Neuro Diseases in Anesthesia Flashcards
(124 cards)
1
Q
What is the cerebral blood flow rate?
A
50 mL/100 g brain tissue/min or 750 mL/min
2
Q
The brain gets what % of CO?
A
15%
3
Q
What are the 3 components in the cranium?
A
- Tissue (Brain + Spinal Cord)
- Blood
- CSF
4
Q
What is the combined volume of the brain, blood and CSF?
A
1200-1500 mL
5
Q
What is normal ICP?
A
5-15 mmHg
6
Q
What does the Monroe-Kellie hypothesis state?
A
Increase in one component of intracranial volume must be offset by a decrease in another to prevent elevated ICP
7
Q
If ICP increases, what happens to MAP?
A
MAP increases to maintain CPP
8
Q
What is the name of the dura that separates the 2 cerebral hemispheres?
A
Falx Cerebri
9
Q
What is the name of the dura that separates the supratentorial (Cerebrum) and infratentorial (cerebellum) spaces?
A
Tentorium Cerebelli
10
Q
Herniation against the falx cerebri is called what? And what branch of artery does it compress causing midline shift?
A
Subfalcine Herniation
Compresses the ACA
11
Q
Herniation of the cerebrum against the tentorium cerebelli compresses the _____ downwards is what kind of herniation?
A
Transtentorial Herniation
Compresses the brainstem downwards
12
Q
This type of herniation causes the uncus (medial portion of the temporal lobe) to herniate over the tentorium cerebelli and cause herniation through foramen magnum?
A
Uncal Herniation
13
Q
What type of ocular problems do we see in uncla herniation?
A
Ipsilateral oculomoter nerve dysfunction, Pupillary dilation, ptosis, lateral deviation of the affected eye
14
Q
Does hyper or hypoventilation decrease ICP?
A
Hyperventilation
15
Q
Which drug class, used to decrease ICP can decrease swelling and enhance the integrity of the BBB?
A
Corticosteroids
16
Q
What affect does propofol have on cerebral bloodflow?
A
Propofol is a cerebral vasoconstrictor that decreases CRMO2 and CBF
17
Q
_________ is an autoimmune dx that causes demyelination of ___ ____ fibers
A
Central nerve
18
Q
Female, 1st degree relative, Epstein Barre virus, smoking are risk factors for what disease?
A
Multiple sclerosis
19
Q
What causes a MS exacerbation?
A
Stress
Temperature swings
Post-partum
20
Q
Symptoms of MS?
A
Vary dramatically:
1. Motor weakness/Sensory disorders
2. Visual impairment
3. Autonomic instability (HR, Postural Hypotension)
21
Q
Treatment for MS?
A
Corticosteroids & IVIG
22
Q
With an MS patient, what medications would cause you to check certain labs?
A
Dantrolene & Azothioprine
-Check LFT’s
23
Q
What drug for MS causes bone marrow suppression?
A
Azothioprine
24
Q
Do MS patients have up or down regulated n-Ach receptors at the end plate?
A
Up-regulated Ach receptors
25
What diseases would you consider stress-dose steroids for?
1. MS
2. MG
26
What NMB do you avoid with MS patients?
Succs, up-regulated n-Ach-R can cause hyperkalemia
27
What are symptoms common in MG?
1. Muscle weakness
2. Ocular Symptoms: Diplopia & Ptosis
3. Bulbar involvement: laryngeal/pharyngeal weakness
27
What disease generates Antibodies against n-Ach-R?
Myasthenia gravis
28
What is common in 10% of MG patients?
Thymic hyperplasia (90% patients improve after thymectomy)
29
What are exacerbation triggers for MG?
Stress-Related Factors
1. Insomnia
2. Pain
3. Surgery
4. Infection
30
What is the treatment for MG?
AchE inhibitors: Pyridostigmine, Azathiaprine, Steroids, PLEX, IVIG
31
Should your MG patient take or hold their Pyridostigmine the morning of surgery?
Take pyridostigmine
32
Ach-E inhibitors may prolong what 2 drugs?
Succs
Ester LA's
33
Should you increase or decrease paralytic dose for MG patients?
Decrease paralytic to avoid prolonged muscle weakness
34
What patients might need post-op Ventilation support?
1. MG
2. EL Syndrome
3. Myotonias
35
What disease creates antibodies against pre-synaptic VG Ca++ channels?
Eaton-Lambert syndrome
36
What pathology is E-L Syndrome associated with?
Small-cell lung carcinoma
37
What are symptoms of EL Syndrome?
1. Progressive limb-girdle weakness
2. Dysautonomia (BP and GI)
3. Oculobulbar palsyT
38
Treatment for EL Syndrome?
