Exam IV: Neuro Diseases Flashcards by Linsley Lloyd

CEREBRAL BLOOD FLOW(CBF):
*autoregulated—normally
*___mL/100g brain tissue when CPP ___-___ mmHG
*is about 750 ml/min (___-___% of cardiac output)

50
50-150
15-20%

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CBF governed by:

Cerebral metabolic rate-CMRO2
Cerebral Perfusion Pressure-CPP
PaCo2 and O2 tension
Various medications
Intracranial abnormalities

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Cerebral Metabolic Rate-CMR

Rate of O2 consumption-3.0-3.8mL O2/100 g brain tissue/min and consumes ____% of total body oxygen

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Cerebral Metabolic Rate-CMR

Most used to generate ATP for ____ ____ activity

neuronal electrical

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Cerebral Metabolic Rate-CMR

*High ____ _____ + low ____ _____ = unconsciousness in 10 sec if perfusion stopped
*If not restored in ___-___ min leads to ATP stores depleted causing cellular injury/death

O2 consumption
O2 reserve
3-8

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Cerebral Metabolic Rate-CMR

Decreased by _____ temps, anesth agents
Increased by _____ temps, seizures

lower
higher

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CPP =

MAP - ICP (or CVP, whichever is greater)

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CPP is normally ___-___ mmHg

60-110

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if ICP increases, MAP must _____ to maintain CPP

increase

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if MAP falls below 60 mmHg, CPP _______________

cant be maintained

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Even with normal MAP, if ICP is ______, CPP (thus CBF) can change

> 30

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CPP less than 50 mmHg shows

slowing on EEG

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CPP 25-50 mmHg shows

flat EEG

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CPP less than 25 mmHg leads to

possible irreversible brain damage

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Autoregulation b/t 50-150 mmHG (pressure dep beyond this)
Arterial constriction with ______ BP
Arterial dilation with ______ BP

increased
decreased

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Normotensive, if CBF…
___mmHg - ischemia (nausea, dizziness)
___mmHG - vessels max constricted; fluid forced out of vessel causing cerebral edema

35
150

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Hypertensive
Autoregulation curve shifted _____
Chronic HTN-lower limit shift _____

right
upward

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Auto regulation lost or impaired with:

intracranial tumors
vessels around tumor are acidotic
maximally dilated, now all pressure dependent
head trauma
volatile anesthetics

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_____ is the most important extrinsic factor

PaCO2

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change the PaCO2, change CBF, they are _____ _____

directly proportional

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CBF changes approx ___-___ ml/100 g/min per mmHg change in PaCO2.
The change is _____

1-2
immediate

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Thought to be b/c of changes in ____ of ____ around walls of arterioles, all compensated after ____-____ hours of hypo or hypercapnia

pH of CSF
24-48

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Marked hyerventilation - PaCo2 < 20 shifts the curve to the ____, may have ____ changes

left
EEG

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“The ability of hypocapnia to acutely decrease ____, ____, and _____ is fundamental to the practice of clinical neuroanesthesia.”

CBF, CBV, and ICP

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CBF not significantly effected by decrease in PaCo2-----until threshold of ____ Below threshold, +cerebral vasodilation and CBF increase; +hyper_____ and +hypo_____ have synergistic effects

50 hypercarbia hypoxemia

Hypocapnia= ____ _____ with RISKS

FINE LINE

Hypocapnia may be ____ ____ during craniotomy Impact with TBI or intracranial hemorrhage ____

well tolerated unclear

CBF changes ___-___% per 1°C

5-7

Hypothermia - decreases ____ & ____

CMR and CBF

Hyperthermia - increases _____ & _____

CMR and CBF

Lower Hct _____ viscosity, but also _____ O2 carrying capacity

decreases decreases

Increased Hct increases viscosity, decreases _____

CBF

Studies suggest optimal Hct for cerebral O2 delivery = ___%

Blood Brain Barrier unique vessels with junctions between endothelial cells that are nearly _____

fused

BBB is a _____ barrier for brain

lipid

lipid soluble (CO2, O2, H2O, and most anesthetics) move across BBB _____

easily

ionized/large molecular weight have _____ movement across BBB

restricted

BBB is disrupted by:

