Exam 3 - Neuro Flashcards by Brandon Simpson

What is CBF per weight of brain tissue?
mL/min?
% of CO?

50 mL/100 g
750 mL/min
15% of CO

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Combined volume of brain tissue, CSF, and intracranial blood?

1200-1500 mL

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Normal ICP?

5-15 mmHg

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This fold seperates the two hemispheres?

Falx cerebri

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This fold seperates the supratentorial and infratentorial spaces?

Tentorium cerebelli

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Herniation of hemispheric against the falx cerebri?

Subfalcine herniation

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Herniation of supratentorial contents against the tentorium cerebelli?

Transtenorial herniation

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What is uncal herniation?

Subtype of transtentorial herniation
The uncus herniates over the tentorium cerebelli

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Label each type of herniation?

Subfalcine
Transtentorial
Tonsillar
Transcalvarial

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What are the 3 reasons tumors increase ICP?

Directly d/t their size
Indirectly by causing edema
Obstructing CSF outflow (3rd ventricle tumors)

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How does propofol decrease ICP?

Cerebral vasoconstrictor, decreases CMRO2 and CBF

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What is MS?
Risk factors?

Progressive, autoimmune demyelination of central nerve fibers
Female, 1st degree relative, EBV, smoking, having other AI disorders

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Treatments for MS?

No cure
Corticosteroids, immune modulators, IVIG

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When should you order LFTs preop for MS patients?

If they are on dantrolene or azathioprine - causes liver impairment

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What are intraop anesthetic concerns for MS patients?

Temp management is cruccial (body swings trigger exacerbations)
Avoid succinylcholine - increased K+ d/t upregulation of nACh receptors

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Why do MG patients have increased risk for aspiration and respiratory insufficency?

Bulbar involvement causes laryngeal/pharyngeal weakness

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Anesthetic concerns for MG patients?

Reduce paralytic dosage to avoid prolonged weakness
AChesterase inhibitors (pyridostigmine) will increase succs and ester LA

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What is Eaton-Lambert syndrome?

Antibodies against presynaptic VG Ca++ channels
Leads to decreased ACh release at the NMJ
Heavily associated small cell lung carcinoma

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Symptoms and treatments for E-L syndrome?

Sx: limb-girdle weakness, dysautonomia, oculobulbar palsy
Tx: 3-4 diaminopyridine (K+ channel blocker), azathioprine, AChesterase inhibitors

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What would you avoid giving to a patient with E-L syndrome?

Non-depolarizing NMB
Extreme caution with dosing of paralytics

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Cause of muscular dystrophy?

Muscle fiber degeneration d/t breakdown dystrophin-glycoprotein complex

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Most common and severe from of MD?

Duchenne
Only occurs in boys, have decreased lifespan

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What lab finding is increased in MD?

Creatine kinase d/t muscle wasting

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What severe anesthetic complication can occur with MD patients?

Hypermetabolic syndrome- similar to MH, triggered by succ and VA
Can cause rhabdo, hyperkalemia, VFib, and cardiac arrest

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What is the best anesthetic and paralytic for MD patients?

Low dose roc and TIVA

What is myotonia?

Prolonged contraction after muscle stimulation

What is myotonic dystrophy?

Muscle wasting - esp in face, masseter, hand, and pretibal muscles

What is myotonia congentia?

milder form, involves only skeletal muscles

What is central core disease?

Core muscle cells lack mithochondrial enzymes → proximal muscle weakness and scoliosis

Triggers for myotonic dystrophies? Treatments?

- Stress and cold temps - No cure - quinine, procanamide, steroids

Anesthetic concerns for myotonic dystrophies?

- Increased aspiration risk from GI hypomotility - Keep warm to avoid flare ups - Avoid succ - fasiculations trigger myotonia

What are the three major dementia syndromes and their occurence?

Alzheimers - 70% Vascular dementia - 25% Parkinsons - 5%

GA choice for dementia patients?

TIVA with propofol

Parkinsons patho? Symptoms? Treatments?

- Unknown → degeneration of dopaminergic fibers of basal ganglia (dopamine suppresses overstimulation of extrapyramidal motor system) - Symptom triad: skeletal muscle tremor, rigidity, akinesia - Treatments: Levodopa (crosses BBB), anticholinergics, MAOIs (prevent dopamine breakdown), deep brain stimulator

Parkinsons anesthesia concerns?

- PO levodopa needs to be given preop to avoid extreme extrapyramidal effects (chest wall rigidity) - Avoid demerol if on an MAOI - Deep brain stimulators need to be turned off or the surgeon needs to use bipolar cautery

What is the most common CNS glial cell?

