Neuro Diseases Flashcards
What 3 regions of the brain are responsible for coma?
Reticular activating system #1, Thalamus, and Cortex
What are 3 things that can cause coma?
disease, injury, drug induced
What are the two subtypes of causes of coma?
Structural lesions, Diffuse disorders
What are some structural lesions that can cause coma?
tumor, stroke, intracranial bleed
What are the diffuse disorders that can cause coma?
hypothermia, hypoglycemia, drugs, postictal states, encephalopathy
What are the eye opening Glasgow coma scale scores for: to pain spontaneously no response to speech
to pain 2
spontaneously 4
no response 1
to speech 3
What are the verbal response Glasgow coma scale scores for: Oriented no response inappropriate words confused incomprehensible sounds
Oriented 5 no response 1 inappropriate words 3 confused 4 incomprehensible sounds 2
What are the motor response Glasgow coma scale scores for: flexion withdraw to pain no response moves to localized pain abnormal flexion (decorticate) obeys commands abnormal extension (decorticate)
flexion withdraw to pain 4 no response 1 moves to localized pain 5 abnormal flexion (decorticate) 3 obeys commands 6 abnormal extension (decorticate) 2
What GCS score is consistent with a comatose patient?
8 or less
What should be included in a basic neuro exam?
pupil response to light, extra ocular muscle reflexes, extremity gross motor response
What are normal pupil diameter?
3-4 mm
What is anascoria? Is is normal?
1mm difference in normal pupil diameter (one eye may be bigger or smaller)
Opioid or organophosphate intoxication, a focal pontine lesion or neurosyphilis is characterized by this pupil size?
Pinpoint 1mm
Diencephalon compression leads to which type of pupils?
small 2mm, but reactive to light
unresponsive midsize (5mm) pupils usually indicates what?
brainstem compression
Compression of this brain area leads to unresponsive midsize (5mm) pupils?
midbrain
Oculomotor nerve compression is indicated by which type of pupils?
fixed and dilated (7mm)
Besides oculomotor nerve compression, fixed and dilated (7mm) pupils may indicate what 2 things?
anticholinergic or sympathomimetic drug intoxication
Which cranial nerves can be assessed by extra ocular muscle function?
3, 4, 6
What is a normal oculocephalic reflex?
eyes deviate opposite the side the head is turned
What is oculocephalic reflex response would be expected in a comatose patient?
eyes follow head movement or stay midline
What is a normal oculovestibular reflex (cold caloric testing)?
Eyes move toward the ear the cold saline is injected into
What is a oculovestibular reflex (cold caloric testing)response would be expected in a comatose patient?
Eyes stay midline
Mild to moderate diffuse brain dysfunction above the diencephalon usually leaves the patient with what reactions to painful stimuli?
intact or semi purposeful reaction
What does a unilateral reaction to painful stimuli indicate?
one sided tumor or stroke
Does Diencephalon dysfunction lead to decorticate or decerebrate posturing?
decorticate
What patient movements are consistent with decorticate posturing?
flexion at the elbow, adduction of shoulder, extension of the knee, plantar flexion
Does more severe brain dysfunction lead to decorticate or decerebrate posturing?
decerebrate
What patient movements are consistent with decerebrate posturing?
elbow extension, internal rotation (pronation) of forearm, leg extension, plantar flexion
What type of posturing does pontine or medullary lesion result in?
no response to pain.
What should you always know about your patient coma before taking care of them?
the cause of the coma
If the cause of your patients coma is a TBI what should be avoided?
steroids, no hyperventilation for 24 hours after insult
What medication should be avoided in TBI?
ketamine
What neuromuscular blocker increases ICP?
succ
What is permanent cessation of total brain function and must involve coma of an irreversible cause?
brain death
What are criteria to determine brain death?
lack of spontaneous movement
lack of cranial nerve reflexes and function
Positive apnea test
Along with lack of cranial nerve function, what other test must be done?
0.04mg/kg Atropine with failure of HR to increase by 5bpm
How is an apnea test performed?
PaCO2 35-45, and pH 7.35-7.45 first. Then ventilation with 100% FiO2 for 10 minutes. Stop ventilating, continue 100% FiO2 for 10 minutes. ABG after 5 and 10 minutes.
What does a positive apnea test mean?
No spontaneous respiratory effort is made during the apnea test.
What is a potent stimulus for ventilation?
hypercarbia
What are some “other” brain death tests?
isoelectric EEG, absence of CBF on doppler, angiography
During organ donation are we more concerned about the donor or recipient?
recipient
Neurogenic shock, DI, 3rd spacing, and pharmacologic management lead to what in the brain dead patient?
hypotension
How is HoTN in brain death patients preferably managed?
aggressive fluids and inotropes.
