Neurological Quiz Flashcards
(146 cards)
1
Q
What are the THREE MAJOR risk factors to identify those at risk of stroke?
A
- Hx of previous stroke/TIA
- Advanced age (none given)
- Renal disease
2
Q
Give some of the ELEVEN predictors of perioperative stroke:
A
- atrial fib
- MI within the last 6 months
- heart failure
- prior cardiac intervention
- Acute OR chronic renal failure
- currently on dialysis
- COPD
- Smoker
- Hemiplegia
- DM
- Female
3
Q
What type of surgery has the highest risk of stroke?
A
Cardiac surgery:
- – 2 or 3 valves (9.7%)
- – Mitral valve (8.8%)
- – combined CABG and valve replacement (7.4%)
- – aortic valve replacement (4.4%)
- – CABG (3.8%)
4
Q
What is the goal when monitoring cerebral saturation?
A
Do not let it drop by more than 20%
5
Q
What is MoyaMoya syndrome?
A
BV leak and create “smoke” on scan
narrowing of distal internal carotid arteries and its proximal branches
6
Q
MoyaMoya may be associated with which 2 other diseases?
A
sickle cell
neurofibromatosis
7
Q
What are the two therapies included in MoyaMoya treatment?
A
- antiplatelet agents
2. revascularization
8
Q
Preanesthetic evaluation in patient with a history of stroke:
A
- cause and timing of previous stroke
- symptoms
- residual effects
*get an ECHO / review any imaging of head & neck
9
Q
When pre-evaluating a patient with a history of stroke, auscultate and palpate what?
A
carotid arteries; for bruits
10
Q
Why should hemiparesis patients not be administered succ?
A
↑ in receptors; can cause an increase in K
11
Q
What are the anesthetic considerations of a stroke?
A
- Is patient on antiplatelet therapy?
- Can therapy be stopped with or without bridging?
- high risk patients include:
- Stroke/TIA within the last 3 months
- genetic predisposition
- CHA2DS2VASC Score >2
- Stroke/TIA within the last 3 months
12
Q
The presence of a carotid bruit is indicative of atherosclerosis?
A
NO; but it should prompt a more focused exam
13
Q
In patients having cardiac surgery, what is a significant risk factor for stroke?
A
pre-existing cerebrovascular disease
14
Q
Anesthetic considerations of a carotid bruit / carotid endarterectomy surgery?
A
Patient will NOT have “train tracks”; large hemodynamic variability expected
- surgery requires significant head/neck manipulation
15
Q
What is the gold standard for imaging diagnosis of a carotid bruit/atherosclerosis?
A
carotid arteriography
16
Q
What is an acceptable first-line study for a carotid bruit/atherosclerosis?
A
carotid duplex imaging
17
Q
When a patient has dementia; what is the MOST IMPORTANT consideration?
A
get a CLEAR baseline
18
Q
Dementia is a neurocognitive disorder characterized by a decline in what 4 things?
A
- memory
- language
- problem-solving
- cognitive skills
19
Q
What are the THREE most common causes of dementia?
A
- Alzheimer disease (60-80%)
- Vascular dementia (10%)
- Parkinson disease
20
Q
Alzheimer diseases affects one in ___ over the age of 85
A
1 in 3
21
Q
Alzheimer disease affects one in ___ under the age of 65
A
9
22
Q
What are TWO cognitive exams that screen for dementia?
A
- Montreal Cognitive Assessment (MoCA)
2. Mini-Cog
23
Q
What are anesthetic considerations of dementia?
A
dementia meds may interact
24
Q
How will cholinesterase inhibitors affect anesthesia?
A
prolong effects of Succ & increase pulmonary complications
25
Gingko biloba can increase what?
bleeding risk
26
What are TWO medications that should be avoided when a patient has dementia?
1. benzodiazepines
| 2. antihistamines
27
How is Parkinson disease defined?
Loss of dopamine-containing neurons from the pars compacta of the substantia nigra with intracytoplasmic inclusion
28
What is the "hallmark finding" of Parkinson disease?
Lewy bodies
29
What causes the classic s/s of Parkinson disease?
unopposed action of acetylcholine in extrapyramidal motor system
30
What are 4 s/s of Parkinson disease?
bradykinesia/slow movement
rigidity
tremor
postural instability
31
Parkinson patients have a high incidence of: (2)
dysphagia*
| respiratory dysfunction*
32
What are 4 anesthetic considerations of Parkinson disease?
- continue medications
- reduced fasting vs aspiration risk?
