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Advanced Principles III > Anesthesia For Neurosurgery PowerPoints > Flashcards

Anesthesia For Neurosurgery PowerPoints Flashcards

1
Q

Presentation of Acute Increase in ICP in Adults (4)

A

1) HA
2) N/V
3) AMS
4) Visual Disturbances

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2
Q

Presentation of Acute Increase in ICP in Peds

A

Lethargy & Vomiting

Bulging Fontanel

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3
Q

Presentation of CHRONIC changes in ICP adult (5)

A

1)HA
2)Lethargy in varying degrees
Cognitive changes
3)6th CN ( Abducens )palsy = Lateral Rectus weak= eyes cross inward toward nose (esotropia)
4)Parinauds’s disturbances : inability to move the eyes up or down
5) Gait disturbances

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4
Q

Kids Presentation of chronic ICP changes (4)

A

1) Failure to thrive
2) Head Circumference Gradually increases
3) Fontanel may bulge
4) CN palsies ( Again dependent on etiology )

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5
Q

WHat is ICH ?

A

ICP > 20 mmHg

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6
Q

Acute ICH features

A

Irregular Respiration
Bradycardia
HTN
Ipsilateral fixed , dilated pupils ( CN 3 compression on the same side of the mask .

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7
Q

Chonic ICH features

A

Papilledema

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8
Q

Treatment for ICH

A 
ABC
Intubation + hyperventilation
PCO2 maintained 25- 30 ish mmHg
Mannitol
Sedation
Steroids
* wean those off ventilator slowly
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9
Q

2 auto regulation Failure

A

Either you get
Hypoperfusion» Ischemia or
Hyperperfusion and Breakthrough :
Breaking BBB, Swelling, Vessel rupture , hemorrhage.

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10
Q

Cerebral Steal

A

Steal from the poor( ischemic area) to give the rich ( non ischemic area). It’s a vasodilator response that decreased CBF to the ischemic area

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11
Q

What therapy do you implement to enhance perfusion ( 3 things )

A

Maintain High Perfusion pressure
Hypocapnia = constricts vessels to counteract the cerebral steal
Barbituates

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12
Q

GCS

A

Severe Brain Injury defines as < 8-9
Moderate = 8-12
Minor ≥ 13
Monitor ICP when GCS <7 *

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13
Q

6 times when you monitor ICP

A 
Trauma 
GCS <7
SAH 
Hydrocephalus
Tumor
AV malformation
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14
Q

Lumbar ICP should not be done when ?

A

When you have IC disorders . It can’t amuse downward her nation bc the there is inaccuracy due to small caliber and Lon length catheter .

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15
Q

What are the 2 modalities of ICP modalities preferred ?

A

Intraventricular : cannulate the ventricular FRONTAL HORN

Intraparenchymal : held in place by bolt screw

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16
Q

What is the effect of ICP on cerebral Blood Flow ?

A

Reduce CBF

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17
Q

What Is CPP , when use it ? What Is normal CPP ? What CPP is considered critical

A

Used as a surrogates for CBF
Used when Stats are rapidly changing i.e during herniation
CPP= MAP - ICP or CVP ( whichever higher)
< 40 is critical
Maintain CPP 50 - 55 but book says 60

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18
Q

Hydrocephalus Communicating vs Non Communicating

A

Communicating :
BLOCKAGE of flow around base of brain or of arachnoid villi = fluid collects outside brain and some collect in the ventricles
Non Communicating :
Aqueduct of Sylvius is blocked ! Lateral 3 rd ventricles is backed up ! Volume increase

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19
Q

Blood Brain Barrier

A

Low permeability of these barriers is due to the “tight junctions” that join the endothelial cells of the brain tissue capillaries…

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20
Q

What is BBB permeable to ?
What is BBB slightly permeable to ?
What is BBB Impermeable to ?

A 
Permeable to :
Water/CO2/O2/ Most lipid soluble stuff
Slightly permeable to:Electrolytes, Na+ Cl-
K+
Impermeable to :
Plasma Proteins
Non Lipid Soluble large molecules
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21
Q

Viscous cycle of Brain edema

A

Edema&raquo_space; decrease blood flow&raquo_space;Ischemia&raquo_space; more edema

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22
Q

What is MOA of Brain edema ( 2)

A

Either capillary pressure increase or

Capillary is damaged = leaky wall

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23
Q

Brain CMRO2 vs Total body’s .

A

Brain CRMO2 is 15% of total body ‘s CRMO2

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24
Q

Can brain do aneorobic metabolism

A

No!