- severe HTN - strokes - trauma - tumors - infection - hypercapnia - hypoxia - sustained seizures (fluid movement now dependent on hydrostatic pressure not osmotic gradient)

CSF major fxn:

protect CNS against trauma

CSF formed by ____ _____ of cerebral ventricles (mostly _____)

choroid plexuses lateral

CSF produced 2 ways

1. ultrafiltration and secretion by the cells of the choroid plexus 2. passage of water, electrolytes, and other things across the BBB

1. CSF is produced by the ____ ____ in the ventricles

choroid plexuses

1. CSF is produced by the choroid plexus in the ventricles 2. CSF flows through the _____ _____ from the 3rd to the 4th ventricle

cerebral aqueduct

lateral and medial aperatures

1. CSF is produced by the choroid plexus in the ventricles 2. CSF flows through the cerebral aqueduct from the 3rd to the 4th ventricle 3. CSF flows into the subarachnoid space by the lateral and medial apertures also into the spinal canal 4. CSF removes _____ and provides _____ from within subarachnoid space

waste bouyancy

1. CSF is produced by the choroid plexus in the ventricles 2. CSF flows through the cerebral aqueduct from the 3rd to the 4th ventricle 3. CSF flows into the subarachnoid space by the lateral and medial apertures also into the spinal canal 4. CSF removes waste and provides buoyancy from within subarachnoid space 5. Excess CSF will be ______ by the _____ ____ which will drain in tho the ____ _____ sinus

absorbed arachnoid villi superior sagittal

Adults: produce ___ mL/hr (500 ml/d) ____ mL is total CSF volume

21 150

LATERAL VENTRICLES Intraventricular foramina of Monro 3rd Ventricle Cerebral aqueduct of Sylvius 4th Ventricle Foramen of Magendie & Foramina of Luschka Cisterna Magna Subarachnoid space Circulates around the brain & spinal cord Absorbed into arachnoid granulations

cranial vault is _____

rigid

vault is made up of 3 things

brain - 80% blood - 12% CSF - 8%

if one thing in the cranial vault increases, another must ________

decrease

ICP usually ____ mmHg or less - measured in the ____ ventricles or over the cerebral _____

10 lateral cortex

Monro-Kellie Doctrine:

Any increase in one compartment must be offset by an equal reduction in another to avoid increases in ICP

ICP reduction mechanisms:

- increased CSF absorption - decreased CSF production - decrease in total CBV (mostly venous) - brain stem herniation

normal ICP

5-10 mmHg

mild increase in ICP

20-30 mmHg

moderate increase in ICP

30-40 mmHg

severe increase in ICP

> 40 mmHg

CBV increases ___ ml/100 g of brain per 1 mmHg ↑ PaCo2

.05

Blood pressure effects of CBV dependent on _______ of ______

autoregulation of CBF

if increase in ICP is sustained, can lead to ______

herniation

4 types of herniation

1. cingulate gyrus under the falx cerebri (subfalcine herniation) 2. uncinate gyrus through the tentorium cerebelli (transtentorial herniation) 3. cerebellar tonsils through the foramen magnum 4. transcalvarial - any area beneath a defect in the skull

subfalcine herniation leads to compression of anterior cerebral artery causing a _____ ____

midline shift

______ brainstem compression leads to altered consciousness, gaze defects, ocular reflex defect, hemodynamic and resp failure and then _____

transtentorial death

*If _____ herniation (medial portion of temporal lobe), oculomotor nerve dysfun

uncal

S&S - pupil ______, ptosis, lat deviation of _____ eye and then death

dilatation affected

S&S - indicates ______ dysfunction—cardio and resp dysfunction and leading to death

medullary

ICP HA, nausea, vomiting, pupillary dilation, blurred vision (CNII)a, inability to adduct (____) or abduct (____)eye Focal neurological deficits and unsteady gait Decreased consciousness, seizures, coma Cushing’s Triad: irregular _____, _____, _____

