FU(7): Brain/Spinal Cord/ANS/PNS

Question 1

Scenario: A 55-year-old patient with a history of hypertension is undergoing craniotomy for tumor resection. Intraoperatively, the patient’s mean arterial pressure (MAP) drops to 60 mm Hg, and the intracranial pressure (ICP) is noted to be 20 mm Hg.
Question: What is the cerebral perfusion pressure (CPP) in this patient, and what is the expected physiological response?

Answer 1

CPP = 40mmHg, leading to cerebral ischemia

Question 2

Scenario: A patient with traumatic brain injury (TBI) exhibits elevated ICP. The anesthetic plan includes the use of propofol for its cerebral effects.
Question: What is the primary effect of propofol on cerebral physiology in this context?

Answer 2

Decreases cerebral blood flow (CBF) and cerebral blood volume (CBV), reducing ICP

Question 3

Scenario: During neurosurgery, a patient is intentionally hyperventilated to achieve a PaCO2 of 30 mm Hg. Question: How does acute hypocapnia affect cerebral blood flow (CBF) and intracranial pressure (ICP)?

Answer 3

Decreases CBF and ICP

Question 4

A 60-year-old patient with a history of chronic hypertension is undergoing a craniotomy. What is the expected alteration in cerebral autoregulation?

Answer 4

Autoregulation curve is shifted to the right

Question 5

During a neurosurgical procedure, a patient develops sudden hypertension and bradycardia. This response is most likely due to:

Answer 5

Cushing’s Reflex

Question 6

A patient with a head injury shows signs of uncal herniation. The initial anesthetic management should focus on:

Answer 6

Maintaining Cerebral Perfusion Pressure

Question 7

A 45-year-old patient with a history of brain tumor presents with signs of increased ICP. Which of the following is the most likely initial compensatory mechanism the body employs to maintain cerebral perfusion in the face of rising ICP?

Answer 7

Compensatory CSF Displacement

Question 8

In a patient with transtentorial herniation, which clinical sign would most likely be observed first due to its pathophysiological mechanism?

Answer 8

Ipsilateral oculomotor nerve dysfunction

Question 9

A patient with increased ICP shows signs of nausea, vomiting, and papilledema. These symptoms are most directly related to:

Answer 9

Decreased intracranial elastance

Question 10

Which type of Lundberg wave is indicative of the most severe intracranial pathology and is associated with poor outcomes?

Answer 10

Lundberg A waves

Question 11

In managing a patient with sustained increased ICP, why is hyperventilation to maintain PaCO2 near 30 to 35 mm Hg recommended over more aggressive hyperventilation?

Answer 11

It prevents cerebral vasoconstriction and potential ischemia

Question 12

A patient with increased ICP is receiving mannitol. Which of the following is a critical consideration in its administration?

Answer 12

Serum osmolarity should be maintained below 320 mOsm/L

Question 13

In a patient with elevated ICP following traumatic brain injury, why are corticosteroids generally not recommended?

Answer 13

Corticosteroids do not effectively reduce nonvasogenic edema

Question 14

A 55-year-old male with a chronic C5 spinal cord injury is scheduled for elective surgery. Which anesthetic management consideration is paramount due to his level of injury?

Answer 14

Vigilant monitoring for autonomic hyperreflexia

Question 15

Propofol is used in the management of increased ICP. Its effectiveness in reducing ICP is primarily due to its ability to:

Answer 15

Reduce CMRO2

Question 16

A patient with Friedreich ataxia is undergoing spinal surgery. What anesthetic consideration is most critical due to the associated cardiomyopathy?

Answer 16

Use low dose inotropic support

Question 17

In a patient with spontaneous intracranial hypotension presenting for surgery to repair a CSF leak, what is the most significant anesthetic consideration?

Answer 17

Risk for rebound intracranial HTN after surgical repair requiring therapeutic Lumbar puncture

Question 18

A 55-year-old patient with a history of post-polio syndrome is scheduled for elective surgery. Which of the following anesthetic considerations is essential due to the patient’s condition?

Answer 18

Sensitive to non-depolarizing NMBs, avoid high doses

Question 19

A 25-year-old patient with a newly diagnosed low-grade astrocytoma is scheduled for a surgical resection. The patient has been experiencing new-onset seizures. What is the most important anesthetic consideration for this patient?

