T3 - Neuro Disease Assessment Flashcards

1
Q

What is the first step in managing patients with neurological disorders before anesthesia?

A

Conduct a thorough assessment, including reviewing the patient’s history, symptoms, and neurological deficits.

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2
Q

What should be included in the diagnostic evaluation of patients with neurological disorders before anesthesia?

A

Review imaging and neurological testing results to understand the extent of the neurological condition.

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3
Q

Why is it important to review the patient’s current drugs and treatments before anesthesia?

A

To assess potential drug interactions, side effects, and their impact on anesthesia.

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4
Q

What should be considered when assessing the potential risks and benefits of various anesthetic options?

A

Factors such as the patient’s neurological condition, comorbidities, and the type of surgery should be evaluated.

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5
Q

How can the patient’s condition be optimized before anesthesia?

A

Implement preoperative measures such as medication adjustments, neurological interventions, and addressing any modifiable risk factors.

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6
Q

Why is clear preoperative documentation important in patients with neurological disorders?

A

It ensures that all relevant factors, including the patient’s history, diagnostic findings, medication review, and chosen anesthetic plan, are documented with a rationale.

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7
Q

What is Multiple Sclerosis (MS)?

A

MS is a progressive autoimmune disorder characterized by the demyelination of central nerve fibers.

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8
Q

What is the typical onset age for Multiple Sclerosis?

A

MS typically begins between the ages of 20 and 40.

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9
Q

What are the risk factors associated with Multiple Sclerosis?

A

Risk factors include being female, having a first-degree relative with MS, Epstein-Barr virus (EBV) infection, other autoimmune disorders, and smoking.

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10
Q

What are the common symptoms of Multiple Sclerosis?

A

Symptoms include motor weakness, sensory disorders, visual impairment, and autonomic instability. Symptoms vary depending on the site of demyelination.

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11
Q

What factors can trigger exacerbations of Multiple Sclerosis?

A

Triggers include stress, elevated temperatures, and the postpartum period.

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12
Q

What is the typical disease course of Multiple Sclerosis?

A

MS is characterized by periods of exacerbations and remissions.

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13
Q

Is there a cure for Multiple Sclerosis?

A

No, there is no cure for MS. However, it can be managed with corticosteroids, immune modulators, and targeted antibodies.

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14
Q

What is the first step in preanesthetic considerations?

A

Assess existing deficits in the patient’s condition.

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15
Q

What should be considered if the patient has respiratory compromise?

A

Consider pulmonary function tests to assess respiratory function.

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16
Q

Which laboratory tests are typically ordered before anesthesia?

A

CBC with platelets, basic metabolic panel (BMP), and optionally liver function tests (LFT) if the patient is on Dantrolene or Azathioprine.

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17
Q

Why is close attention to glucose and electrolytes necessary before anesthesia?

A

Steroids may impact glucose and electrolyte levels, so monitoring is crucial.

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18
Q

When should preoperative steroids be considered?

A

Consider preoperative steroids in patients with long-term steroid use.

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19
Q

Why is temperature management critical before anesthesia?

A

An increase in body temperature can precipitate exacerbations of Multiple Sclerosis symptoms.

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20
Q

What are the acceptable anesthetic options for patients with Multiple Sclerosis?

A

General anesthesia (GA), regional anesthesia (RA), and peripheral nerve blocks (PNBs) are acceptable options.

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21
Q

Why should Succinylcholine be avoided in multiple sclerosis patients?

A

Succinylcholine may induce hyperkalemia and should be avoided in patients with Multiple Sclerosis.

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22
Q

What is Myasthenia Gravis (MG)?

A

MG is an autoimmune disorder characterized by antibodies generated against N-Ach-R’s at skeletal motor endplates.

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23
Q

Which type of muscle does MG affect?

A

MG primarily affects skeletal muscle, not smooth or cardiac muscle.

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24
Q

What are the common symptoms of MG?

A

Symptoms include muscle weakness exacerbated by exercise, cranial nerve involvement (especially ocular symptoms like diplopia and ptosis), and bulbar involvement leading to respiratory insufficiency and aspiration risk.

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25
Q

What is common in Myasthenia Gravis patients related to the thymus?

A

Thymic hyperplasia is common in MG patients, and approximately 90% of patients improve after thymectomy.

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26
Q

What factors can exacerbate symptoms of Myasthenia Gravis?

A

Symptoms can be exacerbated by pain, insomnia, infection, and surgery.

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27
Q

What are the treatment options for Myasthenia Gravis?