CNIII CNVI respiration, ↑ BP,↓HR

ICP Dx:

symptoms, CT or MRI, or direct measurement

_______ - helpful to measure, removal of CSF, and CSF sent to lab for analysis

Ventriculostomy

mean ICP should remain below _____

15 mmHg

dramatic increase in ICP leads to ______ and ______ change

hyperventilation and LOC

causes of increased ICP

- Tumor -Due to size, Indirectly b/c of edema in surrounding tissue, Causing obstruction of CSF flow out (tumor in 3rd vent) - Intracranial hematomas (a lot like tumor) - Blood in CSF (subarachnoid hemorrhage) - Infection (meningitis, encephalitis) - Aqueductal stenosis - congenital narrowing of cerebral aqueduct connecting 3rd and 4th ventricles - Sz disorder seen in 1/3 of these patients

Decreasing ICP elevate HOB ___-___ degrees above heart

15-30

Decreasing ICP head neutral if possible, dont compress _____

jugulars

Decreasing ICP hyperventilation - maintain PaCO2 ___-____ mmHg, effects diminish in 6-12 hours, rebound increases in ICP can be problematic

30-35

Decreasing ICP drain _____

CSF

Decreasing ICP hypo_____

thermia

Decreasing ICP ______ drugs - avoid sig hypovolemia, Mannitol 20% 0.25gm/kg, IV

hyperosmotic

Decreasing ICP c_______

corticosteroids

Decreasing ICP cerebral vasoconstrictors - ______, _____

barbs, prop

Decreasing ICP HTN control - ______, _______, keep MAP _____

labetalol, nicardipine > 70

Seizure Disorder Abnormal _____ _____ activity in the brain ___% of population experience seizure in lifetime Epilepsy-true disorder; recurrent seizures

synchronized electrical 2

underlying mechanisms for seizure disorder: (3)

Loss of inhibitory activity Enhanced release of excitatory amino acids Enhanced neuronal firing due to voltage mediated Ca+ current

precipitants to seizures:

- Genetic predisposition (low sz threshold) - Brain trauma or tumor - Infection/febrile illness - Hypoxia - Drug overdose or withdrawal - Fatigue/stress - Methohexital (small doses) - Ketamine - Demerol - Metabolic defects (Na+, hypo: mag, Ca+, or glycemia, alkalosis)

_____ –also called _____ Manifested by motor, sensory, autonomic or psych symptoms Complex sz - impairment of consciousness

PARTIAL Focal

GENERALIZED ______ ______ electrical activity—no local onset May or may NOT have abnormal _____ activity, loss of consciousness, etc

Bilaterally symmetric motor

Petit Mal - (absence sz) -

transient lapse in consciousness

Grand Mal - (tonic clonic) - ______ common, loss of consciousness followed by clonic and tonic motor activity

most

STATUS EPLEPTICUS: prolonged partial or general sz ______ recovery between attacks; _______ _______

without MEDICAL EMERGENCY

Seizure Disorder Management PreOp eval-focus on ____, ____ of sz, and medications

cause, type

Seizure Disorder Management antiepileptic drugs - ______ ______

Antiepileptic drugs-continue throughout

Seizure Disorder Management Even partial sz can progress to generalized - major risks assoc with _____, ______, ______

injury, aspiration, hypoxemia

Seizure Disorder Management PRIORITIES

airway and oxygenation

Seizure Disorder Management AVOID

- ketamine - methohexital - demerol - atra/cisatracurium (in large doses d/t metabolites)

Seizure Disorder Management expect hepatic enzyme ______, probably will _____ dose of NMB

induction increase

Seizure Disorder Management terminate seizure with:

propofol 50 - 100 mg dilantin 500 - 1000 mg slowly benzos - midazolam - 1 - 5 mg

Most common disorder involving motor tracts of extrapyramidal system (controlled by basal ganglia and cerebellum)

parkinsons disease (PD)

PD affects 3% of _____ _____

elderly americans

primary PD

degenerative disorder of substantia nigra; interferes with dopamine pathways to basal ganglia

primary PD onset

after 50

primary PD etiology

unknown

PD hereditary pattern

none

secondary PD

d/t trauma, drugs, infection, toxins (usually reversible)

Parkinson’s Disease-PD Principle feature: degeneration of ________ pathways (inhibitory) and relative excess of ________ activity (excitatory)

dopaminergic cholinergic

Parkinson’s Disease-PD classic signs (cogwheel rigidity) - ____ _____ tremor - rhythmic, usually at rest, usually disappear with voluntary movement; pill rolling tremor - _______—1st appears in neck muscles; arm swinging, infrequent blinking - _______ of facial muscles - Often oily skin, seborrhea, diaphragmatic spasms, dementia and depression - Eventually includes muscles of ______ and _____ - Upper airway involvement may _____ airflow

