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Neuro Assessment Flashcards

1
Q

incidence of stroke

A

<0.1% in non-neurosurgical and non-cardiac cases

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2
Q

mortality of stroke for non-cardiac surgery and cardiac surgery

A

non-cardiac = eight-fold increase

cardiac = as high as 38%

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3
Q

risk factors for stroke

A

history of previous stroke/TIA
advanced age
renal disease

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4
Q

what type of surgery carries the highest risk?

A

cardiac (and valve surgery within that)

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5
Q

moyamoya syndrome

A

cerebrovascular disease characterized by narrowing of distal internal carotid arteries and its proximal branches

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6
Q

what other diseases is moyamoya syndrome associated with

A

sickle-cell

Neurofibromatosis

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7
Q

how do you treat moyamoya syndrome

A

antiplatelets and revascularization

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8
Q

anesthetic eval for stroke patients

A

cause/timing/symptoms/residual effects
echocardiogram is warranted
auscultate and palpate carotid arteries for bruits

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9
Q

anesthetic considerations for stroke patients

A 
antiplatelet therapy = bleeding risk (cesstion of therapy with or without bridging)
aka risk of thromboembolism must be weighed against bleeding risk

also if patient has been largely immobile - sux is contraindicated

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10
Q

what are increased risk factors for stroke patients undergoing anesthesia

A

stroke/TIA or thromboembolism in the last 3 months
genetic predisposition
CHA2DS2VASC score >2

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11
Q

asymptomatic patients presenting with what problem puts them at great risk for periop stroke

A

carotid stenosis

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12
Q

anesthetic implications of carotid bruit

A

large hemodynamic instability
surgery requires significant head/neck manipulation - watch the tube
positioning compromises blood flow

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13
Q

what is the gold standard for diagnosing carotid bruit and what is the acceptable first-line study

A

carotid arteriography = gold standard

carotid duplex is ok too

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14
Q

dementia

A

neurocognitive disorder characterized by a decline/change in memory, language, problem solving, and cognitive skills

commonly caused by alzheimer, vascular dementia, parkinsons

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15
Q

incidence of alzheimer

A 
>65 = 1/9
>85 = 1/3
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16
Q

perioperative screening for dementia

A

montreal cognitive assessment

mini-cog (3 min)

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17
Q

anesthetic considerations of dementia - meds

A

cholinesterase inhibitors may prolong effects of Succ and increase risk of pulm complications

NMDA antagonist and SSRIs may interact with anesthetics

Gingko can caused increased risk for bleeding

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18
Q

anesthetic considerations of dementia (not meds)

A

KNOW BASELINE
reduce periop risks like post-op delirium
avoid benzos and antihistamines
variable BP can be detrimental to patients with a predisposition for dementia
consider regional when appropriate

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19
Q

Parkinson’s

A

loss of dopamine-containing neurons from the pars compacta of the substantia nigra with intracytoplasmic inclusion “Lewy bodies” is the hallmark finding

results in unopposed action of ach in extrapyramidal motor system

  • bradykinesia
  • rigidity
  • tremor
  • postural instability
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20
Q

what are two major symptoms of parkinsons that put patient at high risk while undergoing anesthesia

A

dysphagia

respiratory dysfunction

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21
Q

anesthetic considerations for patient with Parkinsons

A

continue home meds
avoid meperidine and dopa agonists
bipolar cautery is preferred in patients with deep brain stimulators and keep ground pad as far from possible
NDMBs have little impact

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22
Q

Myasthenia gravis

A

autoimmune disease where antibodies attack the postsynaptic Ach receptor
present with proximal muscle weakness that is exacerbated with activity and relieved with rest

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23
Q

treatment for MG

A 
pyridostigmine - increased circulating Ach
glucocorticoids
immunosuppressives - infection risk
IV immunoglobin
thymectomy - infection risk
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24
Q

how do you differentiate between myasthenic and cholinergic crisis

A

edrophonium administration

this increases Ach so if you give it and they get better its myasthenic crisis and if they get worse its cholinergic crisis

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25
Q

what is MG associated with

A

RA
thyroiditis
autoimmune hematologic disorders
cardiac involvement

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26
Q

anesthetic considerations of MG: elective vs emergency surgery

A

elective: safe in stable patients with well-controlled or mild disease
emergency: optimize with plasma exchange