What are the preferred inotropes in managing HoTN in brain dead patients?
Dopamine and Dobutamine
What is third line treatment for HoTN for organ donation patients?
Epi
Why is Epi avoided in the patient is donating their heart??
causes catecholamine induced cardiomyopathy
Should dysrhythmias be shocked for the patient donating their organs?
No. Pace or treat with drugs.
What can PEEP lead to?
barotrauma, decreased CO, hypoxemia
Hypovolemia, hypotension, hyperosmolarity, and electrolyte abnormalities in brain dead patients is typically caused by what?
DI
What is the preferred treatment of DI in brain death patients?
Desmopressin 1-4mcg
Vasopressin is another treatment
If vasopressin must be used to treat DI what other medication should be given to prevent end organ ischemia?
NTP
What is the rule of 100’s for managing brain dead patients?
SBP > 100
Urine output > 100
PaO2 > 100
Hgb > 100 g/L
What type of stroke is most common?
ischemic
Stroke is most common in what gender? Up until which age then odds are the same/
Males
Age 75
what tests are used to diagnose and determine monitoring in stroke?
noncontrast CT, angiography, doppler
What test is used to determine ischemic or hemorrhagic stroke?
noncontrast CT
What is a sudden vascular related focal neurological deficit that resolves within 24 hours.
TIA
What is the most significant risk factor for acute ischemic stroke?
systemic HTN
What medication is used as initial therapy and prevention of recurrent stoke?
ASA
The mass expanding effects of stroke peaks after how many days after onset and should be prevented?
two days
Large hemispheric stroke may be characterized by what?
middle cerebral artery syndrome
What is middle cerebral artery syndrome?
Edematous infarcted tissue compresses anterior & posterior cerebral arteries resulting in seconding infarctions
Infarction of which brain area results in basilar artery compression and brainstem ischemia?
cerebellum
What is the mortality rate with cerebellum and middle cerebral artery syndrome?
80%
what is the treatment of cerebellum and middle cerebral artery syndrome?
craniotomy and surgical decompression
Is ventilatory drive affected by ischemic stroke?
No
What causes ventilatory drive to be affected by ischemic stroke?
massive hemispheric or medulla infarction
What is common immediately post ischemic injury?
HTN
Immediately post ischemic injury what is the blood pressure goal?
maintain below 220/120
After revscularization of ischemic injury what is the blood pressure goal?
below 180/105
To maintain appropriate intravascular volume, cardiac output, and CPP what should be initiated after ischemic injury?
HHH therapy: HTN, hypervolemia, hemodilution
During ischemic stroke abnormal glucose levels leads to what?
tissue acidosis and injury
What medication and dose is used to prevent DVTs following ischemic stroke?
heparin 5000 SQ
What is the preferred anesthetic for ischemic stroke diagnostic testing?
sedation, not general
Cardiac, neurologic, vascular, and radiologic procedures of heart/major arteries carry the highest risk of what?
perioperative stroke
Perioperative stroke has ___ times increase in 30 day mortality following surgery?
8
amputations, abdominal exploration, small bowel resection, increasing age, MI within 6 months, renal dysfunction, stroke/TIA hx, HTN, COPD, smoking, metoprolol use are risk factors for what?
perioperative stroke
Elective sx should be delayed how long following stroke to allow for return of autoregulation?
9 months
What should be suspected if mental status does not improve as expected following anesthesia?
Perioperative stroke
The hallmark of this disease is progressive stenosis of intracranial blood vessels with secondary development of anastomotic capillary network?
moyamoya
What disease can be characterized by a cluster of abnormal blood vessels?
moyamoya disease
How is moyamoya disease diagnosed?
angiography
Affected arteries of moyamoya disease have a ___ intima and a ____ media.
thick intima
thin media
Patients with moyamoya disease have increased incidence of what?
cerebral aneurysms
What are common initial findings of moyamoya disease in children?
symptoms of ischemia
What are common initial findings of moyamoya disease in adults?
hemorrhagic complications
What medications are common in treating moyamoya disease?
anticoagulants and vasodilators
What treatment of moyamoya disease is not super effective but it is treatment option?
Bypass by direct anastamosis of superficial temporal artery to middle cerebral artery
What medication should you ensure is discontinued before taking a patient with moyamoya disease back to the OR?
anticoagulants
What ventilatory dynamic should be avoided in moyamoya disease?
hypocapnia
What should be avoided during induction of a patient with moyamoya disease?