Skeletal muscle Rigidity Akinesia chewing and swallowing restrict

Tx of PD Goal is to ↑concentration of ______ in basal ganglia OR to decrease effects of _____

dopamine ACh

Tx of PD _______-_______ precursor (Sinemet, Parcopa) - assoc with dyskinesias, confusion, HA, hallucinations

Levodopa-dopamine

Tx of PD increase myocardial _______

contractility

Tx of PD _______ hypotension

orthostatic

Tx of PD Decarboxylase inhibitor - prevents conversion of levodopa to dopamine in _____ to optimize conversion in _____ (Duopa)

periphery CNS

Tx of PD anti______

anticholinergics

Surgical Tx of PD Deep brain stimulation- stimulates various nuclei in _____ ______ to relieve/help with tremor

basal ganglia

Surgical Tx of PD ______ - rigid head frame, MRI, burr hole, electrode advanced

AWAKE

Surgical Tx of PD ______ position (risk of air embolism)

sitting

Surgical Tx of PD opioids (sparingly) and _______ BEST; diphenhydramine

dexmedetomidine

Surgical Tx of PD avoid ____ and ____ bc alter recordings of nuclei thus stimulation of appropriate place

propofol and benzos

Surgical Tx of PD avoid over_____

oversedation

Anesthetic Implications-PD _____ PD meds perioperatively

continue

Anesthetic Implications-PD response to NDMR

generally normal

Anesthetic Implications-PD rare reports of increased ____ with SCh

potassium

Anesthetic Implications-PD avoid ketamine - _____ response

SNS

Anesthetic Implications-PD Predisposed to rigidity related to ______

opioids

Anesthetic Implications-PD avoid dopamine antagonists such as:

- metoclopramide - phenothiazines (compazine, thorazine) - butyrophenones (haldol, droperidol)

Most common neurodegenerative dz responsible for 40-80% dementia cases

Alzheimer’s Dz

Alzheimer’s Dz cause:

unknown

Alzheimer’s Dz characterized by ____ ____ in intellectual function (____ years). Memory, judgement, decision making, emotional lability.

slow decline 5+

Alzheimer’s Dz late signs

EPS, apraxias, aphasia

Alzheimer’s Dz marked _____ atrophy with _____ enlargement

corticol ventricular

Alzheimer’s Dz _____ response to many of our drugs along with loss of ____ matter

altered gray

AD Pathophysiology Proteins in the neurons become twisted and distorted “_______ triangle”

neurofibrillary

AD Pathophysiology “Senile plaques” deposit. This disrupts impulse transmission…especially in the _____ ______ and ______

cerebral cortex and hippocampus

Anesthesia Considerations with AD are ________

COMPLICATED

Anesthesia Considerations with AD New onset of temporary impairment frequent after anesthesia-lasts ___-___ days following

1-3

Anesthesia Considerations with AD Consent—

must have from someone legally able to provide

Anesthesia Considerations with AD Central anticholinergics (_____/_____) - add to confusion; use ______ (doesn’t cross BBB) if anticholinergic needed

atropine/scop glycopyrrolate

Anesthesia Considerations with AD Many studies have shown neuronal injury and cell death is related to _____ _____---much debate related to GA and elderly and pediatrics

anesthetic agents

Anesthesia Considerations with AD bottom line

slow, gentle, careful

Anesthesia Considerations with AD ____ contraindications to regional or GA….but consider how you will provide anxiolysis and potential side effects

Reversible demyelination at random and multiple sites in the brain and spinal cord

Multiple Sclerosis

Multiple Sclerosis Much inflammation which eventually causes _____ - gliosis

scarring

Multiple Sclerosis _______ initiated by a virus??

autoimmune

MS - primarily affects females ___-___ years old 2:1

20-40

MS - unpredictable course of _____/______

attack/remission

MS - 50% require help with walking within ____ years of diagnosis

Considerations with MS ____ or ____ can confirm

CSF or MRI

Considerations with MS remyelination is limited - ____ ____ ____

may not occur

Considerations with MS Conduction ____ still occur across demyelinated axons, but affected by many things—including _____