A

Treatment may include acetylcholinesterase inhibitors (Pyridostigmine), immunosuppressive agents, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).

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28
Q

How does thymectomy affect Myasthenia Gravis?

A

Over 90% of patients improve after thymectomy.

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29
Q

What is the first step in preanesthetic considerations for Myasthenia Gravis?

A

Assess existing deficits in muscle strength and respiratory function.

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30
Q

What should be considered if there is respiratory compromise?

A

Consider pulmonary function tests to evaluate respiratory function.

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31
Q

How should respiratory function be optimized before anesthesia?

A

Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.

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32
Q

What precaution should be taken with neuromuscular blocking agents (NMBs)?

A

Reduce NMB dosage to avoid prolonged muscle weakness and respiratory depression.

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33
Q

Why should caution be exercised with opioids in Myasthenia Gravis patients?

A

Use opioids cautiously to avoid respiratory compromise, especially in patients with compromised respiratory function.

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34
Q

How do acetylcholinesterase (Ach-E) inhibitors affect neuromuscular blocking agents and local anesthetics?

A

Ach-E inhibitors may prolong the effects of Succinylcholine and ester local anesthetics.

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35
Q

Which laboratory tests are typically ordered before anesthesia in Myasthenia Gravis patients?

A

Order CBC, BMP, and optionally LFT (if on Azathioprine) to monitor glucose and electrolyte levels.

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36
Q

When should preoperative steroids be considered in Myasthenia Gravis patients?

A

Consider preoperative steroids in patients with long-term steroid use to prevent adrenal insufficiency.

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37
Q

What should be discussed with Myasthenia Gravis patients before surgery?

A

Counsel patients on the increased risk of needing postoperative respiratory support or ventilation until fully recovered from anesthesia.

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38
Q

What is Eaton-Lambert Syndrome?

A

Eaton-Lambert Syndrome is a rare autoimmune disorder characterized by autoantibodies against voltage-gated calcium channels, leading to reduced calcium influx and decreased acetylcholine release.

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39
Q

What is a significant association of Eaton-Lambert Syndrome?

A

More than 60% of cases are associated with small cell lung carcinoma.

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40
Q

What are the common symptoms of Eaton-Lambert Syndrome?

A

Symptoms include progressive limb-girdle weakness, dysautonomia, oculobulbar palsy, and may resemble those of Myasthenia Gravis.

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41
Q

How is Eaton-Lambert Syndrome treated?

A

Treatment options include
- Selective potassium channel blockers like 3,4-diaminopyridine, acetylcholinesterase inhibitors, immunosuppressive agents such as Azathioprine, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).

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42
Q

What is the first step in preanesthetic considerations for Eaton-Lambert Syndrome?

A

Assess existing deficits in muscle strength and respiratory function.

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43
Q

What should be considered if there is respiratory compromise?

A

Consider pulmonary function tests to evaluate respiratory function.

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44
Q

How does Eaton-Lambert Syndrome respond to neuromuscular blocking agents?

A

Eaton-Lambert Syndrome is very sensitive to both non-depolarizing and depolarizing neuromuscular blocking agents, with significantly higher sensitivity to non-depolarizing agents compared to Myasthenia Gravis.

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45
Q

What should be done to optimize respiratory function before anesthesia?

A

Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.

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46
Q

Why should extreme caution be exercised with neuromuscular blocking agents and opioids?

A

Exercise extreme caution with neuromuscular blocking agents and opioid dosing to prevent respiratory compromise.

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47
Q

What should be discussed with Eaton-Lambert Syndrome patients before surgery?

A

Counsel on risks for needing post-op resp support until fully recovered from anesthesia

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48
Q

What is Muscular Dystrophy?

A

Muscular Dystrophy is a hereditary disorder characterized by muscle fiber degeneration due to breakdown of the dystrophin-glycoprotein complex, leading to myonecrosis, fibrosis, and increased skeletal muscle membrane permeability.

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49
Q

How many types of Muscular Dystrophy are there?

A

There are six types of Muscular Dystrophy, each with its own characteristics and genetic mutations.

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50
Q

What is the most common and severe form of Muscular Dystrophy?

A

Duchenne Muscular Dystrophy is the most common and severe form, occurring only in boys with onset typically between 2-5 years of age. Patients are usually wheelchair-bound by age 8-10 and have an average lifespan of around 20-25 years due to cardiopulmonary complications.

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51
Q

What are the common symptoms of Muscular Dystrophy?

A

Symptoms include progressive muscle wasting without motor/sensory abnormalities, kyphoscoliosis, long bone fragility, respiratory weakness, frequent pneumonia, and EKG changes.

