Brain 4

Question 1

Management considerations for cerebral vasospasm following subarachnoid hemorrhage include:
a. hematocrit 30%
b. nifedipine
c. nimodipine
d. controlled hypotension
e. mannitol
f. daily transcranial doppler exams

Answer 1

a. hematocrit 30%
c. nimodipine
f. daily transcranial doppler exams

Question 2

__________ is the leading cause of morbidity and mortality after subarachnoid hemorrhage.

Answer 2

Vasospasm

Question 3

Most aneurysms arise

Answer 3

in the circle of Willis

Question 4

The most common cause of subarachnoid bleeding is

Answer 4

aneurysm rupture

Question 5

______________ predisposes the aneurysm to rupture

Answer 5

Increased transmural pressure

Question 6

Surgical options for hemorrhagic stroke include

Answer 6

aneurysm clipping or endovascular coiling

Question 7

Cerebral vasospasm is

Answer 7

a delayed contraction of the cerebral arteries

Question 8

Cerebral vasospasm can lead to

Answer 8

cerebral infarction and is the most significant source of morbidity and mortality in the patient with SAH

Question 9

What is the treatment if vasospasm occurs?

Answer 9

triple H therapy (hypervolemia, hypertension, and hemodilution to 27-32%)

Question 10

_______ is the only calcium channel blocker shown to reduce morbidity and mortality associated with vasospasm

Answer 10

Nimodipine- it does not relieve the spasm but increases collateral blood flow

Question 11

Arterial bleeding usually occurs in the

Answer 11

subarachnoid space

Question 12

Venous bleeding usually occurs in the

Answer 12

subdural space

Question 13

Signs of SAh include

Answer 13

an intense headache that is often described as “the worst headache in my life”
focal neurological deficits
LOC
N/V
photophobia
fever

Question 14

To reduce the risk of rebleeding, surgical repair of aneurysm should occur

Answer 14

24-48 hours following the initial bleed

Question 15

If an endovascular coil is placed, the patient will require

Answer 15

heparinization

Question 16

If the aneurysm ruptures during endovascular coiling,

Answer 16

you should immediately reverse heparin with 1 mg of protamine for every 100 U of heparin administered
MAP should be lowered into the low/normal range

Question 17

Describe intraoperative blood pressure control for hemorrhagic stroke.

Answer 17

SBP between 120-150 mmHg
if the patient undergoes an open repair, a clamp is commonly placed on a proximal feeder vessel which reduces transmural pressure and the risk of intraoperative rupture while also circumventing the need for controlled hypotension

Question 18

If a rupture occurs during induction and intubation, the focus of anesthetic management is on

Answer 18

reducing ICP and utilizing methods of cerebral protection

Question 19

The most common presentation of cerebral vasospasm includes

Answer 19

a new neurologic deficit or altered level of consciousness

Question 20

The gold standard for diagnosis of cerebral vasospasm is

Answer 20

cerebral angiography

Question 21

Patients who suffer aneurysmal subarachnoid hemorrhage are at risk for

Answer 21

cerebral salt-wasting syndrome (CSW)

Question 22

Cerebral salt-wasting syndrome is treated with

Answer 22

isotonic crystalloids

Question 23

How does cerebral salt-wasting syndrome occur?

Answer 23

the brain releases natriuretic peptide (just like the overfilled heart) and this leads to volume contraction, hyponatremia, and sodium wasting by the kidney

Question 24

When is cerebral vasospasm most likely to occur?

Answer 24

4-9 days following SAH

Question 25

Management for the patient with traumatic brain injury on clopidogrel includes (select 2):
a. hypertonic sodium chloride
b. methylprednisolone
c. platelet transfusion
d. fresh frozen plasma

Answer 25

a. hypertonic sodium chloride
c. platelet transfusion

Question 26

Clopidogrel or aspirin is reversed with

Answer 26

platelet transfusion
recombinant factor 7a

Question 27

Warfarin is reversed with

Answer 27

FFP
prothrombin complex concentrate
recombinant factor 7a

Question 28

Head trauma can be

Answer 28

blunt or penetrating

Question 29

Initial considerations with head trauma include

Answer 29

stabilization of the cervical spine
airway protection
optimization of hemodynamics
cerebral protection

Question 30

_______ provides an objective assessment of neurologic status.

Answer 30

the Glasgow Coma Scale

Question 31

A GCS < _____- is consistent with traumatic brain injury

Answer 31

<8

Question 32

CPP for the TBI should be maintained at

Answer 32

> 70 mmHg

Question 33

What has been linked to poorer neurologic outcomes in the TBI patient?

Answer 33

albumin & steroids
glucose-containing solutions worse neurologic outcomes in the setting of cerebral ischemia

Question 34

What type of IV therapy should be used for TBI patients?

Answer 34

hypertonic saline restores intravascular volume and reduces brain water

Question 35

Should N2O be used in the patient with TBI?

Answer 35

No- can rapidly expand a penumothorax (which may only become evident after induction) or can cause pneumocephalus

Question 36

What are additional anesthetic considerations for the patient with a TBI?

Answer 36

victims of trauma–> full stomach, unstable cervical spine, intracranial hypertension, questionable volume status, hypoxemia, injury elsewhere in the body, airway issues such as blood, skull-base fracture or laryngotracheal injury

Question 37

Which agent is MOST likely to produce a seizure in a patient with epilepsy?
a. ketamine
b. dexmedetomidine
c. propofol
d. sufentanil

Answer 37

a. Ketamine

Question 38

Seizures are the result of

Answer 38

abnormal electrical discharges in the brain

Question 39

A ____ results when seizure activity is localized to a particular cortical region.

Answer 39

partial (focal) seizure

Question 40

A ______ occurs when the seizure activity affects both hemispheres.

Answer 40

Generalized seizure

Question 41

When a partial seizure progresses to a generalized seizure this is called a

Answer 41

Jacksonian march

Question 42

Epilepsy is characterized by ______- and is typically diagnosed in ____________

Answer 42

idiopathic seizures and diagnosed in childhood

Question 43

New onset seizures in adults are usually the result ofa

Answer 43

a structural brain lesion or metabolic cause

Question 44

___________-can induce seizure activity and should be avoided in the patient with a history of seizures

Answer 44

Ketamine

Question 45

________commonly causes myoclonus. This is not associated with increased EEG activity in patients that do not have epilepsy

Answer 45

Etomidate

Question 46

_________reduce the seizure threshold but when properly executed they do not increase the risk of seizures.

Answer 46

Local anesthetic
(by they meaning regional anesthetic0

Question 47

Although all the __________________ have been implicated in producing seizure activity, these drugs tend to reduce EEG activity in a dose-dependent fashion.

Answer 47

inhalational agents

Question 48

Metabolic causes of seizures include

Answer 48

hypoglycemia, drug toxicity, withdrawal, or infection

Question 49

Structural brain lesions causes of seizures include

Answer 49

tumor, head trauma, or CVA

Question 50

Seizures can occur under

Answer 50

general anesthesia

Question 51

Signs of a seizure occurring under general anesthesia includes

Answer 51

tachycardia, HTN, and increased ETCO2 as a result of increased oxygen consumption