirely of Schwann cells?
schwannomas
114
Which type of neurofibromatosis tend to encase the parent nerve?
neurofibromas
115
Which type of neurofibromatosis displaces the parent nerve?
schwannomas
116
Which type of neurofibromatosis spares the parent nerve during resection?
schwannomas
117
Patients with this type of neurofibromatosis may have macrocephaly, short stature, obstructive hydrocephalus, epilepsy, hypertension, congenital heart defects, MEN type IIb, and learning/behavioral disorders
NF1
118
What complication of neurofibromatosis may complicate airway management?
laryngeal neurofibromas, cervical spine deformities
119
What is the most common cause of dementia in patients over 65, 4th most common cause of death in patients over 65?
Alzheimers
120
What is a chronic neurodegenerative disorder resulting from diffuse amyloid rich plaques and neurofibrillary tangles?
Alzheimers
121
What age separates early and later onset alzheimers?
60
122
Which type of Alzheimers occur from missense gene mutations?
early onset
123
Which type of Alzheimers appears to have less of a genetic role?
late onset
124
What does the cognitive impairment from alzheimers consist of?
memory loss, apraxia (inability to perform purposeful actions), aphasia (cant understand or produce speech), and agnosia (cant interpret or recognize things)
125
Treatment of this disease involves cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and glantamine) and Memantine (NMDA antagonist)?
alzheimers
126
What is the anesthetic consideration of people with alzheimers taking cholinesterase inhibitors?
Cholinesterase inhibitors can result in the prolongation of succinylcholine and resistance to nondepolarizing agents
127
What is the neurodegenerative disorder with loss of dopaminergic fibers normally present in the basal ganglia?
Parkinsons
128
What is the most important risk factor for Parkinson's?
age
129
What does the dopamine depletion in Parkinsons lead to?
reduced inhibition and unopposed stimulation by acetylcholine
130
What is the Classic triad of symptoms in parkinsons?
skeletal muscle tremor, rigidity, akinesia
131
Where does rigidity of Parkinson's first appear?
proximal muscles of the neck
132
Facial immobility, pill rolling, diaphragmatic spasms, dementia, and depression are also frequent are signs of which disease?
parkinsons
133
What may be the first sign of parkinsons?
absence of arm swinging while walking, absence of head rotation when moving the body
134
What is the most common medical management of Parkinsons?
Levodopa and Carbidopa
135
Dyskinesia, psychiatric disturbances, increased HR and myocardial contractility, orthostatic hypotension, and N/V are common symptoms of this parkinsons medication?
levodopa
136
What medications are used to control the side effects of levodopa?
selegilene and rasagiline, amantadine
137
What medication should be avoided in a person with parkinsons?
demerol/meperidine
138
Is levodopa stopped for a surgery?
No
139
Interruption of which medication can result in skeletal muscle rigidity that impedes ventilation and abrupt loss of therapeutic effect?
levodopa
140
Which mediations are used to antagonize the effects of dopamine in the basal ganglia?
droperidol and haloperidol
141
What drugs are typically avoided during deep brain stimulator placement under sedation due to interference with microelectrode recordings?
GABA (-pam)
142
What are potential complications of patient with parkinsons disease undergoing surgery?
air embolism, HTN, seizures
143
How are seizures treated?
benzos, barbiturates, or propofol
144
Which disease has marked atrophy of the caudate nucleus and a lesser degree the putamen and globus pallidus?
huntingtons
145
This disease has deficiencies of acetylcholine, choline acetyltransferase and GABA in the basal ganglia?
huntingtons
146
What are manifestations of Huntington's?
progressive dementia, and choreoathetosis
147
What is the first symptom of Huntington's?
Chorea (uncoordinated muscle movements)
148
What is treatment of Huntington's aimed at?
decreasing chorea with Haloperidol
149
Which medication used to treat Huntington's depletes dopamine stores and which antagonizes dopamine stores?
haloperidol antagonizes
| reserpine depletes
150
People with Huntington's are prone to what?
aspiration
151
How to people with Huntington's respond to paralysis?
Prolonged responses to succinylcholine due to decreased plasma cholinesterase activity and sensitive to nondepolarizers
152
What is the autoimmune disease characterized by diverse inflammation, demyelination (leads to demyelination plaques), and axonal damage in the CNS?
multiple sclerosis
153
Are peripheral or central nerves affected in multiple sclerosis?
CENTRAL
154
What neurodegenerative disease has exacerbations and remissions with no cure?
multiple sclerosis
155
How can we prevent exacerbation of multiple sclerosis symptoms in the OR?
preventing HYPERthermia
156
Which treatment of MS can cause flu like symptoms for 24-48 hours?
interferon beta
157
Factors increasing the risk of exacerbation MS in the postoperative period include:
infection, fever, and spinal anesthesia (questionable but best avoided)
158
Are exacerbations of demyelination from MS seen with nerve blocks or epidural anesthesia?
No
159
What mediation can cause exaggerated potassium release and should be avoided in MS patients?
succinylcholine
160
What causes MS patient to have potential resistance for NDNMBs?
up regulation of acetylcholine receptors
161
Patients with MS will likely need this type of medication in the OR due to long term management?
corticosteroids
162
What are a transient synchronous discharge of groups of neurons in the brain?
seizures
163
How are seizures classified?
loss of consciousness and regions of the brain affected
164
What type of seizure has no loss of consciousness?
simple seizure
165
A seizure with altered levels of consciousness is called what?
complex seizure
166
A seizure that originates from limited neurons in a single hemisphere is called?
partial seizure
167
This type of seizure activates neurons in both hemispheres?
generalized seizure
168
Partial seizure that begins in one hemisphere and becomes generalized when it moves over to the other hemisphere and involves both is called what?
Jacksonian March
169
What is epilepsy?
recurrent seizures resulting from congenital or acquired factors
170
What medications treat seizures?
Phenytoin, Valproate, carbamazepine, barbiturates, gabapentin
171
Side effects of this drug include hypotension, dysrhythmias, gingival hyperplasia, aplastic anemia, steven-johnson’s syndrome, and purple glove syndrome from extravasation or intra-arterial injection?
Phenytoin
172
What seizure medication produces hepatic failure?
valproate
173
Side effects of this seizure medication include diplopia, leukopenia, hyponatremia, and altered hepatic metabolism of several other drugs?
Carbamazepine
174
What is continuous seizure activity or more than one seizure occurring in succession without return to consciousness between?
status epilepticus
175
If a patient is having status epileptics what do you want to rule out as a cause?
hypoglycemia
176
What is a common sequalae of continued seizure activity?
Metabolic acidosis
177
What is common following status epileptics?
hyperthermia
178
What medication can activate epileptic foci and may be utilized during electrocortical mapping for surgical treatment of epilepsy?
Methohexital
179
What two anesthetic agents have both been shown to cause epileptiform EEG activity in patients with known seizure history?
Alfentanil and Sevo
180
Which NMB's has a metabolite that is a proconvulsant? What is the metabolite? How does it cause seizures?
Atracurium and Cisatracurium. Laudanosine. Crosses the BBB.
181
What medications used during electrocorticographic monitoring may be used to enhance epileptiform activity?
alfentanil, methohexital, or etomidate
182
What might you see on the vent if your patient has a seizure?
increased EtCO2
183
Cold saline on a open brain in awake patients prevents what?
somnolence
184
What movements are common under general anesthesia if not paralyzed?
tonic clonic