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52
Q

What laboratory findings would be elevated in muscular dystrophy as a result of muscle wasting?

A

Serum creatine kinase levels are often elevated due to muscle wasting and damage.

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53
Q

What is myotonia?

A

Myotonia is a prolonged contraction after muscle stimulation, commonly observed in several muscle disorders.

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54
Q

What is the most common form of myotonia?

A

Myotonic Dystrophy is the most common form of myotonia, typically manifesting in the 20-30s with muscle wasting in the face, masseter, hand, and pre-tibial muscles. It may also affect pharyngeal, laryngeal, and diaphragmatic muscles, and can lead to cardiac conduction abnormalities. Approximately 20% of patients have mitral valve prolapse.

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55
Q

What is Myotonia Congenita?

A

Myotonia Congenita is a milder form of myotonia characterized by skeletal muscle involvement while smooth and cardiac muscles are spared.

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56
Q

What is Central Core Disease?

A

Central Core Disease is a rare condition where core muscle cells lack mitochondrial enzymes, leading to proximal muscle weakness and scoliosis.

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57
Q

What triggers myotonias, and how are the symptoms managed?

A

Myotonias are triggered by stress and cold temperatures. Symptoms are managed with medications such as Quinine, Procainamide, and steroids, although there is no cure for these conditions.

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58
Q

What laboratory tests should be considered pre-anesthesia for myotonic dystrophies?

A

Pre-operative EKG and echocardiogram should be performed to evaluate for cardiomyopathy.

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59
Q

How should neuromuscular blockade be approached in patients with Myotonic Dystrophies?

A

Exercise caution with non-depolarizing neuromuscular blockers, and ensure careful monitoring throughout the procedure.

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60
Q

```

What syndrome, similar to Malignant Hyperthermia, can be seen with succinylcholine and volatile anesthetics?

A

Hypermetabolic Syndrome can occur, leading to life-threatening hyperkalemia and arrhythmias, particularly with succinylcholine use.

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61
Q

Why should succinylcholine and volatile anesthetics be avoided in patients with Myotonic Dystrophies?

A

Succinylcholine and volatile anesthetics can exacerbate instability of the muscle membrane, leading to complications.

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62
Q

What should be assessed regarding cardiac and pulmonary function pre-anesthesia?

A

Assess the extent of cardiac and pulmonary abnormalities through thorough evaluation, including auscultation of breath and heart sounds for abnormalities.

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63
Q

How does GI hypomotility impact the risk of aspiration?

A

GI hypomotility increases the risk of aspiration, necessitating careful management to mitigate this risk.

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64
Q

What endocrine abnormalities in MD should be considered pre-anesthesia?

A

Assess thyroid and glucose levels due to the high risk of endocrine abnormalities in patients with Myotonic Dystrophies.

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65
Q

Why is it important to keep MD patients warm pre-anesthesia?

A

Keeping patients warm helps to avoid flares of symptoms associated with Myotonic Dystrophies.

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66
Q

What should be done to optimize respiratory status pre-anesthesia in MD patients?

A

Optimize respiratory status to reduce the risk of postoperative respiratory weakness, a common complication in patients with Myotonic Dystrophies.

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67
Q

Why should depolarizing (Succs) neuromuscular blockers and opioids be used cautiously in MD patients?

A

Depolarizing neuromuscular blockers should be avoided because fasciculations can trigger myotonia. Caution should also be exercised with opioids.

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68
Q

What laboratory tests should be considered pre-anesthesia?

A

Consider CBC (Complete Blood Count), BMP (Basic Metabolic Panel), PFTs (Pulmonary Function Tests), and CK (Creatine Kinase) levels.

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69
Q

What are the three major dementia syndromes?

A

The three major dementia syndromes are Alzheimer’s (70%), Vascular dementia (25%), and Parkinson’s (5%).

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70
Q

What assessment should be conducted regarding cognitive function?

A

Assess the level of cognitive dysfunction in patients with dementia.

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71
Q

How should informed consent and decision-making be approached?

A
  • Patient may not be able to give informed consent, look to medical PoA
  • Investigate any advanced directives for medical decision-making
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72
Q

What evaluations should be conducted pre-operatively?

A

Perform basic labs and pertinent tests/imaging to assess the patient’s medical condition.

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73
Q

What is the potential risk related to aspiration?

A

Patients with dementia may have an increased risk of aspiration due to a full stomach, necessitating careful management.

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74
Q

Why is it important to review pre-operative medications?

A

Review pre-operative medications, especially those that may affect anesthesia, such as acetylcholinesterase inhibitors, MAOIs, and psychotropic medications.

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75
Q

What is an increased risk post-operatively in patients with dementia?

A

Patients with dementia are at an increased risk of post-operative delirium, which should be carefully monitored and managed.

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76
Q

How should opioids be managed in patients with dementia?

A

Balance opioids to meet analgesic needs without exacerbating delirium. Regional anesthesia may be preferred to reduce opioid requirements.

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77
Q

```

What is Parkinson’s disease characterized by?