CAN temperature

Considerations with MS Tx-focused on tx symptoms and stopping disease process Effect of sx is _____ _____ _____ procedures during exacerbation

unpredictable NO elective

Considerations with MS Peripheral nerve blocks ____ - MS is CNS disorder

Considerations with MS ____ _____ problems with GA

no specific

Considerations with MS if paresis or paralysis - NO ____

sux

Considerations with MS symptoms may _____ perioperatively - ASSESS

worsen

Neurodegenerative, rapidly progressive of both upper and lower motor neurons

ALS-Amyotrophic Lateral Sclerosis(Lou Gehrig’s Dz)

ALS-Amyotrophic Lateral Sclerosis(Lou Gehrig’s Dz) No specific known cause—some have ____ _____ Usually present in ____ or _____—muscular weakness, atrophy, fasciculation, spasticity __-__ years—progresses to all skeletal muscles and vent failure

gene deformity 50’s or 60’s 2-3

ALS-Amyotrophic Lateral Sclerosis(Lou Gehrig’s Dz) susceptible to _____ anesthesia focus - ____ ____

aspiration resp care

ALS-Amyotrophic Lateral Sclerosis(Lou Gehrig’s Dz) no _____ bc of hyperkalemia risk

anectine

Guillain –Barre’ Syndrome Affects 1-4/100,000 ____ onset—paralysis, areflexia, paresthesias ____ _____ paralysis is common

Sudden Respiratory muscle

Guillain –Barre’ Syndrome Seems to be immunologic rx against ____ _____ of _____ nerves Weakness or paralysis starts in the ____ and spreads cephalad over several days

myelin sheath of peripheral legs

Guillain –Barre’ Syndrome multiple types (3)

Acute inflammatory dymelinating polyneuropathy-75% Acute motor axonal neuropathy Acute motor AND sensory axonal neuropathy

GBS Peak disability ___-___ days, recovery in weeks to months Usually follows URI or GI infections Associated with _____ dz

10-14 Hodgkin’s

GBS Complication of ____ Some respond to ______ Prognosis is good—although 10% die of complications and 10% have lifelong comps

HIV plasmapheresis

GBS ANS is labile +resp insufficiency No ____ Regional anesthesia is _____

anectine controversial

GBS Clinical Manifestations Resp paralysis - 25% require _____ _____

mechanical ventilation

GBS Clinical Manifestations Autonomic dysfunction is common:

Wide changes in BP Profuse diaphoresis Gastroparesis Tachycardia Dysrhythmias

GBS Clinical Manifestations Bulbar involvement-45-75% _____ _____ weakness

pharyngeal muscle

GBS-Anesthesia Implications

Prepare for and anticipate dysrhythmias and autonomic instability Hypotension with position change or small blood loss Exaggerated HTN with laryngoscopy Anectine is contraindicated Possible post op ventilation Regional anesthesia is controversial

Cerebral Vascular Accident (CVA) Cerebral perfusion is interrupted, depriving brain of ____ and _____

O2 and glucose

Cerebral Vascular Accident (CVA) creates cycle - cell hypoxia causes edema, edema causes activation of _____ _____ acids, that creates free radicals causing an influx of _____

excitatory amino acids Ca++

Perioperative Stroke Overall risk with GA < ____ Risk with GA + hx of CVDz= _____ Mortality rate after intraoperative stroke- ____

.4% .4-3% 25%

Most common surgery related to CVA (2)

Open heart procedure for valve disease Surgery on the thoracic aorta

risk factors for CVA

- HTN - Diabetes - Cigarette smoking - Drug abuse - Age >75 - CADz - Hyperlipidemia - Atrial fib - Heredity PRIOR STROKE OR Hx of TIA

classification of CVA - _____ or _____

hemorrhagic or ischemic

ischemic CVAs (3)

- thrombotic - embolic - global hypoperfusion

CVA-Hemorrhagic Most common cause is ____ (60-80%) Other causes: ruptured aneurysm, AV malformation, bleeding into tumor, coag defect ____ usually associated with this type of stroke

