Brain 4 Flashcards
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
a. hematocrit 30%
c. nimodipine
f. daily transcranial doppler exams
__________ is the leading cause of morbidity and mortality after subarachnoid hemorrhage.
Vasospasm
Most aneurysms arise
in the circle of Willis
The most common cause of subarachnoid bleeding is
aneurysm rupture
______________ predisposes the aneurysm to rupture
Increased transmural pressure
Surgical options for hemorrhagic stroke include
aneurysm clipping or endovascular coiling
Cerebral vasospasm is
a delayed contraction of the cerebral arteries
Cerebral vasospasm can lead to
cerebral infarction and is the most significant source of morbidity and mortality in the patient with SAH
What is the treatment if vasospasm occurs?
triple H therapy (hypervolemia, hypertension, and hemodilution to 27-32%)
_______ is the only calcium channel blocker shown to reduce morbidity and mortality associated with vasospasm
Nimodipine- it does not relieve the spasm but increases collateral blood flow
Arterial bleeding usually occurs in the
subarachnoid space
Venous bleeding usually occurs in the
subdural space
Signs of SAh include
an intense headache that is often described as “the worst headache in my life”
focal neurological deficits
LOC
N/V
photophobia
fever
To reduce the risk of rebleeding, surgical repair of aneurysm should occur
24-48 hours following the initial bleed
If an endovascular coil is placed, the patient will require
heparinization
If the aneurysm ruptures during endovascular coiling,
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
Describe intraoperative blood pressure control for hemorrhagic stroke.
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
If a rupture occurs during induction and intubation, the focus of anesthetic management is on
reducing ICP and utilizing methods of cerebral protection
The most common presentation of cerebral vasospasm includes
a new neurologic deficit or altered level of consciousness
The gold standard for diagnosis of cerebral vasospasm is
cerebral angiography
Patients who suffer aneurysmal subarachnoid hemorrhage are at risk for
cerebral salt-wasting syndrome (CSW)
Cerebral salt-wasting syndrome is treated with
isotonic crystalloids
How does cerebral salt-wasting syndrome occur?
the brain releases natriuretic peptide (just like the overfilled heart) and this leads to volume contraction, hyponatremia, and sodium wasting by the kidney
When is cerebral vasospasm most likely to occur?
4-9 days following SAH
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
a. hypertonic sodium chloride
c. platelet transfusion
Clopidogrel or aspirin is reversed with
platelet transfusion
recombinant factor 7a
Warfarin is reversed with
FFP
prothrombin complex concentrate
recombinant factor 7a
Head trauma can be
blunt or penetrating
Initial considerations with head trauma include
stabilization of the cervical spine
airway protection
optimization of hemodynamics
cerebral protection
_______ provides an objective assessment of neurologic status.
the Glasgow Coma Scale
A GCS < _____- is consistent with traumatic brain injury
<8
CPP for the TBI should be maintained at
> 70 mmHg
What has been linked to poorer neurologic outcomes in the TBI patient?
albumin & steroids
glucose-containing solutions worse neurologic outcomes in the setting of cerebral ischemia
What type of IV therapy should be used for TBI patients?
hypertonic saline restores intravascular volume and reduces brain water
Should N2O be used in the patient with TBI?
No- can rapidly expand a penumothorax (which may only become evident after induction) or can cause pneumocephalus
What are additional anesthetic considerations for the patient with a TBI?
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
Which agent is MOST likely to produce a seizure in a patient with epilepsy?
a. ketamine
b. dexmedetomidine
c. propofol
d. sufentanil
a. Ketamine
Seizures are the result of
abnormal electrical discharges in the brain
A ____ results when seizure activity is localized to a particular cortical region.
partial (focal) seizure
A ______ occurs when the seizure activity affects both hemispheres.
Generalized seizure
When a partial seizure progresses to a generalized seizure this is called a
Jacksonian march
Epilepsy is characterized by ______- and is typically diagnosed in ____________
idiopathic seizures and diagnosed in childhood
New onset seizures in adults are usually the result ofa
a structural brain lesion or metabolic cause
___________-can induce seizure activity and should be avoided in the patient with a history of seizures
Ketamine
________commonly causes myoclonus. This is not associated with increased EEG activity in patients that do not have epilepsy
Etomidate
_________reduce the seizure threshold but when properly executed they do not increase the risk of seizures.
Local anesthetic
(by they meaning regional anesthetic0
Although all the __________________ have been implicated in producing seizure activity, these drugs tend to reduce EEG activity in a dose-dependent fashion.
inhalational agents
Metabolic causes of seizures include
hypoglycemia, drug toxicity, withdrawal, or infection
Structural brain lesions causes of seizures include
tumor, head trauma, or CVA
Seizures can occur under
general anesthesia
Signs of a seizure occurring under general anesthesia includes
tachycardia, HTN, and increased ETCO2 as a result of increased oxygen consumption
