CNRN Flashcards
1
Q
Lhermitte’s sign
A
May be present in MS. It’s described a electric shock sensation
2
Q
Lhermitte’s sign
A
May be present in MS. It’s described a electric shock sensation
3
Q
Draining cerebrospinal fluid with lumbar drain trials
A
Normal
Pressure
Hydrocephalus
4
Q
Caused by hypercoagulable state
A
Stroke caused by central venous thrombosis
5
Q
Which presents with visual changes, h/a and depression ?
A
Pseudomotor cerebri
6
Q
Demyelinatimg disorder of the CNS
A
MS
7
Q
Measures 2.5 cm in diameter
A
Giant aneurysm
8
Q
Measures 2.5 cm in diameter
A
Giant aneurysm
9
Q
Out pouching of the vessel wall
A
Fusiform aneurysm
10
Q
How many pairs of cervical nerve roots are found in the cervical region?
A
8
11
Q
Wet-incontinence
Wacky-dementia
Wobbly-gait disturbance
A
Normal pressure hydrocephalus
12
Q
Small cells. Stellate cells with numerous long processes, found
primarily in the gray matter of the brain and spinal
cord
A
Microglia
13
Q
Support the neurons functions through secretion of metabolic neurotrophic factor , insulin like growth factor
A
Oligodendrocytes
14
Q
Glial cells with extremely long processes that wrap round neuronal axons . A single one can myelinate multiple axons
A
Oligodendrocytes
15
Q
Much more common. Occur in gray matter along cells bodies.
Help make up pia matter
A
Protoplasmatic
Astrocytes
16
Q
Type of glial cell. Star like bodies numerous processes that extend to multiple structures of the CNS
A
Astrocytes
17
Q
Transmit signal via action potential forms within the nervous system to lower neuron , muscles and glands
A
Motor neurons
18
Q
Receive signal from the outside world and transmit it to specific areas of the brain
A
Sensory neurons
19
Q
Gold standard for determining brain death
A
Cerebral blood flow
20
Q
Primitive behavior (sex, rage, fear, biological rhythms)
Emotional control
Filters external stimuli
A
Lymbic system
21
Q
Can be fixed by coiling
Sack like
Most common type
A
Berry aneurysm
Sacular aneurysm
22
Q
Patient with h/a. Loses consciousness after intubation
A
Emergency head CT
23
Q
Patient presents with acute onset of cortical blindness
A
Occlusion of bil posterior cerebral arteries
24
Q
Ich of 4
A
Associated with 97 percent mortality at 30’days following an intracerebral hemorrhage
25
Patient c/o shock like pain to the L side of the face and seem to be associated with chewing
Trigémino neuralgia
Compression of CN V
26
Yellow appearance of CSF that occurs several hour after bleeding into the subarachnoid space
Xantheochromia
27
Yellow appearance of CSF that occurs several hour after bleeding into the subarachnoid space
Xantheochromia
28
Pt post bleed day 4 develops a right sided pronator drift r arm weakness
Suspect cerebral vasospasm which occur 3-14 days post bleed and up to 21 days from initial bleed
29
Vision loss on the same side of both eyes
Homonymous hemianopia
30
Gold standard for signaling cavernous malformation
Gradient echo MRI
31
Vertigo, nausea, fullness of the ear
Most common symptom of Menieres Disease
32
Dilantin should be administered iv
No faster than 50 mg/ min
If too fast cardiac arrest. Do not give it ICP
33
During vasospasm period of hemorrhagic stroke
Nimodipine
60 mg po q 4 hrs for 21 days
34
Gold standard for dx leptomeningeal tumor
Cerebrospinal analysis
35
Connective tissue disease that causes weakening of the medial layer within the vasculature
Places the patient at risk for arterial dissection
Ehlers Danlos
36
Myathenia gravis
associated with thyroid disorder
37
Chemo medication for glyoblastoma. Crosses the blood/brain barrier
Temodar
38
Common in carotid dissection which can be caused by
Whiplash, coughing, sneezing, sexual intercourse
39
CPP adults and pediatric normal values
Cerebral
Perfusion pressure
Adults 60-80
Pediatrics 40-50
40
Map-ICP
CPP-cerebral perfusion pressure
Normal 60-80
41
Is associated with hypoxic state and tissue ischemia
Low CPP
42
What is commonly confused with Dementia?