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27
Q

MG considerations for muscle relaxants

A

NDMRs - effect is increased due to diminished number of ACh receptors
succ - effect is reduced, however block can be prolonged due to therapeutic cholinesterase inhibitors

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28
Q

anesthetic considerations for MG

A

may require post-op ventilation
administration of glucocorticoids preop
aspiration prophylaxis

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29
Q

scoring system to predict post op vent support needs

A

MG >/= 6 years (12 pt)
history of chronic resp disease (10 pt)
pyridostigmine dose > 750 mg/day (8 pt)
vital capacity < 2.9 L (4 pt)

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30
Q

multiple sclerosis

A

rare autoimmune demyelinating disease of the brain and spinal cord with varied symptoms that progress toward fixed deficits

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31
Q

multiple sclerosis treatments

A

supportive: corticosteroids and immunosuppresant drugs

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32
Q

multiple sclerosis anesthesia implications

A

review chart for chronic pain meds
upregulation of Ach - so no succ
aspiration risk
GA: risk for post op resp failure and cardiac dysfunction and hypotension
RA: poor response to fluids or pressors and also it can be difficult to assess return to baseline with blocks because these patients often have parasthesias at baseline
maintain normothermia

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33
Q

muscular dystrophy

A

group of inherited disorder presenting with muscle wasting and weakness
recessive mutation in the dystrophin gene on the x chromosome

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34
Q

what are the most common types of muscular dystrophy

A

duchenne and becker

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35
Q

periop complications of muscular dystrophy include

A 
rhabdo
hyperkalemia
malignant hyperthermia
cardiac arrest
dilated cardiomyopathy (duchenne's)
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36
Q

preop considerations of muscular dystrophy

A

all patients with duchenne will develop dilated cardiomyopathy

  • 75% will have ECG abnormalities
  • need a preop ECG and echocardiography

restrictive lung disease occurs

  • determine baseline O2 sat on room air
  • PFTs important (FVC<50% with ineffective cough requires training in NIPPV as well as cough assist)
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37
Q

lambert eaton syndrome

A

autoantibodies attack presynaptic calcium channels

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38
Q

treatment for lambert eaton

A

3,4 diaminopyridine, pyridostigmine
plasmapheresis
immune globulin

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39
Q

presenting symptom of lambert eaton

A

proximal weakness in pelvic and truncal areas

patient weakest in morning with improvement during day

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40
Q

anesthetic considerations of lambert eaton

A

comp history and exam (extent of weakness, stiff aching muscles, altered gait)
assess for pharyngeal weakness
spirometery and PFTs determine risk of postop resp complications
- vital capacity < 2.9 may indicate need for post op vent

continue meds
avoid blocks if possible
increased risk of post op pulm complications
avoid hyperthermia

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41
Q

incidence of aneurysms

A

3.2 % and only 0.25% rupture (10% die pre-hospital)

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42
Q

sign of aneurysm

A

worst headache of their life

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43
Q

treatment goal of aneurysm

A

prevent subsequent hemorrhage
microvascular clipping
endo-vascular clipping

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44
Q

what disorders are aneurysms associated with

A

marfan, ehler danlos, autosomal dominant polycystic kidney disease, coarctation of the aorta, bicuspid aortic valve, pseudoxanthoma elasticum, pheo

45
Q

arteriovenous malformation

A

triangle of abnormal vessels referred to as a nidus

presentation includes hemorrhage seizures and neuro deficits

46
Q

treatment options for AVM

A

endovascular embolization
stereotactic radiosurgery
surgical removal

47
Q

Fluid and electrolyte probs with aneurysm and AVM

A

hyponatremia caused by SIADH/CSW

hypokalemia
hypocalcemia
hypomagnesemia

intravascular volume deficit

48
Q

cardiac considerations of aneurysm/avm

A

mycocardial dysfunction possible d/t catecholamine release = dysrhythmia, prolonged QT, T-wave abnormalities

49
Q

Guillian Barre’