HoTN or HTN
What is a necessary monitor for moyamoya disease?
A-line
In a patient with moyamoya disease, avoided factors that cause cerebral vaso______?
vasoconstriction
How is HoTN in moyamoya disease best treated?
dopamine or ephedrine
What is a congenital displacement of the cerebellum, four types, treated with surgical decompression and enlargement of foramen magnum?
Chiari malformation
Which type of chiari malformation is characterized by cerebellar tonsils over cervical spinal cord?
1
Which type of chiari malformation is characterized by downward displacement of vermis?
2
Which type of chiari malformation is characterized by cerebellum into an occipital encephalocele?
3
Which type of chiari malformation is characterized by cerebellar hypoplasia without displacement?
4
People with type 2 chiari malformations typically have this intraoperative complication?
significant blood loss
Signs of what are present in 50% of people with chiari malformations?
syringomyelia
What are benign lesions occurring throughout the body including the brain?
Tuberous sclerosis
What are complications of tuberous sclerosis?
intellectual disability, seizures, and facial angiofibromas
What is the most common cardiac dysrhythmia caused by tuberous sclerosis lesions?
WPW
What is a familial disease characterized by benign retinal angiomas, hemangioblastomas, visceral tumors, and CNS tumors?
Von hippel-lindau disease
Where does Von-Hippel Lindau typically occur?
Cerebellum
What is a common complication of Von-Hippel Lindau disease?
Pheochromocytoma
What type of anesthesia should be avoided in Von-Hippel Lindau disease? why?
Neuraxial, spinal lesions
What is a condition involving tumors that grow in the nervous system primarily of Schwann cell?
Neurofibromatosis
What are the three types of neurofibromatosis?
Nf 1, NF 2, schwannomatosis
What type of neurofibromatosis consist of neurons, fibroblasts and collagen?
neurofibromas
What type of neurofibromatosis consist almost entirely of Schwann cells?
schwannomas
Which type of neurofibromatosis tend to encase the parent nerve?
neurofibromas
Which type of neurofibromatosis displaces the parent nerve?
schwannomas
Which type of neurofibromatosis spares the parent nerve during resection?
schwannomas
Patients with this type of neurofibromatosis may have macrocephaly, short stature, obstructive hydrocephalus, epilepsy, hypertension, congenital heart defects, MEN type IIb, and learning/behavioral disorders
NF1
What complication of neurofibromatosis may complicate airway management?
laryngeal neurofibromas, cervical spine deformities
What is the most common cause of dementia in patients over 65, 4th most common cause of death in patients over 65?
Alzheimers
What is a chronic neurodegenerative disorder resulting from diffuse amyloid rich plaques and neurofibrillary tangles?
Alzheimers
What age separates early and later onset alzheimers?
60
Which type of Alzheimers occur from missense gene mutations?
early onset
Which type of Alzheimers appears to have less of a genetic role?
late onset
What does the cognitive impairment from alzheimers consist of?
memory loss, apraxia (inability to perform purposeful actions), aphasia (cant understand or produce speech), and agnosia (cant interpret or recognize things)
Treatment of this disease involves cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and glantamine) and Memantine (NMDA antagonist)?
alzheimers
What is the anesthetic consideration of people with alzheimers taking cholinesterase inhibitors?
Cholinesterase inhibitors can result in the prolongation of succinylcholine and resistance to nondepolarizing agents
What is the neurodegenerative disorder with loss of dopaminergic fibers normally present in the basal ganglia?
Parkinsons
What is the most important risk factor for Parkinson’s?
age
What does the dopamine depletion in Parkinsons lead to?
reduced inhibition and unopposed stimulation by acetylcholine
What is the Classic triad of symptoms in parkinsons?
skeletal muscle tremor, rigidity, akinesia
Where does rigidity of Parkinson’s first appear?
proximal muscles of the neck
Facial immobility, pill rolling, diaphragmatic spasms, dementia, and depression are also frequent are signs of which disease?
parkinsons
What may be the first sign of parkinsons?
absence of arm swinging while walking, absence of head rotation when moving the body
What is the most common medical management of Parkinsons?
Levodopa and Carbidopa
Dyskinesia, psychiatric disturbances, increased HR and myocardial contractility, orthostatic hypotension, and N/V are common symptoms of this parkinsons medication?
levodopa
What medications are used to control the side effects of levodopa?
selegilene and rasagiline, amantadine
What medication should be avoided in a person with parkinsons?
demerol/meperidine
Is levodopa stopped for a surgery?