Normal pressure hydrocephalus
43
Patient with SAH is at increased risk for what type of hydrocephalus?
Communicating
44
The skull is a
Fixed box there is no room for additional contents
Monroe-Kellie doctrine
45
Irregular respirations
Bradycardia
Widening pulse pressure
S/S Cushings syndrome
46
Hypo ventilation, fever, HTn, Sz, drugs, altitude
Secondary cause of increased ICP
47
What produces CSF?
Choroid plexus
48
2-6 months after acute injury. This is sympathetic overload
autonomic dysreflexia
49
2-6 months after acute injury. This is sympathetic overload
autonomic dysreflexia
50
Results from compression of the 3rd portion of the deudenum between aorta and superior mesenteric artery leading to upper GI obstruction
S/s nausea and vomiting
Superior messenteric artery syndrome
51
What spinal injury require continuous mechanical ventilation?
Intermittent?
Cont- C1-C3
Intermittent- C3-C5
52
Hallmark clinical s/s of neurogenic shock
Hypotension
Bradycardia
53
Gold standard technique for
Initial immobilization to temporarily stabilize the cervical spine
Garner-Wells tongs
54
Secondary spinal cord injury
24-2 hours after initial injury
55
Loss of proprioception occurs in which injury?
Posterior syndrome
56
Flexión injury causes
Anterior cord syndrome
57
Hyper extension injury causes
Posterior cord syndrome
58
Motor and proprioceptive loss on ipsilateral side
Pain and temp loss on contralateral side
Brown sequard syndrome
59
Weakness of arms greater than legs
Central cord syndrome
60
Eye opening
Verbal response
Motor response
Components of the GCS
61
Spontaneous
To voice
To pain
None
Eye opening response
GCS
62
alert
Confused
Incomprehensible words
Incomprehensible sounds
None
Verbal response GCS
63
Normal
Location to pain
Withdraw from pain
Decorticate posture
Decerebrate
Motor response GCS
64
What is the most sensitive indicator of change in neurological status in a baseline intact patient?
LOC
65
Cause of pin point pupils
Narcotics
Pons issues
66
Optic control central and peripheral test by having pt read
CN 2
67
Olfactory smell test
Have patient smell coffee
CN 1
68
Occulomotor
Pupil response
Test via cardinal fields
CN 3
69
Trochlear motor
Moves eyes toward tip of nose
Test via cardinal field
CN 4
70
Trigéminal
Three deviations of the nerve
V1- ophthalmic
V2- maxillary
V3-mandibular
Test- have pt chew
Facial sensation on forehead, maxilla and mandible
CN5
71
Trigéminal
Three deviations of the nerve
V1- ophthalmic
V2- maxillary
V3-mandibular
Test- have pt chew
Facial sensation on forehead, maxilla and mandible
CN5
72
Abducents -motor
Innervates lateral rectus- lateral movement of the eyes
Test by having patient moves eyes form ear to ear
CN 6
73
Motor to facial muscle for expression
Sensory of anterior 2/3 of tongue
Test- have it wrinkle forehead, raise eyebrows, close eyes tight, show teeth
CN7
74
Vestíbulo cochlear sensory for hearing
Test- running fingers by pts ears
CN 8
75
Vestíbulo cochlear sensory for hearing
Test- running fingers by pts ears
CN 8
76
Glossopharingeal both sensory to the posterior 2/3 of the tongue, larynx and pharynx to mediate the gag reflex
Test- have pt say Ahh
CN9
77
Vagus
Branches from the vagus innervates organs throughout the body
Test-have pt cough
CN 10
78
Spinal accessory nerve-motor
Motor movement of the ne ck and shoulders
Test- have pt shrug and turn the head
CN 11
79
Hypoglossal nerve
Movement of tongue
Test- Have pt stick tongue out
Left dysfunction -left deviation
Right dysfunction - right deviation
CN 12
80
79 y/o with acute onset of homonymous hemianopia. Where is the stroke?
Occipital
81
Expressive aphasia can be the result of an occlusion on which cerebral
Artery?