3,4 Diaminopyridine (K+ channel blocker that increases circulating Ach levels)
39
Patients with what disease are VERY sensitive to depolarizing and Non-depolarizing NMB?
E-L syndrome (already Ach deficit at synapse)
40
Are EL Syndrome pt. or MG patients more sensitive to Non-depolarizing NMB?
EL syndrome are more sensitive
41
What type of anesthesia is the preferred route for EL patients?
Regional - Reduce paralytic and opioid doses
42
What gene is affected in Muscular dystrophy?
Dystrophin-glycoprotein complex
43
Why is the lifespan of DMD patients 20-25 years?
Cardiopulmonary complications
44
Symptoms of DMD?
1. Muscle wasting without sensory abnormalities
2. Kyphoscoliosis
3. Long-bone fragility
4. Respiratory Weakness
5. Frequent pneumonia
6. EKG changes
7. Elevated CK levels due to muscle breakdown
45
What is at trigger for hypermetabolic syndrome in DMD?
Succs & Volatiles
46
DMD are susceptible to _______ ______ which leads to rhabdomyolysis, Inc. K+, V-fib
Hypermetabolic Syndrome
47
What type of anesthesia is preferred for DMD?
Regional is preferred
Low-Dose Rocuronium and TIVA for GA
48
What is myotonia?
Prolonged contraction after muscle stimulation
49
What is myotonic Dystrophy and where do you see muscle wasting?
Most common myotonia
Wasting in:
1. Face
2. Masseter
3. Hands
4. Pre-tibial muscles
5. Maybe laryngeal and diaphragm
50
20% of myotonic dystrophy patients have what cardiac complication?
mitral valve prolapse
51
What is myotonia congenita?
mild form of myotonia, involving only the skeletal muscles
52
What is central core disease? and hallmark symptom?
Rare type of myotonia where core muscles lack mitochondrial enzymes
-Proximal muscle weakness & scoliosis
53
What are all myotonias triggered by?
Stress & cold temperature
54
What medications are symptoms of myotonias managed by?
1. Quinine
2. Procainamide
3. Steroids
55
What are anesthesia considerations for myotonias?
1. GI hypomotility
2. Keep patients warm
3. Look at thyroid and glucose
4. Avoid Succs (Fasciculations)
56
What patients are treated as full stomachs?
Dementia patients
57
What is the preferred anesthetic for dementia patients?
Regional Anesthesia
58
What is the biggest risk for parkinson's?
Advanced Age
59
Parkinson's pathophysiology?
Degeneration of dopaminergic fibers of basal ganglia
60
______ suppresses overstimulation of the extrapyramidal motor system
Dopamine
61
In parkinson's, motor neurons become _____
Over stimulated
62
What is the Parkinson's triad?
1. Skeletal muscle tremor
2. Rigidity
3. Akinesia
63
Treatments for Parkinson's
1. Levodopa
2. Anticholinergic
3. MAO-I
4. Deep-Brain stimulator
64
Should levodopa be continued or discontinued in pre-op
Levodopa should be continued to avoid chest wall rigidity
65
When assessing parkinson's patients pre-op, pay attention to the degree of
Respiratory compromise
66
Which drugs do we avoid in parkinson's patients?
1. Reglan
2. Phenothiazines
3. Butyrophenones
67
If your patient is on an MAO-I, what drug should we avoid?
Demerol
68
Which type of cautery is preferred to avoid interaction with deep brain stimulators?
Bipolar
69
What is the most common CNS glial cell?
Astrocytes
70
Which astrocytoma is the least aggressive that is primarily tumors and found in young adult with new onset ________
Glioma; new onset seizures
71
Which astrocytoma is found in young adults/children, benign and has good outcomes when resected
Pilocyctic Astrocytoma
72
Which astrocytoma is poorly differentiated and usually evolves into a glioblastoma?
Anaplastic astrocytoma
73
Which astrocytoma is a high mortality that requires surgery and chemo with short life expectancy?
Glioblastoma multiforme
74
Which benign brain tumor arises from dura and arachnoid tissue and has good prognosis?
Meningioma
75
Which tumor is non-cancerous and fixed via transsphenoidal or open crani methods?
Pituitary adenoma
76
Which involves benign schwannomas involving vestibular component of CN 8 in the auditory canal?
Acoustic neuroma; good prognosis with resection
77
What is characteristic of a metastatic carcinoma?
Varies in origin and symptoms
-Outcomes are less favorable
78
What % of strokes are ischemic/Hemorrhagic?
Ischemic - 88%
Hemorrhagic - 12%
79
Brain blood supply is fed via
1. Internal carotid arteries
2. Vertebral arteries
80
What is a symptom of occluded ACA?