No
Interruption of which medication can result in skeletal muscle rigidity that impedes ventilation and abrupt loss of therapeutic effect?
levodopa
Which mediations are used to antagonize the effects of dopamine in the basal ganglia?
droperidol and haloperidol
What drugs are typically avoided during deep brain stimulator placement under sedation due to interference with microelectrode recordings?
GABA (-pam)
What are potential complications of patient with parkinsons disease undergoing surgery?
air embolism, HTN, seizures
How are seizures treated?
benzos, barbiturates, or propofol
Which disease has marked atrophy of the caudate nucleus and a lesser degree the putamen and globus pallidus?
huntingtons
This disease has deficiencies of acetylcholine, choline acetyltransferase and GABA in the basal ganglia?
huntingtons
What are manifestations of Huntington’s?
progressive dementia, and choreoathetosis
What is the first symptom of Huntington’s?
Chorea (uncoordinated muscle movements)
What is treatment of Huntington’s aimed at?
decreasing chorea with Haloperidol
Which medication used to treat Huntington’s depletes dopamine stores and which antagonizes dopamine stores?
haloperidol antagonizes
reserpine depletes
People with Huntington’s are prone to what?
aspiration
How to people with Huntington’s respond to paralysis?
Prolonged responses to succinylcholine due to decreased plasma cholinesterase activity and sensitive to nondepolarizers
What is the autoimmune disease characterized by diverse inflammation, demyelination (leads to demyelination plaques), and axonal damage in the CNS?
multiple sclerosis
Are peripheral or central nerves affected in multiple sclerosis?
CENTRAL
What neurodegenerative disease has exacerbations and remissions with no cure?
multiple sclerosis
How can we prevent exacerbation of multiple sclerosis symptoms in the OR?
preventing HYPERthermia
Which treatment of MS can cause flu like symptoms for 24-48 hours?
interferon beta
Factors increasing the risk of exacerbation MS in the postoperative period include:
infection, fever, and spinal anesthesia (questionable but best avoided)
Are exacerbations of demyelination from MS seen with nerve blocks or epidural anesthesia?
No
What mediation can cause exaggerated potassium release and should be avoided in MS patients?
succinylcholine
What causes MS patient to have potential resistance for NDNMBs?
up regulation of acetylcholine receptors
Patients with MS will likely need this type of medication in the OR due to long term management?
corticosteroids
What are a transient synchronous discharge of groups of neurons in the brain?
seizures
How are seizures classified?
loss of consciousness and regions of the brain affected
What type of seizure has no loss of consciousness?
simple seizure
A seizure with altered levels of consciousness is called what?
complex seizure
A seizure that originates from limited neurons in a single hemisphere is called?
partial seizure
This type of seizure activates neurons in both hemispheres?
generalized seizure
Partial seizure that begins in one hemisphere and becomes generalized when it moves over to the other hemisphere and involves both is called what?
Jacksonian March
What is epilepsy?
recurrent seizures resulting from congenital or acquired factors
What medications treat seizures?
Phenytoin, Valproate, carbamazepine, barbiturates, gabapentin
Side effects of this drug include hypotension, dysrhythmias, gingival hyperplasia, aplastic anemia, steven-johnson’s syndrome, and purple glove syndrome from extravasation or intra-arterial injection?
Phenytoin
What seizure medication produces hepatic failure?
valproate
Side effects of this seizure medication include diplopia, leukopenia, hyponatremia, and altered hepatic metabolism of several other drugs?
Carbamazepine
What is continuous seizure activity or more than one seizure occurring in succession without return to consciousness between?
status epilepticus
If a patient is having status epileptics what do you want to rule out as a cause?
hypoglycemia
What is a common sequalae of continued seizure activity?
Metabolic acidosis
What is common following status epileptics?
hyperthermia
What medication can activate epileptic foci and may be utilized during electrocortical mapping for surgical treatment of epilepsy?
Methohexital
What two anesthetic agents have both been shown to cause epileptiform EEG activity in patients with known seizure history?
Alfentanil and Sevo
Which NMB’s has a metabolite that is a proconvulsant? What is the metabolite? How does it cause seizures?
Atracurium and Cisatracurium. Laudanosine. Crosses the BBB.
What medications used during electrocorticographic monitoring may be used to enhance epileptiform activity?
alfentanil, methohexital, or etomidate
What might you see on the vent if your patient has a seizure?
increased EtCO2
Cold saline on a open brain in awake patients prevents what?
somnolence
What movements are common under general anesthesia if not paralyzed?
tonic clonic