MCA
Middle cerebral artery
82
Supplies anterior cerebral circulation
Expressive and receptive aphasia
MCA
83
Pt with anterior cerebral artery ischemic stroke
LLE weakness
84
IV rtPA for eligible patients should be administered within
3 -4.5 hrs
85
Visual -spatial information /orientation
Sensory interpretation
Voluntary movements
Object manipulation
Key characteristics of the parietal
Lobe
86
Patient can form words but is incoherent and in appropriate
Can’t follow verbal commands but may follow if demonstrated
Wernickes aphasia
87
Receptive aphasia due to damage of the temporal
Lobe (primarily left)
Interprets the meaning of spoken / written words
Werneckes aphasia
88
Receptive aphasia due to damage of the temporal
Lobe (primarily left)
Interprets the meaning of spoken / written words
Werneckes aphasia
89
Auditory ability
Long term
Memory
Werneckies area
Key characteristics of the temporal lobe
90
Expressive aphasia
Damage to the broca causes the inability to perform the motor aspect of speech
Types of aphasia
Damage to the broca area
91
Patient can understand but can’t form words
They follow verbal commands and execute requests
Brocas aphasia
92
Emotions
Impulse control
Motor function
Broca’s area
Social , sexual behavior
Memory
Frontal lobe
93
Imbalanced movement
ETOH
Ataxia
94
Gait movement
Paralysis of one side of the body
Dragging of paralyzed leg
Hemiparetic
95
Gait movement
Side to side jerkiness
Decreased hip
rotation
Primary cause hip
arthritis
Antalgic
96
Thalamus
Hypothalamus
Pituitary gland
Structures inside the diencephalon
97
Relay center for major nerve tracts
Key function of the thalamus
98
Eating, hunger, hormone regulation
Hypothalamus
99
Carry out functions that support the neurons
Glia
100
drive function of the body
Neurons
101
drive function of the body
Neurons
102
Hormonal regulation
Key function of the pituitary gland
103
Unable to speak due to
laryngeal damage/paralysis
Laryngeal inflammation , thickening of vocal cords
Dysphonia
104
76 year old male with right side weakness and severe head ache and vomiting
Hemorrhagic stroke
105
Patient with severe head ache and focal symptoms : Weakness . Severe hypertension and vomiting
Emergency CT of the head plain to assess for hemorrhagic stroke
106
Pontine perforations of which cerebral blood vessel perfuse the pons?
Basilar artery
107
Patient with new onset of cortical blindness cause by occlusion of
Bil posterior cerebral
artery
108
Patient with acute onset homonymous hemianopia
Occipital lobe stroke
109
Where is the extrapyramidal system
located?
Basal ganglia
110
Link between thalamus and motor cortex
Coordinates muscles contractions
Related to posture and I part of the extrapyramidal system that regulates autonomic movement
Basal ganglia
111
Thick band of nervous fibers that facilitate the communication and transfers motor, sensory and cognitive information
Corpus collosum
112
Single pathway of nerves that connect the left and right hemispheres of the brain
Corpus collosum
113
Abnormal =eyes follow direction of the head
Occulocephalic reflex
114
Dolls eyes reflex . Open eye lids and turn heads dr side to side
Normal response -eyes fixate and do not move with head
Occulocephalic reflex
115
Cerebral blood flow
Dolls eyes
Cold caloric testing
Apnea test
Gold standard for determining brain death
116
Pt c/o progressive unilateral hearing loss and posterior h/a
Cerebellopontine angel tumor
Acoustic neuroma
117
Most common pediatric brain tumor
Cerebellum
118
Hemangioma Dx
Which is malignancy?
Astrocytoma
119
Ependymomas arise from ependymal cells lining the ventricles and spinal
Cord
Hydrocephalus may develop
Pt with ependymoma . Slightly lethargic and a little
Off
120
Benign , slow growing tumor
Can be sx removed
No radiation or chemo
Acoustic neuroma
121
69 yo malnourished and admitted with ETOH withdraw. What med?