A

Parkinson’s disease is characterized by the degeneration of dopaminergic fibers in the basal ganglia.

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78
Q

What is considered the biggest risk factor for Parkinson’s disease?

A

Advanced age is considered the biggest risk factor for Parkinson’s disease.

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79
Q

How does dopamine normally regulate the extrapyramidal motor system?

A

Dopamine regulates the extrapyramidal motor system by inhibiting excess stimulation, which is primarily driven by acetylcholine.

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80
Q

What are the main symptoms that comprise the triad of Parkinson’s disease?

A

The triad of symptoms in Parkinson’s disease includes skeletal muscle tremor, rigidity, and akinesia.

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81
Q

What are some other symptoms commonly associated with Parkinson’s disease?

A

Other symptoms include
- Rhythmic “pill rolling” tremors
- Facial rigidity
- Slurred speech
- Difficulty swallowing
- Respiratory difficulty
- Depression
- Dementia

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82
Q

Question: What is important to assess regarding Parkinson’s disease before anesthesia?

A

Assess the severity, with special attention to the degree of pulmonary compromise.

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83
Q

Why is it important to review a Parkinson’s patient’s home medications before anesthesia?

A

Many home medications may interact with anesthetic drugs, for example, MAOIs.

84
Q

What basic preoperative tests should be done for Parkinson’s patients?

A

Basic labs along with Pulmonary Function Tests if there are respiratory symptoms.

85
Q

When are an EKG and Echo indicated preoperatively for Parkinson’s patients?

A

An EKG and Echo are indicated if clinically indicated.

86
Q

Why are Parkinson’s patients at an increased aspiration risk under anesthesia?

A

They are at an increased risk due to dysphagia and possible dementia.

87
Q

Why must PO Levodopa be continued for Parkinson’s patients undergoing surgery?

A

To avoid unstable extreme extrapyramidal effects such as chest wall rigidity.

88
Q

What medications should be avoided in Parkinson’s patients due to potential adverse interactions?

A

Avoid reglan, phenothiazines, butyrophenones, and demerol if the patient is on MAOIs.

89
Q

What consideration should be taken regarding deep brain stimulators during surgery for Parkinson’s patients?

A

Deep brain stimulators may need to be disabled to avoid interaction with cautery.

90
Q

: What type of cautery is recommended for use in Parkinson’s patients during surgery?

A

If cautery is used, bipolar is recommended.

91
Q

What are the two main types of brain tumors?

A

Brain tumors may be primary or metastatic.

92
Q

What is the etiology and severity of brain tumors?

A

Brain tumors have a wide etiology and varying severity.

93
Q

What are gliomas and how common are they among brain tumors?

A

Gliomas are primary brain tumors and are the most common type, comprising approximately 45%.

94
Q

How are many types of gliomas categorized?

A

Many types of gliomas are based on histologic cell-type and subclasses based on oncogenic mutations.

95
Q

What are benign meningiomas and how often do they occur?

A

Benign Meningiomas account for about 15% of brain tumors and arise from dura or arachnoid tissue.

96
Q

What are pituitary adenomas and their prevalence?

A

Pituitary adenomas are noncancerous, make up about 7% of brain tumors, and the majority are found on autopsy.