HTN HA

CVA-Thrombotic Arterial occlusion caused by thrombi in _____ or _____ vessels Assoc with: atherosclerosis, diabetes, hypercoags, dehydration, arteritis, polycythemia vera, hypertension Typically evolves over _____ to ____s

carotid or cerebral minutes to hours

CVA-Embolic Fragments break from thrombi formed ______ the brain Associated with atrial fib, endocarditis, valve prosthesis, carotid dz, valvular and aortic surgery Less common: ____, _____, or _____ emboli Often lodge in the ____ ____ ____

outside air, fat, or tumor middle cerebral artery (MCA)

Thrombotic or Embolic Stroke IV fibrinolytic tx within ___ ____ of onset of symptoms

3 hours

Thrombotic or Embolic Stroke Do NOT give ____, ____, or ____ until CAT scan has ruled out an intracranial hemorrhage

ASA, heparin, or tPA

Thrombotic or Embolic Stroke No fibrinolytic Rx: (4)

- Hx or evidence of bleed - Known AVM, aneurysm, or neoplasm - Platelet count <100,ooo or INR >1.7 - Stroke, neurosurgery, or head trauma within the past 3 months

CVA-Anesthetic Implications ____ ____ before discontinuing antiplatelet and anticoags before surgery

Neuro consult

CVA-Anesthetic Implications Resistance to NMB in ____ ____

paretic limb

CVA-Anesthetic Implications Monitor TOF in _____ _____

nonparetic limb

CVA-Anesthetic Implications avoid ____

sux

CVA-Anesthetic Implications ____ may be safer for some procedures (Hip fx)

CVA-Anesthetic Implications Post CVA, area of infarct: Loss of ______ Loss of ____ responsiveness Loss of _____ integrity

autoregulation CO2 BBB

CVA-Anesthetic Implications Keep BP slightly higher than normal in the hypertensive patient *____ ____ in autoreg curve

right shift

Cerebrovascular Dz Typically have hx of ____ or _____ Risk of stroke ↑ with ____ and _____ of procedure

TIA or stroke age and type

Cerebrovascular Dz Asymptomatic ____ _____ —up to 4% in those <40

carotid bruits

Cerebrovascular Dz Those at greatest risk :

open heart procedures with valvular dz, CADz with ascending aortic atherosclerosis, and diseases of thoracic aorta

Cerebrovascular Dz All due to _____ (air, clots, debris)

embolism

Cerebrovascular Dz Non cardiac surgery-risk assoc with _____/_____

hyper/hypotension

CVAs and HTN

- Hemorrhagic stroke due to intercerebral bleed - Sustained HTN causes BBB breakdown - Pulse pressures >80 mmHg leads to endothelial injury thus hypoperfusion or embolism - Blood flow abnormalities-resolve in 2 weeks - BBB and CO2 responsiveness-takes 4 weeks to heal - Emergency: hemorrhage, cardiac sources emboli, symptomatic carotid dz

CVAs and HoTN

- watershed infarcts

CVA management - Neuro and CV eval—no ____ _____ in those with TIA’s that haven’t been evaluated - Most have comorbidities (HTN, renal dz, diabetes, hyperlipidemia, etc) - Many on long term ______ or ______ ______

elective surgery coumadin or antiplatelet therapy

may see CVA pts for:

- Removal of emboli - CEA - Endovascular procedures - Hematoma evac - Decompressive craniotomy (Arterial line, have iv vasodilators and β blockers ready)

Spinal Cord Disorders Numerous types: (5)

- Tumors - Abscess - Spinal stenosis - Fractures (vertebral) - Degenerative disc disease

SC disorders divided up into ____, _____, _____ and/or _____ issues

cervical, thoracic, lumbar, and/or sacral

Symptoms of SCD Loss of _____ Weakness or paralysis of extremities Reflex changes (_____ or _____) Bladder or bowel incontinence Back pain ______ spasms

sensation hyper or hypo Muscle

SCD - DX by:

DX by MRI/CT, Xray, myelogram

Causes of Spinal Cord Disorders

Trauma (fall, MVA, diving, trampoline, GSW, etc.) Infection/abscess Autoimmune disorders

SCD AIs: - Airway-neutral intubation, possible obstruction/edema, recurrent laryngeal damage - Positioning issues/injuries - Cardiovascular issues: reflex bradycardia, arrhythmias, hyper and hypotension - Respiratory issues-ventilation, ? Paralysis, need for post op ventilation ?pneumonia - Potential loss-blood and CSF