Thiamine B1
Diminished risk for Werneckes encephalopathy
122
Patient with left basal hemorrhagic stroke 5 days ago. Today-fever, lethargic and worsening weakness
Toxic metabolic encephalopathy
123
Patient co sporadic, elective like shock feeling on the left side of the face (cheek and forehead)
CN V
Trigeminal
Neuralgia
124
F/u 2 weeks after vertebral column fracture
Ibuprofen is an anti inflammatory Nd should be avoided during first 3 months owing compression fracture to promote bone healing
125
Surgical opt for trigeminal
Neuralgia
Microvascular decompression or Rhizotomy
Radio frequency rhizotomy for patient in whom MVD failed
126
White matter located in the brain and spinal
Cord
Myelinated nerve fibers
127
Vertebral column
7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccyx
128
Tinel test - assess
Positive sign- tingling of shock after light tapping over the medial nerve
Carpal tunnel
129
Tinel test - assess
Positive sign- tingling of shock after light tapping over the medial nerve
Carpal tunnel
130
Patient in the ICU at night becomes agitated
Delirium
131
Pain in the right side of the face associated with chewing
Trigeminal
Neuralgia
132
Central nystagmus is associated with
Brain stem stroke
133
A patient underwent. Posterior fosa craniotomy for Arnold Chiari malformation
Most common post op problem
Nausea and vomiting
Cerebellum is located in the posterior fossa - balance problems and nausea
134
After Altapase in acute stroke, BP should be kept at
SBP<180
DBP<105
135
Single unprovoked seizure standard of care
Avoid precipitants: ETOH , sleep deprivation
136
Single unprovoked seizure standard of care
Avoid precipitants: ETOH , sleep deprivation
137
Indication for a de compressive craniectomy following a traumatic brain injury
Impending herniation. Surgical removal of a large portion of the skull to allow room for swelling
138
Sensory abnormality . Light touch can be painful. CP patients experience it
Allodynia
139
Sensory abnormality . Light touch can be painful. CP patients experience it
Allodynia
140
Tx for cerebral edema and increased ICP is not recommended
Therapeutic hypothermia
141
Most common cause for drug induced thrombocytopenia
Occurs 5-10 days of being on this med
Heparin
142
Not a
Common cause of trigeminal
Neuralgia
Traumatic brain injury
143
Central nystagmus is associate with
Stroke or anoxic brain injury
144
Main complaint of a patient with benign positional vertigo
Nausea
145
Meniers disease
Avoid high Na foods
146
Benign essential tremors most often affects what area of the body?
Hands
Starts with hands and
Can progress to head and voice
147
Parkinson’s patient. What foods can they take Levadopa with?
Crackes
Protein should be avoided bc it decreases effectiveness
148
Patient with Parkinson’s is worsening. Experiences periods of standing in a frozen condition and can’t move
Pt begins to not feel effectiveness of Levadopa
Off time
149
Dopamine producing cells
Parkinson’s
150
Stroking inner thigh of a male causes ipsilateral scrotom to rise
Abnormal L2-3 lesion
Cremasteric reflex
151
What kind of test can be ordered with patient with S/S of dementia?
MMSE
Monitor cognitive changes over time
Mini mental state examination . Normal score 30-24
152
What kind of test can be ordered with patient with S/S of dementia?
MMSE
Monitor cognitive changes over time
Mini mental state examination . Normal score 30-24
153
Lab test in work up for dementia
Vitamin B12
Associated with memory and is considered a reversible cause of dementia
154
Baby with myelomeninhocele. The nurse knows the surgical repair will be
In 24 hrs due to increased risk of infection
155
28 Y/O male with Cp and númerous BP shunt revisions presents with lethargy, fever and leukocytosis
Infection - Requires intrathecal antibiotics and externalization of VP shunt
156
What type of dementia is a patient with h/o of small strokes and elevated BP at risk for?
Vascular dementia
157
Baby with Down’s syndrome is at risk for
Cardiovascular problems
158
Baby with Down’s syndrome is at risk for
Cardiovascular problems
159
A child with h/o VP shunt . S/s- lethargy, anorexia, nausea, vomiting
Obstruction
160
Irritable baby, bulging fontanels, downward gaze, not taking the bottle
Hydrocephalus- classic signs lethargy, irritability, poor appetite
161
Developmental degenerative disease
Nausea and vomiting
Cerebellum is in the posterior fosa
162
Pt underwent posterior fossa craniotomy for Arnold Chianti malformation . Common post of problem
Nausea and vomiting
163
73 YO with head ache and right sided . BP 235/-119. CT- large left frontal ICH
Treatment?