Astrocytes

What are the 4 types of astrocytomas?

Gliomas - least aggressive Pilocytic astrocytomas - usually benign Anaplastic astrocytomas Glioblastoma multiforme - high mortality despite treatment

This brain tumor arises from dura or arachnoid tissue and is usually benign?

Meningiomas

This brain tumor is non-cancerous and can be cured with transphenoidal or open crainotomy?

Pituitary adenomas

Tumor that involes vestibular component of CN VIII within the auditory canal?

Acoustic neuromas

What is the leading cause of disabilty and death worldwide?

Stroke

Blood is supplies to the brain from the ____ and ____ arteries ?

internal carotid and vertebral

What area may their be a stroke in if there is contralateral leg weakness?

anterior cerebral artery

Strokes in this area present with contralateral hemipareises/hemisensory defect, aphasia, and contralateral visual field defect?

middle cerebral artery

Features of a posterior cerebral artery stroke?

Contralateral visual field defect and hemiparesis

Features of penetrating artery stroke?

Contralateral hemiparesis and hemisensory deficits

Basilar artery stroke symptoms?

Oculomotor deficits and/or ataxia with crossed sensory and motor deficits

Vertebral artery stroke symptoms?

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

TOAST classifications for ischemic stroke?

1. Large artery atherosclerosis (stenosis) 2. small vessel occlusion (laclunar stroke) 3. cardioaortic embolic (a fib emboli) 4. other etiology (hypercoaguable states) 5. undetermined etiology

Treatments for ischemic stroke?

- Aspirin - TPA within 3-4.5h onset - Revascularization

Hemorrhagic CVA treatment?

Conservative: reduce ICP, BP, seizure precautions, monitoring Invasive: surgical evacuation

What are the 2 most reliable predictors of outcome for hemorrhagic CVA?

blood volume and change in LOC

How long should someone wait to have an elective cases after starting a new anticoagulant for thrombus?

3 months

Patients on warfarin will need what perioperatively?

Short acting anticoags (heparin) to bridge the gap

Causes of cerebral aneurysm rupture?

HTN, smoking, female, oral contraceptives, cocaine

When should intervention be completed after a ruptured aneurysm?

Within 72 hours

When is the highest risk for post SAH vasospasm?

3-15 days after a SAH

What causes SAH vasospasm?

Free hgb triggers inflammatory mediators → reduces nitric oxide availibility and increases endothelin 1 → vasoconstriction

Primary treatment to prevent Post SAH vasospasm?

Triple H therapy (hypertension, hypervolemia, hemodilution)

More invasive treatment for SAH vasospasm?

Balloon dilation and direct injection of vasodilators

What 2 grading scales are used for aneurysm prognosis?

Hunt and Hess Classification World Federation of Neurological Surgeons Grading System (uses GCS and major deficit)

What are AVM?

AV connections without capillaries Creaties an area of high flow, low resistance shunting

What is the scale for AVM grading?

Spetzier-Martin AVM Grading System

What is a chiari malformation and the types?

Congenital displacement of the cerebellum Type 1-4

Treatment for chiari malformations?

Surgical resections

Another name for tuberous sclerosis?

Bourneville disease

What is tuberous sclerosis?

Genetic disease causing benign abnormal tumors/growths all over the body Usually presents with mental retardation and seizure disorders

What is Von-Hippel Lindau Disease?

Genetic disease involving formations of benign tumors of the CNS, eyes, adrenals, pancreas and kidneys May present with pheochromocytoma

Anesthetic concerns for VHLD?

NA anesthesia may be limited d/t co-existing spinal tumor Exaggerated HTN from pheochromocytoma

What is neurofibromatosis?

Tumors form on the nerves in the body anywhere Types 1, 2, and schwannomatosis

Anesthesia concerns for neurofibromatosis?

account for increased ICP, airway issues, scoliosis, possibility of pheochromocytoma avoid NA d/t high likelihood of spinal tumors

Treatments for hydrocephalus?

Diuretics - furosemide and acetazolamide VP shunt ETV - endoscopic third ventriculostomy

When does shunt malfcunction occur most frequently?

Within 1st year of placement

What should you avoid in TBI patients?

NGT/OGT - potential for basal skull fracture

What transient abnormalities can cause seizures?

hypoglycemia, hyponatremia, hyperthermia, and intoxication

What drugs that treat seizures are enzyme inducers? What does this mean for us?

Phenytoin, Tegretol, and Barbituates Require higher doses of hepatically cleared medications