- Avoid meperidine and dopaminergic antagonists
- NDMB have little impact
33
What kind of cautery is preferred in patients with deep brain stimulators?
bipolar cautery.
keep grounding pad as far as possible from stimulator
34
What medications should be avoided in patients with parkinson disease?
benzodiazepines
antihistamines
MEPERIDINE
DOPAMINERGIC ANTAGONISTS
35
What is Myasthenia Gravis?
antibodies attack post-synaptic acetylcholine receptors
36
What is usually the presenting symptom of myasthenia gravis?
proximal muscle weakness;
| alleviated with rest, exacerbated with activity
37
What is treatment for myasthenia gravis?
```
Pyridostigmine: first line therapy [Acetylcholinesterase inhibitor]
Glucocorticoids
Immunosuppressive agents
IVIG
Thymectomy
```
38
What is pyridostigmine?
acetylcholinesterase inhibitor
39
Will edrophonium help or hurt myasthenic crisis? Why or why not?
helps, will increase the amount of acetylcholine in the synaptic cleft
40
Will edrophonium help or hurt a cholinergic crisis? Why or why not?
NO! there is already too much acetylcholine triggering
41
Should elective surgery be done in patients with myasthenia gravis?
yes, it is safe if patient is stable and well controlled
42
What can be used to optimize myasthenia gravis patients when emergency surgery is necessary?
plasma exchange
43
What amount of NMBD should be given to patients with myasthenia gravis?
LESS! effect is INCREASED (antibodies act as NMB molecules)
44
Is the effect of succinylcholine increased or decreased in patients with myasthenia gravis?
effect of succinylcholine is reduced, but duration is prolonged [patient will have decreased acetylcholinesterase activity due to treatment medications]
45
What is the scoring system to predict post op ventilatory support in MG patients?
duration of MG >= 6 years = 12 points
Hx chronic resp dz = 10 points
Pyridostigmine dose >750mg/day = 8 points
vital capacity <2.9L = 4 points
46
What medications should be given to MG patients preoperatively?
- glucocorticoids
| - aspiration prophylaxis
47
What is multiple sclerosis?
autoimmune demyelinating disease of the brain & spinal cord
48
Two considerations for patients with multiple sclerosis
1. keep them warm
| 2. maintain good pain management
49
Will multiple sclerosis have any altered regulation of their acetylcholine receptors?
Yes, UPregulation
Will have increased response to succinylcholine
Will have decreased response to NDMB
50
What is muscular dystrophy?
muscle wasting and weakness
51
MD is linked to which gene?
recessive mutation in the dystrophin gene on the X chromosome
52
What are the two most common forms of MD?
Duchenne and Becker
53
4 perioperative complications that can occur when a patient has muscular dystrophy
1. rhabdomyolysis
2. hyperkalemia
3. Malignant hyperthermia
4. cardiac arrest
54
Patients with muscular dystrophy will all eventually develop _____. Because of this, preoperatively MD patients should all have __ & ___.
cardiomyopathy
ECG & ECHO
55
What kind of lung disease occurs with MD?
restrictive lung disease d/t the inability to create adequate negative pressures
56
What is an important study to determine the severity of restrictive lung disease in the presence of MD?
pulmonary function studies.
57
What are the indications for NIPPV & cough assist training for a patient with MD?
FVC <50% & ineffective cough
58
What are the indications for NIPPV & cough assist training for a patient with MD?
FVC <50% & ineffective cough
59
What is Lambert-Eaton Syndrome?
autoantibodies attacking the pre-synaptic VG calcium channels (no vesicles to membrane) = ↓ release of acetylcholine by pre-synaptic neuron
60
What 3 medications and 1 therapy is included in the treatment of Lambert-Eaton Syndrome?
- 3,4-diaminopyridine
- pyridostigmine
- IVIG
- plasmapheresis
61
What is the presenting symptom of Lambert-Eaton syndrome & what is their pattern of weakness?
proximal weakness in the pelvic & truncal areas;
weakest in the morning, strength improves throughout the day.
62
What are 5 anesthetic pre-op considerations/evaluations of patients with Lambert-Eaton syndrome?
1. progressive proximal weakness
2. altered gait
3. stiff, aching muscles
4. ASSESS for pharyngeal weakness
5. Evaluate spirometry & pulmonary function tests; <2.9L may indicate need for postoperative ventilation
* continue medications
* patient's will be SENSITIVE to NMB - avoid if possible
* AVOID HYPERTHERMIA
63
What is the incidence of aneurysms?
3.2%, 0.25% will rupture → 10% dead before hospital, 5% dead w/n 30 days
64
What are 2 surgical methods of managing/treating an aneurysm?
1. microvascular clipping
| 2. endovascular coiling
65
What are some of the disorders associated with aneurysms?