Anti hypertensives agents
Prevent extension of hemorrhage
164
Patient with a large hemispheric ICH. The NrS note states ICP score of 4
Predicts mortality at 30
Days -97 percent chance
165
Patient with a large hemispheric ICH. The NrS note states ICP score of 4
Predicts mortality at 30
Days -97 percent chance
166
76 yo right residual weakness and severe h/a and vomiting
Hemorrhagic stroke
CT of the head, plain . Possible severe hypertension and vomiting
167
What is the #1 modifiable risk factor to decrease risk of intracerebral hemorrhage?
Hypertension
168
Hemorrhagic stroke
Mild ha and photophobia
CT negative for blood
LP
What would indicate SAH?
Xanthocromia
Caused by bilirubin due to bleeding during 2-36 hrs
If s/s of increased ICP, LP is contraindicated
169
Pt post bleed day 4 develops r sides pronator drift indicating right arm weakness
Cerebral vasaspasm
Can happen : 3-14 days up
To 21 days post bleed
Nimodipine 60 mg po twice a day for 21 days
170
Hormonal regulation
Pituitary gland
171
Relay center for major nerve tracts
Thallamus
172
Single pathway of nerves that connect the L and R hemispheres
Thick band and nervous fibers that facilitate the communication and transfer motor, sensory and cognitive information
Corpus collosum
173
Cerebral blood flow
Dolls
Eyes
Cold caloric testing
Apnea test
Common brain death test
174
Cerebral blood flow
Dolls
Eyes
Cold caloric testing
Apnea test
Common brain death test
175
Gold standard for determining brain death
Cerebral blood flow
176
Loss of all brain and brain stem function
Spinal reflexes may stay intact
Definition of brain death
177
CN IX through Cn XII functions
Autonomic function
Relays information between stem and brain
Key function of medulla oblongata
178
CN IX through CN XII functions
Autonomic function
Relays information between stem and brain
Key function of medulla oblongata
179
CN V through CN VIII function awakening and rep failure
Key function of the Pons
180
CN V through CN VIII function awakening and rep failure
Key function of the Pons
181
CN III and IV function
Eye and trunk movement in response to visual input
(Reaction time)
Key function of the midbrain’s
182
Midbrain . Pons
And medulla
Components of the brain stem
183
Básica of life
Breathing
HR
Autonomic nervous systems
Characteristics of the brain stem
184
Coordination of
voluntary movements, balance, equilibrium
Cerebellum
185
Secondary visual cortex
The occipital lobe
Interprets meaning of written words
186
Where is the primary visual cortex?
Occipital lobe
It processes primary visual input
Ex objects , colors
187
Primary visual cortex-visual input processing
Secondary visual cortex -interprets meaning of
Written words
Optic Tracy end point
Occipital lobe
188
Damage to expressive broca and receptive Werner areas of the brain
Damage of language centers of the brain
But motor speech muscles on the face are intact
189
Damage to expressive broca and receptive Werner areas of the brain
Damage of language centers of the brain
But motor speech muscles on the face are intact
190
Damage to expressive (broca) and receptive (wernike) areas of the brain
Global aphasia
191
Inability to articulate words -slurred speech
Dysarthria
192
Pontine perforations of which cerebral blood vessel perfuse the Pons?
Basilar artery
193
Insufficiency may present with dizziness . Diplopia, dysarthria, dysphonia, dysmetria
Basilar artery
194
Meats containing nitrates ex bacon, hot dogs should be avoided
Avoid for h/a
195
Total intracranial volume
1700 ml
Brain- 1400 ml
CSF-150 ml
Blood 150 ml
196
Within the skull
Volume of 3 components
Brain 80 %
Blood 10%
CSF 10 %
197
Have a cell body, often with many dendrites , an axon covered in myelin and
multiple axon terminals
Multipolar neurons
198
Projections of the cell body that are dense with actin
Receive signal from other cells and carry the action to the cell body
Neuron dendrites
199
Provides structure to the neuron
Facilitate movement of substances
Holds organelles in place
Cytoskeleton structure of a neuron
200
Provides structure to the neuron
Facilitate movement of substances
Holds organelles in place
Cytoskeleton structure of a neuron
201
Similar structure to membranes of other cells-phospholipid bilayer of protein
Cellular membrane of a neuron
202
Also called projection neurons
Have long axons
Neurons of the brain and spinal cord
Axon makes
Up the gray matter
Golgi I neuron
203
Neurons have a short axon or no
Axon at all
Star like appearance
Found in cerebral cortex
Cerebellum and retina
Golgi II
204
Have a cell body with one dendrite which may branch off into multiple dendrites
Smaller dendrites
Found in olfactory nerve CNI -optic nerve
Bipolar neurons
205
After transphenoidalhypiphysectomy for pituitary tumor large UO . DI?