A

leading cause of acute autoimmune neuromuscular paralysis
-2/3 of patients who develop GB had an infection within the prior 6 weeks (campylobacter jejuni, Epstien-Barr, mycoplasma pneumoniae, cytomegalovirus)

characterized by general weakness that begins in lower extremities

50
Q

how do you diagnose GB

A

lumbar puncture

51
Q

anesthetic considerations of GB

A

avoid NMBDs, ET intubation, and mechanical vent when possible

  • upregulated nAChRs, exaggerated response to surgical stim, GBS worsens after surgery
  • regional anesthesia is safer and LA reqs are often decreased
52
Q

focal seizure

A

originates from one point in the cerebral hemisphere

53
Q

generalized seixure

A

arises from both hemispheres

54
Q

therapy for seizures

A

preferred monotherapy anti-epileptics

also can use adrenal corticotropic hormone, corticosteroids, ketogenic diet

55
Q

anesthetic considerations of seizures

A

get a good history
seizures should be well-controlled and triggers limited prior to surgery
benzos can help enhance sedative effects
NS is preferred for patients on ketogenic diet
antiepilileptic drugs should be continued

56
Q

meningiomas

A

36% of intracranial tumors

  • arise from dura or arachnoid
  • most benign
  • more common in women
57
Q

gliomas

A

24% of intracranial tumors

  • arrive from astrocyte anaplasia
  • numerous types (glioblastoma worst)
  • median survival 14 months following diagnosis
58
Q

common features of tumors

A 
mass effect with neuro deficit - may cause false localizing signs
increase in ICP
papilladema and headache
unsteady gait
seizures
vomiting
59
Q

anesthetic considerations of tumors

A

review history including symptoms and current/past therapies

preop study - electrolytes (glucose), CBC, blood type and cross, ECG

60
Q

monroe kelly doctrine

A

skull is a closed vault containing tissue, blood, and CSF and if there is an increase in one the others have to decrease, or ICP will rise

61
Q

what icp causes cerebral ischemia

A

50-60mmhg

62
Q

cushings triad

A

hypertension, bradycardia, irregular breathing

63
Q

anesthetic considerations of intracranial hypertenstion

A 
detailed neuro history and determine etiology
GCS < 8 intubate
labs = CBC, osmolality (expect hyponatremia)
get ECG (neurogenic myocardial ischemia)
continue meds as indicated
64
Q

TBI classified by

A

etiology
severity
location

65
Q

TBI severity as rated by GCS

A

mild = 13-15
moderate = 9-12
severe < 8

66
Q

anesthetic implications of TBI

A

are there concominant injuries? - aka spine?

support BP, O2, and thermoreg (expect low BP, high temp, and low O2)

monitor ICP and treat

labs - CMP, CBC, PT/INR, toxicology

67
Q

what is your ICP goal for TBI

A

ICP < 20 with CPP 50-70

CPP = MAP - ICP

68
Q

how to treat elevated ICP

A

elevate HOB 30-45
keep body midline
hyperosmolar/hypertonic solution (mannitol/3-23% saline)

69
Q

dosing for mannitol

A

initial bolus 1g/kg with repeat dosing every 6 hours 0.25 g/kg

70
Q

lab goals for hypertonic saline infusion

A

maintain serum osmolality <360 and serum sodium <160 mg/dl

71
Q

quick way to determine sodium from serum osmolality

A

half your serum osmo and it should be within 10 pt

72
Q

autism

A

neurodevelopment disorder diagnosis 1 in 68
4x greater in males

social communication deficits and social interaction deficits with repetitive patterns of behavior

patients exhibit intellectual disability (IQ<70), anxiety, panic, oppositional defiant disorder, self-injury, attention deficit, fine and gross motor probs

73
Q

anesthetic considerations of autism

A

continue preop meds because risk for withdrawal/psychosis
assess routines
simple language and use visual aids
premed with benzos

74
Q

protopathic

A

noxious sensation

75
Q

epicritic

A

non-noxious sensation

76
Q

nociception

A

the neural responses to traumatic or noxious stimuli (causes pain)

77
Q

pain perceptions can be different d/t

A

gender (men>women)

age (decrease with age, infants unable to communicate)

78
Q

how is pain classified

A

clinically (acute/chronic)
patho (nociceptive vs neuropathic)
etiology (what is causing it)
location

79
Q

evolution of chronic pain

A

failure of resolving pain despite tissue healing resulting in occult inflammation and unrecognized failure of tissue healing

or when faced with persistent stimulation changes occur to afferent nervous system leading to allodynia