97
Q

```

What are metastatic carcinomas in the context of brain tumors?

A

Metastatic carcinomas account for about 6% of brain tumors and can vary widely in origin and symptoms.

98
Q

What are some other less common types of brain tumors?

A

Other types include Schwannomas, Craniopharyngiomas, and Dermoid tumors.

99
Q

Other types include Schwannomas, Craniopharyngiomas, and Dermoid tumors:

A

The mass effects of any brain tumor can cause increased intracranial pressure (ICP), papilledema, headaches, mental impairment, mobility impairment, vomiting, autonomic dysfunction, and seizures.

100
Q

What should be reviewed during pre-anesthesia for a patient with a brain tumor?

A

Review the patient’s history, previous therapies, and presenting symptoms.

101
Q

What effect can radiation have on patients with brain tumors?

A

Radiation damage may lead to lethargy and altered mental status (AMS).

102
Q

What are potential neurological effects of chemotherapy in patients with brain tumors?

A

Chemotherapy may also have neurological effects.

103
Q

Why are patients with brain tumors often on steroids before surgery?

A

Patients are often on steroids to minimize cerebral edema.

104
Q

What is important to monitor when continuing steroids in brain tumor patients?

A

It is important to continue steroids and monitor glucose levels.

105
Q

How may autonomic dysfunction manifest in brain tumor patients and what should be monitored?

A

Autonomic dysfunction may manifest on EKG, with labile heart rates and blood pressures.

106
Q

Why are anticonvulsants commonly used in patients with brain tumors?

A

Anticonvulsants are common, especially for those with supratentorial lesions.

107
Q

What routine tests should be performed preoperatively for brain tumor patients?

A

CBC, BMP (especially glucose), and EKG should be performed preoperatively.

108
Q

What medications should be managed preoperatively for brain tumor patients according to the surgeon’s instructions?

A

Manage pre-operative steroids and anti-seizure medications per the surgeon’s instructions.

109
Q

What is Mannitol’s role in the preoperative management of brain tumor patients?

A

Mannitol is often used to reduce intracranial volume and pressure preoperatively.

110
Q

What should be reviewed pre-operatively in patients with cerebrovascular disease?

A

Review the patient’s history, deficits, imaging, treatments, and co-existing diseases carefully.

111
Q

What physical assessments should be done for pre-op cerebrovascular disease patients?

A

Assess orientation, pupils, bilateral grip strength, and lower extremity (LE) strength.

112
Q

What symptoms should be asked about in patients with cerebrovascular disease?

A

Ask about headaches, tinnitus, vision/memory loss, and bathroom issues.

113
Q

What are the causes of a cerebrovascular accident (CVA) that should be considered?

A

Look at the root cause of CVA, including vascular disease, embolic causes (such as atrial fibrillation, prosthetic valve, right to left shunt/Patent Foramen Ovale).

114
Q

What imaging is recommended for preoperative assessment in cerebrovascular disease?

A

Imaging should include Carotid Ultrasound, CT/MRI of head & neck, and echocardiogram.

115
Q

What are the routine preoperative investigations for cerebrovascular disease?

A

Preoperative investigations should include an EKG and a CBC, BMP including glucose.

116
Q

What is the guideline for elective cases in patients on new anticoagulants for cardiac thrombus?

A

No elective cases should be scheduled within 3 months for patients on new anticoagulants for cardiac thrombus.

117
Q

What should be done pre-operatively for patients on anticoagulants for cerebrovascular accident (CVA) prophylaxis?

A

Consult the prescriber to establish a protocol for managing anticoagulants pre-operatively.

118
Q

What is the management strategy for high-risk CVA patients who pause long-acting anticoagulants?

A

High rx pts for CVA that pause LA anticoags (Warfarin) will need SA anticoags (LMWH, IV unfractionated heparin) to bridge the gap
Close monitoring of coagulation status is required

119
Q

What is required when managing cerebrovascular disease patients who are pausing anticoagulants for surgery?

A

Close monitoring of coagulation status is required for patients who are pausing anticoagulants for surgery.

120
Q

What is the protocol for discontinuing anticoagulants in relation to regional anesthesia?

A

Regional Anesthesia requires discontinuing anticoagulants for a sufficient time to safely perform the block.

121
Q

What are the clinical features of an anterior cerebral artery stroke?

A

Contralateral leg weakness.

122
Q

What are the clinical features of a middle cerebral artery stroke?

A

Contralateral hemiparesis and hemisensory deficit (face and arm more than leg), aphasia if it affects the dominant hemisphere, and contralateral visual field defect.

123
Q

What are the clinical features of a posterior cerebral artery stroke?