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25
Q

Most brain energy supplied by

A

Glucose

Only 2 minute of glucose stored as glycogen in neurons

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26
Q

MC 1º brain tumor

A 
Astrocytoma 
Grave prognosis
< 1 year life expectancy
Found in cerebral hemisphere
Treatment: Resection, radiation and chemo
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27
Q

2nd MC 1º tumor:

A

Meningioma
Occurs in convexities of brain and parasagittal region
Arise from arachnoid cells external to brain (NOT dura)
Slow growing
Resectable

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28
Q

Pituitary Adenoma

A

Most commonly prolactinoma
Bitemporal hemianopia “ tunnel vision”
Hyper or hypo pituitarism are sequelae

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29
Q

Shwannoma

A

3rd MC 1º tumor
Origin is : Schwann Cell
Often in CN VIII&raquo_space; acoustic Shwannoma
Respectable

30
Q

Seizure causes in Children

A

Causes

Children- genetic, infection (febrile), trauma, congenital, metabolic

31
Q

Seizures causes in adult

A

Adults- tumors, trauma, stroke, infection

32
Q

Seizure causes in Elderly

A

Elderly- stroke, tumor, trauma, metabolic, infection

33
Q

IV anesthetic effect on CMR and CBF

A

Decrease CMR and CBF in a parallel fashion
Whereas …
Most Inhalation decrease CMR while increasing CBF ( vasodilation )

34
Q

With IC pathology responses to anesthetics may be ≠ from those of normal subjects . They may have :

A

Brain tissue hypoxia, acidosis, edema
Cerebral vasoparalysis may occur and coupling b/w blood flow and metabolism can be impaired…
Under these circumstances… Autoregulation and CO2 reactivity are also disturbed…

35
Q

What strict parameters are required during neuroanesthesia ?

A

Strict BP

Strict Resp management

36
Q

Why is Hyperventilation NOT recommend in pts with stroke ?

A

Low CO2&raquo_space; divert blood from normal area to Ischemia bc of cerebral vasoconstriction&raquo_space;not recommended in stoke
Reverse Steal
2) Marked decreased in CBF in pts w/ head trauma

37
Q

HYPOCAPNEA = reverse steal or steal ?

A

Steal bc of vasodilation of good healthy vessels, blood shunts from Ischemic area to vasodilated area

38
Q

Does Anesthesia cause a steal effect ?

A

Yes !

39
Q

What other way outside of increase in CBF do anesthetic agents affect ICP ?

A

Change the rate of production and reabsorption of CSF

40
Q

ICH can be rapidly controlled by doing ____but after a while it will cause

A

Hyperventilation ( decrease ICP )

Marked decreased in CBF in pt w/ head trauma ( another reason why not to give it to stroke patients)

41
Q

N2O effect on CBF CMR ICP

A

CBF : 2 arrows up
CMR: little or none
ICP : 2 arrows up

42
Q

Isoflurane ( Furane ) effect on CBF CMR ICP

A

CBF : little or nine
CMR 2 arrows down ( decreased )
ICP : none, or slightly or up ( dose dependent)

43
Q

Sevo effect on CBF CMR ICP

A

CBF : decreased , none , or slightly up
CMR : 1 or 2 arrows down
ICP : None , Slightly or up

44
Q

Des effects on CBF , CMR, ICP

A

CBF : Up or down
CMR: 2 Arrows down
ICP: Up or one

45
Q

Which Fossa is : Cerebellum , Midbrain, Pons, Medulla

/

A

Posterior Fossa

46
Q

S/of ICP inc, Initial non specific ( Post Fossa Sx topic )(6)

A 
Listlessness 
HA
Fatigue
Vomiting 
Anorexia 
Personality change
47
Q

What are the Cerebellar or brainstem signs

A

Dysmetria ( Lack of coordination )
Hemoparesis ( Unilateral weakness )
Crania Nerve Deficits

48
Q

Specific clinical syndromes occur with elevated ICP due to what kind of Tumor ?

A 
Acoustic Neuroma 
CP angle tumors (cerebellarPontine Angle tumor )
Brainstem glioma 
Carotid body tumor 
* they rapidly involve neural structures
49
Q

Midline and 4th Ventricle lesions have what s/s?

A 
Truncal ataxia 
Wide based gait 
Nystagmus 
Extraocular Movement abnormalities 
Truncal titubation ( Nodding head/body- nervous)
Hydrocephalus ( early &amp; common)
Frequent papilledema 
Signs of brainstem lesion
50
Q

S/S of lateral cerebral hemisphere

A

Lots

51
Q

Herniation of cerebellar tonsils through the Foramen _____especially in _____ appear as

A 
Magnum ; children; appear as 
Meningismus : (neck stiffness, photophobia , HA )
Head Tilt 
Muscle Spasm 
Opisthotonus
Vomiting 
Skew deviation of eyes 
Downbeat/vertical nystagmus
52
Q

Typical posturing from tonsillitis herniation may be mistaken for

A

Cerebral fits

53
Q

how do you know , you have brainstem involvement ?