Answer 19

Avoid meds that lower seizure threshold

Question 20

A patient with a high spinal cord injury presents for surgery. Which anesthetic technique would be most appropriate to prevent autonomic hyperreflexia?

Answer 20

High spinal anesthesia.

Question 21

A patient with glioblastoma multiforme has undergone surgical debulking. Which postoperative strategy is most important for this patient?

Answer 21

Strict BP control to avoid hemorrhagic complication

Question 22

When planning anesthesia for a patient with ALS, which of the following considerations is most pertinent due to the risk of hyperkalemia?

Answer 22

Avoid Succinylcholine

Question 23

During the postoperative management of a patient who has undergone evacuation of a subdural hematoma, which of the following blood pressure targets is MOST appropriate to prevent rebleeding?

Answer 23

SBP <140

Question 24

For a patient with a known history of syringomyelia, which of the following anesthetic plans should be carefully considered due to potential impaired autonomic regulation?

Answer 24

Continuous epidural anesthesia

Question 25

A 70-year-old patient with a history of poliomyelitis in childhood is scheduled for total knee arthroplasty. Which of the following anesthetic considerations is most crucial due to postpolio sequelae?

Answer 25

Extreme sensitivity to sedative effects of anesthesia & delayed awakening from GA

Question 26

A 40-year-old patient with a T4 spinal cord injury is undergoing minor open abdominal surgery. Which anesthesia approach is most appropriate to prevent autonomic hyperreflexia?

Answer 26

High thoracic epidural anesthesia

Question 27

During an elective craniotomy for epilepsy, what is the most appropriate anesthetic management to avoid seizure exacerbation?

Answer 27

Using Isoflurane as the primary anesthetic agent due to its anticonvulsant properties

Question 28

A patient with a history of spinal cord injury at T5 presents with severe hypertension and bradycardia during a below-the-knee amputation. What is the initial best management step?

Answer 28

Use of a short-acting antihypertensive (clevidipine)

Question 29

When considering spinal anesthesia for a postpolio patient, what is the most important consideration?

Answer 29

Possible increase sensitivity to LA requiring dose adjustment

Question 30

For labor analgesia in a parturient with a T4 spinal cord injury, which of the following would be the preferred method to prevent autonomic hyperreflexia?

Answer 30

low-dose combined spinal-epidural anesthesia

Question 31

For a patient with a history of seizures and controlled hypertension, which antiepileptic agent would be most concerning in the perioperative period?

Answer 31

valproate: assoc with surgical bleeding (thrombocytopenia & decreases in vWF & Factor 8)

Question 32

A patient with a complete T4 spinal cord injury is undergoing elective surgery. Post-operatively, which symptom would indicate the onset of autonomic hyperreflexia as the anesthesia wears off?

Answer 32

HTN & bradycardia

Question 33

Scenario: A patient with multiple system atrophy (MSA) presents for surgery. MSA has led to significant autonomic dysfunction, including orthostatic hypotension and impaired baroreceptor function.
Question: What anesthetic management strategy is most appropriate for this patient?

Answer 33

Manage hypotension with IVF or direct-acting vasopressors (neo is preferred)

Question 34

A patient with Multiple System Atrophy (MSA) is scheduled for surgery. What is the most appropriate anesthetic management regarding blood pressure control?

Answer 34

treat promptly w/ fluids and vasopressors (direct acting preferred)

Question 35

A patient with a history of Postural Orthostatic Tachycardia Syndrome (POTS) is undergoing a minor surgical procedure. Which anesthetic management strategy is most appropriate to prevent perioperative complications?

Answer 35

Pre-op IVF
+ low dose neo gtt ready

Question 36

During surgery for a patient with Postural Orthostatic Tachycardia Syndrome (POTS), which drug should be used cautiously to avoid exacerbating the condition?

Answer 36

Phenylephrine

Question 37

A patient with a diagnosed paraganglioma is undergoing tumor resection. Which of the following should be included in the anesthetic plan?

Answer 37

Administration of phenoxybenzamine or prazosin preoperatively

Question 38

In managing a patient with Paraganglioma, which of the following is the most critical preoperative assessment?

Answer 38

Urinary catecholamine metabolites

Question 39

A patient with a diagnosed paraganglioma is undergoing surgery. If intraoperative hypertension occurs, which of the following management strategies is most appropriate?