A

Contralateral visual field defect and contralateral hemiparesis.

124
Q

What are the clinical features when penetrating arteries are occluded?

A

Contralateral hemiparesis and contralateral hemisensory deficits.

125
Q

What are the clinical features of a basilar artery stroke?

A

Oculomotor deficits and/or ataxia with crossed sensory and motor deficits.

126
Q

What are the clinical features of a vertebral artery stroke?

A

Lower cranial nerve deficits and/or ataxia with crossed sensory deficits.

127
Q

What percentage of aneurysm patients experience symptoms before rupture?

A

Only about 1/3
of aneurysm patients have symptoms before rupture.

128
Q

How often are cerebral aneurysms diagnosed before rupture?

A

The majority of aneurysms are not diagnosed before rupture.

129
Q

What are the common symptoms of cerebral aneurysms before rupture?

A

Symptoms include headache, photophobia, confusion, hemiparesis, and coma.

130
Q

What are the risk factors associated with cerebral aneurysms?

A

Risk factors include hypertension, smoking, being female, oral contraceptive use, and cocaine use.

131
Q

How are cerebral aneurysms diagnosed?

A

Diagnosis is via CT angiography, MRI, or lumbar puncture with CSF analysis if rupture is suspected.

132
Q

When should intervention for a ruptured cerebral aneurysm be performed?

A

Intervention should be performed within 72 hours of rupture for the best outcomes.

133
Q

Why is glucose monitoring important for patients with cerebral aneurysms?

A

Patients may be on steroids, making glucose monitoring important.

134
Q

What are the pre-anesthesia considerations for a patient with a cerebral aneurysm?

A

Pre-anesthesia considerations include CT/MRI, EKG, echocardiogram, CBC, BMP, type and crossmatch with blood available.

135
Q

What is important in the pre-anesthesia management of blood pressure in cerebral aneurysm patients?

A

BP control, mannitol? c*aim is to avoid rupture

136
Q

What prophylactic measures should be considered pre-anesthesia in cerebral aneurysm patients?

A

Seizure prophylaxis and possibly the placement of a central venous catheter (CvC).

137
Q

What are the surgical treatment options for cerebral aneurysms?

A

Surgical treatment options include coiling, stenting, and trapping/bypass for very large aneurysms.

138
Q

Why might a neurosurgeon be on standby during operations on patients with cerebral aneurysms?

A

A neurosurgeon may be on standby in case of intraoperative rupture or subarachnoid hemorrhage (SAH).

139
Q

When is the risk for vasospasm highest after a subarachnoid hemorrhage (SAH)?

A

The risk for vasospasm is highest 3-15 days post-SAH.

140
Q

What is triple H therapy in the context of post-SAH management?

A

Triple H therapy refers to Hypertension, Hypervolemia, and Hemodilution.

141
Q

Which component of triple H therapy is initially the main treatment to avoid complications of hypervolemia?

A

Hypertension is the initial main treatment to avoid complications of hypervolemia.

142
Q

What interventional treatments are used to relieve vasospasm?

A

Interventional treatments such as balloon dilation and direct injection of vasodilators are used to relieve the spasm.

143
Q

What pre-anesthesia interventions are similar between managing cerebral aneurysms and post-SAH?

A

Pre-anesthesia interventions for post-SAH vasospasm are the same as with aneurysm, although normally they are less-invasive.

144
Q

What does a score of 0 on the Hunt and Hess classification indicate?

A

An unruptured aneurysm with a mortality rate of 0%-2%.

145
Q

What are the findings and mortality rate for a score of 1 on the Hunt and Hess classification?

A

A ruptured aneurysm with minimal headache and no neurologic deficits, with a mortality rate of 2%-5%.

146
Q

What does a score of 2 on the Hunt and Hess classification signify?

A

A ruptured aneurysm with moderate to severe headache, no deficit other than cranial nerve palsy, and a mortality rate of 5%-10%.

147
Q

How is a score of 3 on the Hunt and Hess classification characterized?

A

Drowsiness, confusion, or mild focal motor deficit, with a mortality rate of 5%-10%.

148
Q

What does a Hunt and Hess score of 4 represent?

A

Stupor, significant hemiparesis, early decerebration, with a mortality rate of 25%-30%.

149
Q

What does a score of 5 on the Hunt and Hess classification indicate in terms of patient condition and mortality rate?

A

Deep coma, decerebrate rigidity, with a mortality rate of 40%-50%.

150
Q

In the World Federation of Neurologic Surgeons grading system, what does a score of 1 represent?

A

A Glasgow Coma Scale score of 15 with no presence of major focal deficit and an intact, unruptured aneurysm.

151
Q

What does a score of 2 or 3 on the World Federation of Neurologic Surgeons grading system indicate?

A

A Glasgow Coma Scale score of 13 or 14 with no presence of major focal deficit for a score of 2, and possible presence for a score of 3.