A

Ocular Problems : pupil size, ocular mobility , nystagmus
Sensory + motor deficits
Resp changes : vary depending on brainstem compression i.e hyperventilation vs apnea
Multiple CN dysfunction including bulbar palsy
Progressive compression on brainstem = gaze + facial palsies&raquo_space;rapid loss of consciousness, Resp changes , brady, HTN

54
Q

Posterior fossa is home to

A 
Brainstem 
Major motor and sensory pathways 
CV &amp; Resp center
RAS 
Lower CN nuclei
55
Q

Challenge for anesthesia providers with post fossa sx

A

1) facilitate surgical Acces while minimizing nervous tissue trauma/ischemia , while maintaining Resp and CV stability

56
Q

Pre op a Post Fossa patient please

A 
Complete Medical Hx
Review List of Meds
Physical Exams
Neuro Exam 
Routine investigation ( labs, imaging)
57
Q

What is the monitoring goal for PFS ?

A

Adequate CNS perfusion
Maintain Cardiorespiratory Stability
Detect & treat VAE

58
Q

Positions for PFS?

A

Sitting

1) Head in 3 pin holder
2) LA infiltration of scalp and periosteum at pin site= reduces hypertensive response
3) pad bony prominences
4) thigh high stockings
5) support elbows w/ pillow/pads so they don’t touch table = avoid streth or brachial plexus injury ,
6) legs feee of pressure at level of common Peroneal just distal and lateral of fibula head

59
Q

How to prevent cervical cord stretching and obs of venous drainage from the face and tongue

A

Maintain 1 inch space btw chin and chest

60
Q

What do you avoid during PFS?

A

AVOID Large airway and bite block placement
AVOID Excessive neck rotation
Avoid excessive flexion of knees toward chest = prevent abdominal compression , LE ischemia & sciatic nerve injury

61
Q

What are advantages of sitting position ?

A

1) Lower airway pressure
2) Eases of diaphragmatic excursion ?
3) Better able to hyperventilate
4) Easy Acces to extremities for monitoring fluid / blood administration & blood sampling
5) Number of blood transfusion less in sitting position
6) can see the face for obs of motor response in face during CN stimulation
7) better surgical exposure , less tissue retraction , less cranial nerve damage , more complete resection of tumor

62
Q

Contraindications for PFS? ( 8)

A 
Intra cardiac defects
Severe hypovolemia 
Cachexia 
Severe hydrocephalus 
Lesion vascularity 
Extremes of age / impaired cardiac function 
Degenerative Disease of cervical spine 
Significant CVD
63
Q

What physio changes happen during sitting position ?

A

Head elevated higher than Rt Atrium

Decrease in Dural sinus pressure up to 10 mmHg = 1) increased risk VAE( 45% ) & 2) decreases venous bleeding

64
Q

PFS in prone position . Advantage vs Disadvantage

A

Advantage :
Heap is elevated to decrease venous bleeding
No face compression by keeping head elevated, and shoulders at/or above the edge of the OR table
Less VAE
Disadvantage:
Surgical field not clear
Eye compression = blindness from retinal artery thrombosis
Conjunctival edema
Venous pooling in the lower ext sufficient to impair venous return and hypotension especially in elderly , debilitated patients

65
Q

What positions can posterior fossa surgery be in ?

A 
Sitting 
Prone 
Lateral 
3/4 prone 
Park Bench
66
Q

When to use lateral position in PFS ?

A

When unilateral in upper post fossa

67
Q

What advantages do Three Quarter prone and park bench have ?

A

Greater head rotation and access to more axial structures

68
Q

Complex tangle of abnormal dilated channels directly shunt blood btw artery & vein

A

Nidus

69
Q

Where are aneurysms often found

A

On the arteries feeding the AVM

70
Q

AVMs present with symptoms?

A

Seizures, hemorrhage, progressive neurological dysfunction and or HA

71
Q

Complications of AVMs

A

Hemorrhage into surrounding tissue
Ischemia
Seizures
Brain cell death

72
Q

S/S of AVM

A 
Seizure 
HA
Whooshing sound in skull
Other :
Subtle behavioral changes
Paralysis/weakness in one part of body
Loss of coordination /balance
Visual disturbances
Abnormal sensations

Advanced Principles III (11 decks)

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