DI is post op complication of decreased ADH from pituitary gland
206
Percussion wave sharp peak
Representing Ryer pressure being transmitted into the choroid plexus
ICP intra cranial pressure waveform P1
207
Onset in early childhood
Many underlying etiologies, often cryptogenic
Multiple seizures- atypical
absence, generalized convulsive, atonic, myoclonic, partial
Neg neuro developmental impact-mental retardation
Slow spike and wave (2 hertz)
Lennox-Gastaut Syndrome
208
Rare complication that may occur following carotid artery revascularizarion
It can develop anytime from immediately after surgery to 30 days after
Causes: Impaired cerebral
auto regulation and post op elevated systemic BP symptoms; ha, eye and face pain, vomiting, focal deficit, seizures, ICH
Cerebral hyperperfusion syndrome
209
Treatment: iv meds to lower BP, ex labetalol and clonidine, seizure meds, manitol and hypertonic saline may be used to treat brain swelling
Cerebral hyperperfusion syndrome
210
Rare neurological condition occurs after viral or bacterial infection
Causes inflammation in the CNS
Common symptoms; head ache, confusion, weakness, numbness
More common in children
Dx-MRI, spinal fluid testing
Acute disseminated encephalopathy
211
Increasingly recognized cause of acute dissemaninated encephalopathy, especially in children.
Myelin oligodendrocyte antibody associated disease
212
Auto immune condition that attacks the nervous system and can sometimes cause acute disseminated encephalopathy
Spinal fluid often shows increased in wbc predominantly lymphocytes
Myelin oligodendrocyte antibody associated disease
213
Auto immune condition that attacks the nervous system and can sometimes cause acute disseminated encephalopathy
Spinal fluid often shows increased in wbc predominantly lymphocytes
Myelin oligodendrocyte antibody associated disease
214
Treatment: Steroid, IV immunoglobulin (IVIG)
Plasma exchange
Treatment for myelin olingodendroxyte antibody associated disease
215
Contra lateral lower limb weakness sensory loss
Trans cortical
Apraxia - if only corpus collosum is involved
Frontal lobe syndrome signs
ACA anterior cerebral artery
216
Contra lateral lower limb weakness sensory loss
Trans cortical
Apraxia - if only corpus collosum is involved
Frontal lobe syndrome signs
Aca-Anterior central artery
217
Contralateral upper limb and face weakness sensory loss
Contra lateral homonymous hemi anopsia
Deviation of eyes toward the affected hemisphere
If left side is affected- aphasia, brocas Wernike, condition , global
Right- contra lateral hemineglect and dysprosody
MCA middle cerebral artery
218
Contralateral homonymous hemianopsia with macular spearing
Left-Alexia without a graphic
PCA- posterior cerebral artery
219
Supplies midbrain and cerebellum
Basilar artery
220
ICP monitoring wave forms
P1-percussion - arterial pulsation
Should be the highest
221
ICP monitoring wave forms
P1-percussion - arterial pulsation
Should be the highest
222
P2 tidal wave
Represents intracranial compliance
223
P3
Dicrotic wave
Represents venous pulsation
Lowest upstroke
224
ICP waveforms
P1-percussive. Transmission arterial pulse from choroid plexus
225
ICP waveforms
P1-percussive. Transmission arterial pulse from choroid plexus
226
ICP waveform
Interpretation
P2 -tidal wave compliance
227
P3
Dicrotic notch-closure of aortic valve
228
Normal ICP
Normal cpp
10-15
60-80
229
Cerebral
Perfusion pressure
60-80
230
Cerebral
Perfusion pressure
60-100
Map-ICP=CCP
Normal ICP-0-15
231
Normal CSF
5-13
232
Normal CSF
5-13
233
MAP-ICP
CPP
234
Meds that can cause leukoencephalopathy
Rituxab
235
Meds that can cause leukoencephalopathy
Rituxab
236
Subdural bleed-venous bleed
Epidural bleed is arterial bleed