152
Q

How is a score of 4 on the World Federation of Neurologic Surgeons grading system defined?

A

A Glasgow Coma Scale score of 7-12, with the presence of a major focal deficit being possible or not.

153
Q

What does a score of 5 on the World Federation of Neurologic Surgeons grading system imply?

A

A Glasgow Coma Scale score of 3-6 with the presence of a major focal deficit being possible or not.

154
Q

What characterizes an arteriovenous malformation (AVM)?

A

An AVM is an arterial to venous connection without intervening capillaries, resulting in high flow, low resistance shunting.

155
Q

What is the commonly believed origin of arteriovenous malformations?

A

AVMs are believed to be congenital.

156
Q

What is the range of symptoms for arteriovenous malformations?

A

Symptoms can range from mass-effects to hemorrhage.

157
Q

Where are the majority of arteriovenous malformations located?

A

The majority of AVMs are supratentorial.

158
Q

How are arteriovenous malformations diagnosed?

A

AVMs are diagnosed via angiography and MRI.

159
Q

What pre-anesthesia assessments are important for patients with arteriovenous malformations?

A

Pre-anesthesia assessments include history and physical, review of medications, imaging, CBC, BMP, type and crossmatch, EKG, and echocardiogram.

160
Q

What are the treatment options for arteriovenous malformations?

A

Treatment options include radiation, angio-guided embolization, and surgical resection, which carries a higher mortality risk.

161
Q

What are key considerations in the pre-anesthesia management of arteriovenous malformations?

A

Pre-anesthesia management should focus on BP control, potential use of mannitol, seizure prophylaxis, ensuring large bore IV access x2, and arterial line placement.

162
Q

How is the nidus size of an AVM graded in the Spetzler-Martin system?

A

Nidus size is graded as small (<3 cm) for 1 point, medium (3-6 cm) for 2 points, and large (>6 cm) for 3 points.

163
Q

What does eloquence of adjacent brain mean in the Spetzler-Martin AVM grading system?

A

Eloquent brain areas are those that, if affected, would result in a significant neurological deficit. Eloquent areas score 1 point, while noneloquent areas score 0 points.

164
Q

How is the pattern of venous drainage graded in the Spetzler-Martin AVM system?

A

The pattern of venous drainage is graded as superficial only for 0 points and deep only or deep and superficial for 1 point.

165
Q

What is the likelihood of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1?

A

There is a 100% chance of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1.

166
Q

How does the Spetzler-Martin AVM grade correlate with the percentage of patients with no postoperative neurological deficit?

A

Grade 1 correlates with 100% of patients having no deficits,
- Ggade 2 with 95%
- Grade 3 with 84%
- Grade 4 with 73%
- Grade 5 with 69% having no postoperative neurological deficits.

167
Q

How are traumatic brain injuries categorized?

A

Traumatic brain injuries are categorized as either “penetrating” or “non-penetrating,” depending on the breach of the dura.

168
Q

How is the severity of a traumatic brain injury categorized?

A

The severity is categorized by the Glasgow Coma Scale.

169
Q

What is considered a primary injury in the context of traumatic brain injury?

A

Primary injury occurs at the time of the initial insult.

170
Q

What are secondary injuries in the context of traumatic brain injury?

A

Secondary injuries include neuroinflammation, cerebral edema, hypoxia, anemia, electrolyte imbalances, and neurogenic shock.

171
Q

When is intubation required for traumatic brain injury patients?

A

Intubation is required in severe TBI (GCS < 9, airway trauma, respiratory distress).

172
Q

What role does mild hyperventilation play in the management of TBI?

A

Mild hyperventilation is used to control intracranial pressure (ICP).

173
Q

What imaging is required as soon as possible in cases of traumatic brain injury?

A

A CT scan of the head and neck should be done ASAP.

174
Q

What are the pre-anesthesia considerations for a patient with traumatic brain injury?

A

Review co-morbidities, degree of injury, imaging, labs, and perform a gross neurologic exam. Emergent surgery should not be delayed.

175
Q

What are some key preoperative measures for traumatic brain injury?

A

C-spine stabilization, adequate IV access, central venous catheter (CVC), arterial line (Aline), and possibly uncrossmatched blood if there is no time for type and crossmatch.

176
Q

Why should nasogastric or orogastric tubes be avoided in TBI patients?

A

Refrain from nasogastric (NGT) or orogastric (OGT) tube placement due to the potential for basal skull fractures.

177
Q

What intraoperative management is involved for traumatic brain injury patients?

A

Intraoperative management includes ISTAT labs, pressors, hypertonic saline or mannitol, and calcium.