80
Q

two aspects of perceptive pain

A

sensory discriminators in the dorsal horm to the thalamus and sensory cortex
- causes perception of pain
affective motivators from the dorsal to limbic system and prefrontal cortex
- causes perception of repulse

81
Q

neurologic pain

A

an infrequent symptom of a neuro disease including conditions such as trigeminal neuralgia, cluster headaches, shingles, sciatica

82
Q

inflammation of the meninges S&S

A

complain of pain with neck flexion and extension

83
Q

brudzinskis sign

A

pain with resistance to motion

84
Q

kernigs sign

A

pain with resistance to knee extension

85
Q

what is the other name for trigeminal neuralgia and how does it present

A

tic douloureux

presents with jabbing pain lasting seconds in the maxillary and mandibular distributions of trigeminal nerve

86
Q

components of a neuro assessment

A 
general appearance
mental status
cranial nerves
motor function
reflexes
sensory function
cerebellar function
87
Q

general appearance assessment includes

A

body symmetry and musculoskeletal assessment

88
Q

mental status assessment includes

A

LOC (behavior and arousability)
orientation

describe in observational terms

89
Q

motor function scale

A 
0= no muscle twitch with attempted movement
1= muscle twitch with no movement
2=movement along horizontal plane
3=movement against gravity
4=movement against slight resistance
5=movement against full resistance
90
Q

reflexes occur through

A

activation of the stretch receptor that communicates with lower motor neurons in the anterior horn

can be deep tendon or superficial

91
Q

reflex scale

A 
0 - no response
1 - diminished response
2- normal
3 - increased
4 - clonus
92
Q

hyporeflexia

A

indicates lower motor function neuron lesions

myopathies and spinal cord (anterior) lesions

93
Q

hyperreflexia

A

usually present in MS patients and neuro diseases

corticospinal tract

94
Q

jendrassiks manuever

A

in patients with decreased reflexes, isometric contraction of other muscles will increase reflex action

95
Q

what reflexes do we test

A 
biceps
Triceps
brachioradialis
patellar
achilles
96
Q

testing reflex of biceps tendon

A

tests nerve c5-6
observe for contraction of biceps tendon
(hammer hits in crease of AC over provider thumb)

97
Q

testing brachioradilais reflex

A

tests nerve roots of c5-c6

observe for flexion at the elbow and simultaneous supination of forearm

reflex hammer hits about 2-3cm above thumb on side of forearm (per pic)

98
Q

testing of triceps tendon

A

test nerve roots c6-8

prompt contraction of the triceps tendon with extension of the elbow

hammer hits just above elbow with patient arm bent

99
Q

testing patellar reflex

A

test nerve roots L2-4

quadriceps contraction

hammer hits on soft spot of knee with patient leg dangling and bent over table/chair (per pic)

100
Q

testing achilles reflex

A

assess S1-2

plantar flexion of ankle

provider support foot and hits achilles tendon on back of heel at about the same level as the lateral malleolus (per pic)

101
Q

superficial reflex test - the babinski reflex

A

assess nerve roots L5-S2

if positive you sill see dorsiflexion of big toe with fanning of toes

should be negative in adults

102
Q

touch and pain are conducted where?

A

at representative dermatome levels

103
Q

vibratory assessment is performed where

A

at distal joints, working proximally as deficiencies are identified

104
Q

cerebellar function

A

brain GPS

coordinates motor, vestibular, and sensory

105
Q

how to test cerebellar function

A

finger to nose, heel to shin, romberg test

106
Q

carotid artery atherosclerosis is a significant contributor to

A

ischemic brain attack and CVA

107
Q

what puts you at an increase risk for significant carotid stenosis

A

cervical bruit, AAA, previous neuro event

108
Q

carotid ultrasound

A

in transverse orientation you should see SCM above IJ (collapsable) and you should see the carotid artery and should be able to follow it up until it splits into the external and internal carotid artery

in longitudinal view, at the bifurcation you should see the external carotid above your internal carotid cephalad and just the common carotid caudally

109
Q

ICP ultrasound assessment of optic nerve

A

optic sheath is the most distal portion of the nerve with dura

as ICP increases, CSF is distributed through the dura, dilating the sheath

3mm from vitreous humor (eyeball) you can measure the width of the optic nerve sheath

<5mm = normal, >5mm = problem

Assessment (1 decks)

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