2c. Diseases Affecting the Brain

Question 1

clinical features of basilar artery occlusion

Answer 1

oculomotor deficits and/or ataxia
with crossed sensory-motor deficits

*tip = basilar = posterior = occipital lobe

Question 2

clinical features of vertebral artery occlusion

Answer 2

lower cranial nerve deficits and/or ataxia with crossed sensory deficits

Question 3

anterior cerebral artery occlusion clinical features

Answer 3

contralateral leg weakness

Question 4

sudden onset of neurologic dysfunction or neurologic signs and symptoms evolving over minutes to hours is most likely a …

Answer 4

stroke

Question 5

sudden vascular-related focal neurologic deficit that resolves promptly 24-hours

Answer 5

TIA

Question 6

most significant risk factor for acute ischemic stroke

Answer 6

systemic hypertension

Question 7

other risk factors for stroke:

Answer 7

cigarette smoking
hyperlipidemia
diabetes mellitus
excessive alcohol consumption

Question 8

large hemispheric strokes may be categorized by …

Answer 8

malignant middle artery syndrome

Question 9

infarction of the cerebellum may result in …

Answer 9

basilar artery compression and brainstem ischemia

Question 10

initial therapy of acute ischemic stroke

Answer 10

ASA

Question 11

intravenous recombinant tissue plasminogen activator (tPA) used in patients…

Answer 11

• who meet specific eligibility requirements
• in whom treatment can be initiated within a limited time window from onset of acute symptoms

Question 12

blow flow to ischemic regions is dependent on …

Answer 12

CPP

Question 13

why is rapid lowering of BP at initial stroke presentation not advised?

Answer 13

systemic HTN is common at initial time of stroke presentation but rapid lowering of BP can impair CBF and worsen ischemic injruy

Question 14

upper limit of BP goal for stroke and what may be used to lower it

Answer 14

BP < 220/120
small doses of labetalol

BP below 180/85 is recommended.

Question 15

intravascular volume replacement for stroke improves …

Answer 15

cardiac output and cerebral perfusion

hypervolemic hemodilution increases CBF and decreases blood viscosity

Question 16

DVT prophylaxis heparin dosing

Answer 16

5000 units SQ Q 12

pneumatic compression stockings when heparin is contraindicated

Question 17

temperature management in stroke patients

Answer 17

normothermia
avoid fever
hypothermia has benefits but is controversial

Question 18

patients undergoing which surgeries are at greatest risk of stroke?

Answer 18

cardiac
neurologic
major vascular surgery

non-vascular/neuro surgery risks include: amputations, abdominal exploration, or small bowel resection

Question 19

how long should elective surgery be delayed following a stroke?

Answer 19

9 months

allows for return of cerebral autoregulation, risk factor reduction, and treatment of a cause

Question 20

moyamoya disease

hint: “puff of smoke”

Answer 20

progressive stenosis of intracranial blood vessels (poor blood flow)

2nd development of anastomotic capillary network – seen on CT as a cluster or small abnormal blood vessels

Question 21

what is crucial in identifying suspicions of stroke postoperatively?

Answer 21

preoperative assessment and documentation of preexisting neurologic deficits

Question 22

anticoagulant and antiplatelet therapy for diagnosis of moyamoya disease?

Answer 22

discontinue

Question 23

anesthetic induction and maintenance goals for moyamoya

Answer 23

hemodynamic stability
avoid cerebral or peripheral vasoconstriction (VAAs enhance cerebral vasodilation, hyperventilation causes constriction)
rapid emergence

Question 24

meds to increase BP for moyamoya (remember – want to limit vasoconstriction)

Answer 24

dopamine and ephedrine

Question 25

succinylcholine in moyamoya?

Answer 25

use with caution in patients with preexisting neurologic deficits b/c of risk of hyperkalemia

Question 26

leading cause of death and disability in young adults in the US

Answer 26

TBI

Question 27

initial management of TBI

Answer 27

immobilize cervical spine
establish patent airway
protect lungs from aspiration
treat hypotension to maintain brain perfusion

Question 27

most useful diagnostic procedure for TBI

Answer 27

CT

Question 28

TBI patients may deteriorate suddenly d/t…

Answer 28

delayed hematoma formation w/ cerebral edema

Question 29

severe head injury defined as GCS score less than…

Answer 29

8

Question 30

MAP contributing to poor outcome in TBI

Answer 30

< 70 mm Hg

Question 31

what Rx are contraindicated in TBI?

Answer 31

CORTICOSTEROIDS

Question 32

what fluids/fluid management Rx may decrease brain volume and t/f should be used with caution if at all in TBI?

Answer 32

Administration of hypertonic saline and mannitol may decrease brain volume

Hypotonic crystalloid solutions should be avoided because they decrease plasma osmotic pressure and increase cerebral edema

Control ICP with mannitol carefully as it may damage the BBB and worsen ICP. Use an ICP monitor

Glucose-containing solutions must be avoided unless indicated to treat hypoglycemia

Question 33

overall anesthesia management goals for TBI:

Answer 33

optimize CPP, minimize cerebral ischemia and avoid drugs and techniques that increase ICP

Question 34

TBI: CPP should be maintained in range of …

Answer 34

50-70 mm Hg