Contralateral leg weakness
81
What is a symptom of occluded MCA?
Aphasia
Contralateral hemiparesis
Contralateral vision deficit
82
What is a symptom of occluded Basilar?
Ataxia
83
What is a symptom of occluded Vertebral artery?
Ataxia
Crossed sensory deficit
84
What is a symptom of occluded PCA?
Contralateral visual deficit
Contralateral hemiparesis
85
When does a TIA resolve and what fraction will suffer a stroke after?
24 hours; 1/3
86
What imaging is required to distinguish ischemia from hemorrhage?
Non-contrast CT
87
Ischemic stroke prognosis depends on the time from ________ to _______
Onset to thrombolytic intervention
88
What are the 5 TOAST categories for ischemic stroke classification?
1. Large artery atherosclerosis
2. Small vessel occlusion
3. Cardioarotic embolic
4. Other etiology (hypercoagulable)
5. Undetermined
89
What is the initial treatment for CVA?
PO aspirin
90
When does TPA need to be initiated if within the criteria?
3-4.5 hrs post symptom onset
91
The 2 most reliable predictors of outcome after hemorrhagic stroke is:
1. Blood volume
2. Degree of change in LOC
92
Blood within the brain is a:
Intraparenchymal hemorrhage
93
If a patient wants to have a hernia repaired 2 months after starting anticoagulation for a thrombus, should you delay or continue the case?
Delay the case
94
If a patient wants to have a breast augmentation repaired 4 months after starting anticoagulation for a thrombus, should you delay or continue the case?
Continue the case
95
What is the guideline for elective cases and new anticoagulation for thrombus?
No elective cases within 3 months
96
If your patient is on anticoagulation for CVA prophylaxis, what should you do?
Consult the prescriber to see if risks of stopping outweigh benefits of surgery
97
What should high risk patients on warfarin be put on to bridge the gap until warfarin can be resumed?
Short acting anticoagulation (Heparin)
98
As anesthesia providers, what should we assess pre-op for CVA patients?
Root cause of CVA
Imagine
99
What are symptoms of an aneurysm?
1. Headache
2. Photophobia
3. confusion
4. Hemiparesis
100
Intervention for aneurysm should be performed within ____ hrs of rupture for best outcome
72 hours
101
In Post-SAH Vasospasm, ______ ___ triggers inflammatory mediators which reduce __________ and increases _________ leading to ________
Free-hgb; nitric oxide; endothelin-1; vasoconstriction
102
What is triple H therapy?
1. Hypervolemia
2. Hypertension
3. Hemodilution
103
Interventional treatments for SAH Vasospasm are
Direct injection of vasodilators and balloon dilation
104
AVM is a connection without capillaries that creates an area of _____ ______ shunting
High flow, Low resistance
105
Where are majority of AVM's?
Supratentorial
106
What is the name of the AVM grading scale?
Spicer Martin Grading system
107
What is a chiari malformation Type 1
Displacement of the cerebellum downward thru the foramen magnum
108
Type 2 Chiari malformation?
Downward of cerebellum associated with Myelomeningocele
109
What are symptoms of Chiari malformation?
H/A that extends to shoulders/arms
Visual disturbances
Ataxia
110
What are anesthesia interventions for chiari malformation?
Hyperventilate to decrease ICP
111
Tubular sclerosis patients present with
Mental retardation and seizure disorders
112
Tubular sclerosis is characterized by
Lesions "everywhere": Brain, Kidney, Skin, Eye, Lungs, heart, Face
113
Von Hippel Lindau Disease is characterized by tumors of the CNS, Eyes, Adrenals, Pancreas and kidneys. it can be differentiated from TS by presence of
Pheochromocytoma
114
What are anesthesia considerations for Von Hippel Lindau Disease
Exaggerated HTN (Pheochromocytoma)
115
What type of anesthesia is better for Von Hippel Lindau Disease
General
-Regional anesthesia limited d/t potential spinal tumor
116
Anesthesia considerations for Neurofibromatosis?
1. Increased ICP
2. Airway issues
3. Scoliosis
4. Possible pheochromocytoma
117
What are the diuretic tx for hydrocephalus?
Furosemide, Acetazolamide (decreases CSF production)
118
You should intubate if GCS is less than
9
119
What should you refrain from in TBI surgery?
Refrain from OGT/NGT due to potential for basilar skull fracture
120
Which drugs are enzyme inducers?
Phenytoin
Tegretol
Barbiturates
121
Seizure patients on certain meds need higher doses of
hepatically cleared medications
122
If you have to intubate post seizure, whats the plan?
RSI with cricoid pressure
123
What can transiently cause a seizure?
1. Hypoglycemia
2. Hyponatremia
3. Hyperthermia
4. Intoxication
