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Prodigy Quick Review > Intracranial Surgery > Flashcards

Intracranial Surgery Flashcards

1
Q

List various treatments that will lower intracranial

hypertension and cerebral edema.

A

Fluid restriction, mannitol, furosemide, corticosteroids, and
hyperventilation. These actions lower intracranial hypertension
and cerebral edema, which in turn lower the ICP.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 596.

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2
Q

Why is it necessary to hyperventilate a patient during

surgery for an intracranial aneurysm?

A

Hyperventilation decreases PaCO2, which decreases the
cerebral blood volume, and provides brain relaxation. The goal
is to maintain PCO2 levels between 30 and 35mmHg.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 8.

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3
Q

Upon induction of anesthesia, what are three things

that can be deleterious to the neurosurgical patient?

A

Apnea, hypertension, and hypotension.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1009

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4
Q

How is mild hypothermia helpful in craniotomies for

intracranial aneurysms?

A

It causes a reduction in CMRO2 and reduces the chance of
ischemic injury while the surgical clip is in place. There is an
approximate 30% reduction in CMRO2 at 33 degrees Celsius.
At temperatures between 33 and 34 degrees C, there is minimal
incidence of cardiac dysrhythmias, and there is little effect on
coagulation. This can be attained through bladder irrigation and
water-circulating pads.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 9.

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5
Q

What is meant by the term Triple H therapy?

A

It refers to Hypervolemia, Hypertension, and Hemodilution. This
term is in reference to patients with symptomatic vasospasms.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 605.

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6
Q

What is the desired level of anesthetic if brain
relaxation is desired and SSEP monitoring is used
during a neurosurgical case?

A

Less than 1 MAC of volatile anesthetic. Opioids are often
employed to reduce the anesthetic requirement of the volatile
agent.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1010.

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7
Q

What is the opioid of choice during neurosurgery if
extubation is desired at the end of the case, and a
neurological assessment is desired?

A

Remifentanil
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1010.

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8
Q

Hyperventilation is one method used in providing
brain relaxation during neurosurgery. Name 3 other
substances that produce brain relaxation.

A

Hypertonic Saline, IV anesthetics, and mannitol
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1010.

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9
Q

What drugs are appropriate for controlling

hypertension when emerging neurosurgical patients?

A

Apresoline, nicardipine, and labetalol
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1012.

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10
Q

What actions would be appropriate to minimize

coughing upon emergence from neurosurgery?

A

1-1.5mg/kg IV lidocaine, 4% lidocaine put directly into the ETT
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1012.

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11
Q

At what age does bleeding from an AVM usually

present?

A

between the ages of 10 and 30
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 607.

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12
Q

What is the most common symptom of an unruptured

aneurysm? What is the most common sign?

A

Headache is the most common symptom, while a oculomotor
nerve palsy is the most common sign.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 604.

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13
Q

What is the incidence of cerebral vasospasm in
patients that have undergone surgery to repair a
ruptured aneurysm? When is it most likely to occur?

A

30% of patients experience cerebral vasospasm that usually
occurs between 4 to 14 days after surgery for ruptured
aneurysm repair.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 642.

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14
Q

What are the anesthetic goals for the patient

undergoing surgery for intacranial aneurysm?

A

Adequate CPP, reduction of CMRO2, and to provide an optimal
working space within the surgical site by decreasing intracranial
volume (tissue and blood), which lessens the requirement of
surgical retraction of the brain tissue.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 8.

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15
Q

Why should patients undergoing craniotomies in the
sitting position be evaluated for a patent foramen
ovale?

A

Patent foramen ovales increase the risk for paradoxical
embolisms.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1012.

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16
Q

What electrolyte disorder can precipitate or worsen

cerebral edema?

A

Hyponatremia causes the extracellular fluid to become
hypotonic. As this occurs, water begins moving into the brain
cells causing cerebral edema and intracranial hypertension.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 359.

17
Q

In what patient populations should mannitol be

avoided?

A

Mannitol is an osmotic diuretic that transiently increases
intravascular volume, therefore it should not be used in patients
with borderline renal or cardiac function. Caution should also be
used when administering mannitol in patients with AVMs and
intracranial aneurysms. Mannitol can expand hematomas,
therefore its use should be limited to the open cranium.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 594.

18
Q

For patients presenting with intracranial

hypertension, why is it best to avoid premedication?

A

Premedication results in respiratory depression, which in turn
causes hypercapnia. Increased PCO2 results in increased ICP.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 633.

19
Q

Blood flow to the brain is provided by what arteries?

A

2 vertebral arteries, 2 carotid arteries, and collateral circulation
is provided by the Circle of Willis
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 996-997.

20
Q

A patient is undergoing a craniotomy in the sitting
position. A venous air embolism is detected. What
actions do you take

A

The surgeon must first be notified in order for the surgical field
to be flooded and packed until the site of entry can be
detected. The patient should be given 100% O2, and aspiration
of the central venous catheter should be done to retrieve
entrained air. The CVP should be increased through
intravascular volume infusion, and any hypotension should be
treated with vasopressors. Also helpful to the surgeon in
indentifying the location of the embolism, is compression of both
jugular veins. This increases CVP, slowing down air
entrainment and produces back bleeding. The patient should
be placed head down and the wound closed as quickly as
possible if the above measures are not effective.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 600.

21
Q

CO2 greatly affects CBF. How does O2 affect CBF?

A

Little effect on CBF is seen until excessively low PaO2 levels
are reached. CBF begins to increase greatly when the PaO2
falls to less than 50 mm Hg.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 999.

22
Q

How does Ketamine affect cerebral blood flow and

metabolism?

A

Ketamine increases both cerebral blood flow and metabolism.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 999.

23
Q

The IV agents thiopental and propofol exert what

effects on CMRO2 and CBF?

A

Thiopental and propofol reduce metabolism and cause cerebral
vasoconstriction (lower CBF).
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 999.

24
Q

How do inhalational agents affect CBF?

A

Inhalational agents cause vasodilation in a dose-related
fashion. At low doses, little to no change is seen, however with
higher doses, CBF is increased.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 999.

25
Q

A patient has developed the Cushing reflex (also

called the Cushing triad). Describe this phenomena.

A

The Cushing reflex consists of bradycardia, hypertension, and
respiratory irregularity. It is seen when ICP levels rise so
significantly, that brain stem herniation occurs.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 484.

26
Q

Succinylcholine should be avoided in what

neurosurgical populations?

A

Patients with muscle denervation from myelopathy, spinal cord
injury, or stroke. (Succinycholine is acceptable during the acute
phase of stroke and spinal cord injury if within 24-72 hours of
the injury). These patient populations have an up-regulation of
acetylcholine receptors resulting in severe hyperkalemia upon
the administration of succinylcholine.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1010.

27
Q 
List four interventions for inadequate cerebral
perfusion pressure (CPP).
A
  1. Decrease cerebral blood volume 2. Remove CSF 3. Reduce
    brain water 4. Elevate MAP
    Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
    Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
    Lippincott Williams and Wilkins; 2013: 1019.
28
Q

What are some interventions that elevate MAP, thus

enhancing CPP?

A

Administration of vasopressors, intravascular volume
resuscitation
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1017.

29
Q

List some mechanisms used to remove CSF.

A

The intravenous administration of hypertonic fluid and the
placement of lumbar or external ventricular drains
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1019.

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