Answer 39

Rapidly titratable anyihypertensives: clevidipine, nipride, nicardipine

Question 40

What is the preferred method of anesthesia in patients with Carotid Sinus Hypersensitivity undergoing carotid endarterectomy?

Answer 40

Regional anesthesia

Question 41

A patient with Guillain-Barré syndrome (GBS) requires emergency surgery. Question: What is a key consideration in the anesthetic plan for this patient?

Answer 41

Patient may need post-op mechanical ventilation even if not required pre-op

Question 42

A patient with POTS develops significant tachycardia during a surgical procedure. Which of the following would be an appropriate management strategy?

Answer 42

Administration of a β-adrenergic blocker

Question 43

A patient with a history of traumatic brain injury is exhibiting signs of Paroxysmal Sympathetic Hyperactivity (PSH) during surgery. Which of the following would be the most appropriate initial management step?

Answer 43

Administration of ß blockers

Question 44

In a patient with familial dysautonomia undergoing surgery, why is rapid sequence induction preferred?

Answer 44

Increased aspiration risk due to GERD
(Aka Riley-Day syndrome: hereditary ANS disorder: autonomic crises in response to stress)

Question 45

Which of the following is a crucial consideration during anesthetic emergence in a patient with familial dysautonomia?

Answer 45

ensure adequate NMBD reversal
(hypotonia = aspiration risk)

Question 46

In a patient undergoing microsurgical decompression for trigeminal neuralgia, what intraoperative complication should be closely monitored?

Answer 46

Bradycardia from activation of the trigeminocardiac reflex

Question 47

A patient with glossopharyngeal neuralgia is undergoing surgery. What preoperative consideration is most critical?

Answer 47

Assess cardiac status: possibility of syncope or bradycardia

Question 48

After intracranial transection of the glossopharyngeal nerve in a patient with glossopharyngeal neuralgia, which of the following is a potential postoperative complication?

Answer 48

VC paralysis

Question 49

A patient with Guillain-Barré syndrome is undergoing surgery. Due to autonomic nervous system dysfunction, which of the following anesthetic considerations is most critical?

Answer 49

Continuous intraarterial blood pressure monitoring

Question 50

In a patient with Guillain-Barré syndrome, which muscle relaxant is most appropriate to use?

Answer 50

Vecuronium

Question 51

Why might a patient with Guillain-Barré syndrome require mechanical ventilation postoperatively, even if breathing spontaneously before surgery?

Answer 51

Progressive muscle weakness affecting respiratory muscles

Question 52

A patient with CRPS (Chronic Regional Pain Syndrome) in the upper limb exhibits excessive sweating and changes in skin color in the affected area. These symptoms are

Answer 52

Dysregulation of the Symapthetic Nervous System

Question 53

In a patient with CRPS, which of the following pathophysiological mechanisms primarily contributes to the allodynia often observed in these patients?

Answer 53

CNS sensitization

Question 54

A 60-year-old patient with a long history of poorly controlled diabetes mellitus is undergoing surgery. The patient reports numbness and tingling in the lower extremities. What anesthesia-related complication is this patient at increased risk for?

Answer 54

Increased risk of peripheral nerve injury

Question 55

A patient with vitamin B12 deficiency undergoing anesthesia is at increased risk for which of the following?

Answer 55

Prolonged effect of Non-Depolarizing NMBs

Question 56

A patient with AIDS-associated neuropathy requires anesthesia for a surgical procedure. What is a key consideration for this patient regarding anesthesia management?

Answer 56

Potential for altered response to LAs

Question 57

A male patient undergoing abdominal surgery develops ulnar neuropathy postoperatively. Which of the following factors is most likely to have predisposed him to this condition?

Answer 57

Preexisting obesity & nerve conduction abnormalities

Question 58

In a patient who underwent surgery in the lithotomy position, which nerve is most at risk for perioperative neuropathy?

Answer 58

Common peroneal nerve

Question 59

A patient experiences postoperative brachial plexus neuropathy. Which surgical position is most likely to have contributed to this complication?

Answer 59

Prone with shoulder abduction and contralateral head rotation

Question 60

When assessing a patient with suspected peri-operative peripheral neuropathy, what is the most critical initial step?

Answer 60

Thorough History and physical exam.

Question 61

In a patient with purely sensory deficit postoperatively, what is the suggested management approach?

Answer 61

Expectant management