178
Q

How is traumatic brain injury categorized?

A

Traumatic brain injury is categorized as “penetrating” or “non-penetrating,” depending on the breach of the dura.

179
Q

How is the severity of a TBI categorized?

A

Severity of a TBI is categorized by the Glasgow Coma Scale.

180
Q

What is a primary injury in TBI?

A

Primary injury occurs at the time of the initial insult.

181
Q

What constitutes secondary injuries in TBI?

A

Secondary injuries include neuroinflammation, cerebral edema, hypoxia, anemia, electrolyte imbalances, and neurogenic shock.

182
Q

When is intubation required in TBI?

A

Intubation is required in severe TBI, which is defined as a Glasgow Coma Scale (GCS) score of less than 9, airway trauma, or respiratory distress.

183
Q

How is intracranial pressure (ICP) controlled in a patient with TBI?

A

Mild hyperventilation may be used to control ICP.

184
Q

What imaging is essential in TBI cases?

A

A CT of the head and neck should be done as soon as possible.

185
Q

What are the pre-anesthesia considerations for a patient with TBI?

A

: Review comorbidities, degree of injury, imaging, labs, and conduct a gross neurologic exam. Do not delay emergent surgery.

186
Q

What is important regarding IV access and potential blood transfusion in the context of emergent TBI surgery?

A

Ensure C-spine stabilization, adequate IV access, central venous catheter, arterial line placement, and possibly use uncrossmatched blood if there is no time for type and crossmatch.

187
Q

What should be refrained from in TBI patients and why?

A

Refrain from using nasogastric or orogastric tubes due to the potential for basal skull fractures.

188
Q

What are intraoperative considerations for managing a TBI patient?

A

Intraoperative considerations include iSTAT labs, pressors, bicarbonate, and calcium administration.

189
Q

What characterizes Chiari 1 malformation?

A

Downward displacement of medulla and cerebellar tonsils and syringomyelia.

190
Q

What are the features of Chiari 2 (Arnold-Chiari) malformation?

A

Herniation of the cerebellar tonsils, hydrocephalus, kink in the medulla, (Myelo)meningocele, and syringomyelia.

191
Q

What is seen in a Chiari 3 malformation?

A

Further herniation of the cerebellum below the foramen magnum forming an encephalocele in addition to spina bifida.

192
Q

How is Chiari 4 malformation defined?

A

Hypoplasia/Aplasia of the cerebellum with spina bifida.

193
Q

What are common complaints in patients with congenital displacement of the cerebellum?

A

Complaints include headache extending to shoulders/arms, visual disturbances, and ataxia.

194
Q

What is the treatment for Chiari malformations?

A

Treatment typically involves surgical decompression.

195
Q

What are the pre-anesthesia considerations for patients with Chiari malformations?

A

Review the patient’s history and physical, deficits, imaging, CBC, BMP, type and crossmatch. You may hyperventilate to decrease ICP, and ensure large bore IV x 2 or central venous catheter, and arterial line are in place.

196
Q

What is a seizure?

A

A seizure is a transient, paroxysmal, and synchronous discharge of neurons in the brain.

197
Q

What can cause seizures transiently?

A

A seizure is a transient, paroxysmal, and synchronous discharge of neurons in the brain.

198
Q

What can cause seizures transiently?

A

Seizures can be caused by transient abnormalities such as hypoglycemia, hyponatremia, hyperthermia, or intoxication

199
Q

How can seizures caused by transient abnormalities be treated?

A

Treating the underlying cause is curative for seizures caused by transient abnormalities.

200
Q

What distinguishes epilepsy from a single seizure event?

A

Epilepsy is characterized by recurrent seizures due to congenital or acquired factors.

201
Q

What is the action of antiepileptic drugs?

A

Antiepileptic drugs decrease neuronal excitability and enhance inhibition.

202
Q

What should be determined pre-anesthesia in patients with seizure disorders?

A

Determine the source of the seizures (if known) and how well they are controlled. It is important to have anti-seizure drugs on board before incision.

203
Q

Why is it important to review drugs and their pharmacokinetic/pharmacodynamic actions in patients with seizure disorders?

A

Understanding the drugs and their actions is important for managing anesthesia in patients with seizure disorders.

204
Q

Which antiepileptic drugs are enzyme inducers?

A

Phenytoin, Tegretol, and Barbiturates are enzyme-inducers.

205
Q

What may an anesthesiologist be called to do post-seizure?

A

An anesthesiologist may be called to intubate post-seizure, typically employing Rapid Sequence Intubation (RSI) with cricoid pressure.

206
Q

What are some treatment options for Parkinson’s disease?

A

Treatment options include
- Levodopa (which crosses the blood-brain barrier),
- Anticholinergics
- MAOIs (which inhibit dopamine degradation)
- Deep brain stimulation.