1. Marfan syndrome
2. Ehler-Danlos Syndrome
3. Pseudoxanthoma elasticum
4. Coarch of the aorta
5. bicuspid aortic valve
6. Autosomal dominant polycystic kidney disease
7. pheochromocytoma
66
What is an AVM?
triangle of abnormal vessels, referred to as a nidus
67
What is the typical presentation of an AVM?
hemorrhage, seizures, neurological deficits
68
What are 3 treatment options of an AVM?
endovascular embolization
stereotactic radiosurgery
surgical removal
69
What is the most common electrolyte abnormality in aneurysm and AVM? Why?
hyponatremia d/t cerebral salt wasting or SIADH
70
Other than hyponatremia, what are other common electrolyte abnormalities in aneurysm and AVM?
hypokalemia
hypocalcemia
hypomagnesemia
71
What can cause myocardial dysfunction when repairing/treating an aneurysm or AVM?
catecholamine release =
cardiac dysrhythmias
prolonged QT
T wave abnormalities
72
What can cause myocardial dysfunction when repairing/treating an aneurysm or AVM?
catecholamine release =
cardiac dysrhythmias
prolonged QT
T wave abnormalities
73
What is the leading cause of acute autoimmune neuromuscular paralysis?
Guillian barre
74
What 4 infections are associated with development of Guillian Barre?
campylobacter jejuni
Epstein-Barr virus
mycoplasma pneumoniae
cytomegalovirus
75
What are the first 4 signs of Guillian Barre?
pain
numbness
paresthesia
weakness in limbs, extending up
76
Diagnosis of Guillian Barre requires what?
a lumbar puncture
77
Diagnosis of Guillian Barre requires what?
a lumbar puncture
78
What 3 things should be avoided if possible in patients with Guillian Barre?
1. NMB
2. endotracheal intubation
3. mechanical ventilation
79
If a patient has Guillian Barre can they receive regional anesthesia?
Yes, generally considered safe.
80
Are local anesthetic requirements altered in patients with Guillian Barre?
usually they are decreased.
81
What are 2 classifications of seizures?
focal [originate from one point]
| general [arise from both hemispheres
82
For the treatment of seizures, what are 3 treatment options other than antiepileptic monotherapy?
1. adrenal corticotropic hormone
2. corticosteroids
3. ketogenic diet
83
History of a patient with seizures should focus on: (6)
```
type of sz
triggers
frequency
most recent seizure
current medication regimen and if they are compliant
prior anesthetic history
```
84
What medication should be given in the OR for a seizure?
Propofol.
| Ativan will linger (Benzos will enhance sedative effects)
85
What medication should be given in the OR for a seizure?
Propofol.
| Ativan will linger (Benzos will enhance sedative effects)
86
What is the most common type of intracranial tumor?
Meningioma (36%)
87
Gliomas account for what percentage of intracranial tumors?
24%
88
What type of cell do gliomas arise from?
astrocytes d/t anaplasia
89
Which type of glioma has the poorest prognosis, and what is the median survival?
multiforme; 14 months
90
Pre-op testing for a patient with a neurological tumor will include what?
electrolytes (glucose)
complete blood counts
blood type and cross
ECG
91
What is the theory discussing ICP?
Monroe-Kelley Doctrine
92
At what ICP can cerebral ischemia occur?
50-60mmHg
93
What is included in Cushing's triad?
hypertension (severe)
bradycardia
irregular respirations
94
Pre-op diagnostic testing for a patient with elevated ICP will include..?
Complete blood counts
electrolytes (hyponatremia r/t cerebral salt wasting)
osmolality
ECG (neurogenic myocardial ischemia)
Continue medications (steroids, anticonvulsants)
95
Mild TBI = what GCS score?
13-15
96
Moderate TBI = what GCS score?
9-12
97
Severe TBI = what GCS score?
<8
98
To minimize secondary injury r/t TBI, AVOID
hypotension (SBP <90mmHg)
hypoxia (PaO2<60mmHg)
hyperpyrexia
99
To minimize secondary injury r/t TBI, AVOID
hypotension (SBP <90mmHg)
hypoxia (PaO2<60mmHg)
hyperpyrexia (↑ temp)
100, 100, 100
SpO2 100
SBP >100
HR <100
100
What is goal ICP and CPP?
ICP <20mmHg
| CPP 50-70mmHg
101
Treatment of elevated ICP
HOB 30-45
head midline
hyperosmolar or hypertonic solution
102
Mannitol dosing in TBI
1g/kg with repeating Q6H 0.25g/kg
103
Goal serum osmolality & serum sodium in TBI
<360 and <160mg/dL
104
Pre-op testing for TBI patient
metabolic profile
complete blood counts
PT, INR
Toxicology
105
What are the two diagnosis criteria of autism?
social communication deficits
| social interaction deficits with repetitive patterns of behavior
106
What 5 components may autistic persons exhibit?
1. intellectual disability (IQ<70)
2. anxiety, panic, ODD
3. self-injury
4. attention deficit
5. fine and gross motor problems
107
Withdraw of autistic medications can result in (4):
dystonia, dyskinesia, delirium, psychosis
108
What are the two descriptions used for pain?
Noxious / Protopathic
| Non-noxious / Epicritic
109
What is nociception?
the neural response to traumatic or noxious stimuli
110
When do pain perceptions begin to disappear?
after 40 years old
111
What is chronic pain associated with in the CNS pain pathway?
central sensitization (modulation)
112
What is somatic pain?
acute pain that is either superficial or deep
113
What is superficial pain?
skin, subQ, mucous membranes: well localized, sharp, prickling, throbbing, burning
114
What is deep pain?
muscles, tendons, joints, bones (dull, aching, not well localized)
115
What is visceral pain?
dull diffuse, usually midline
116
What are four common forms/causes of chronic pain?
musculoskeletal & visceral
lesions to nerves
lesions to central nervous system
cancer
117
Pain travels from the periphery to the cerebral cortex via:
three neuronal pathways (1st, 2nd, 3rd order neurons)
118
Failure to resolve pain results in:
occult inflammation and changes to the afferent pain pathway
119
Persistent stimulation of the pain pathways leads to:
changes to the afferent nervous system & allodynia
120
What are two locations of pain perception in the brain/CNS?
Sensory discriminators in the dorsal horn to the thalamus & sensory cortex
Affective motivators from the dorsal to limbic system and prefrontal cortex
121
What are four diseases that cause neurologic pain?
shingles
sciatica
cluster headaches
trigeminal neuralgia
122
If a patient has inflammation of the meninges, they may complain about..
pain with neck flexion & extension
123
What is Brudzinski's sign?
pain with resistance to motion (head flexion/extension) - indicative of inflammation of the meninges
124
What is Kernig's sign?
pain with resistance to knee extension - indicative of inflammation of the meninges
--- Hip is bent 90degrees. Pain with trying to straighten leg
125
What is trigeminal Neuralgia?
tic doulourex
| jabbing pain lasting seconds in the maxillary & mandibular distributions of the trigeminal nerve
126
Scale of motor function
```
0/5 no muscle twitch with attempted movement
1/5 muscle twitch with no movement
2/5 movement along horizontal plane
3/5 movement against gravity
4/5 movement against slight resistance
5/5 movement against full resistance
```
127
What do reflexes occur through?
activation of the stretch receptor that communicates with lower motor neurons in the anterior horn
128
What are the two main types of reflexes?
1. Deep tendon
| 2. superficial
129
Reflex grading scale
```
0/4 no resposne
1/4 diminished response
2/4 normal
3/4 increased
4/4 clonus
```
130
Upper motor neuron disease will lead to what kind of spascitity?
rigid
(HYPER-REFLEXIA)
corticospinal tract
131
Lower motor neuron disease will lead to what kind of spasticity?
flaccid
(HYPOREFLEXIA)
myopathies & spinal cord lesions
132
What are FOUR reflexes?
Biceps
Brachioradialis
Patellar
Achilles
133
Bicep tendon reflex is testing which nerve?
C5-6
134
Brachioradialis reflex is testing which nerve?
Nerve roots C5-6
| - observe for flexion at the elbow and supination of the forearm
135
Triceps tendon reflex is testing for which nerve?
Nerve roots C6-8
| - prompt contraction of the triceps tendon with extension of the elbow
136
Patellar reflex is testing which nerve?
Nerve roots L2-4
| - quadriceps contraction
137
Achilles reflex is testing which nerve?
S1-2
| - plantar flexion of the ankle
138
What is babinski's sign?
dorsiflexion of the big toe with fanning of the toes
139
What is babinski's sign assessing?
Nerve roots L5-S2
140
What is the function of the cerebellum?
coordination between multiple systems
141
What are three ways to test the cerebellar function?
finger to nose
heal to shin
Romberg test
142
Stimulation at the carotid bulb will result in what?
bradycardia
143
What is the most distal portion of the optic nerve that has dura?
the optic sheath
144
As ICP increases, what change occurs at the optic sheath?
Dilation in the middle (measurable)
145
What vital sign should be avoided, specifically in LEMS patients
Hyperthermia- will make weakness worse
146
Who is at highest risk of having a stroke? What 3 factors
- Stroke/TIA within the last 3 months
- genetic predisposition
- CHA2DS2VASC Score >2
