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Neuro Anesthesia > Neuro Diseases > Flashcards

Neuro Diseases Flashcards

1
Q

What 3 regions of the brain are responsible for coma?

A

Reticular activating system #1, Thalamus, and Cortex

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2
Q

What are 3 things that can cause coma?

A

disease, injury, drug induced

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3
Q

What are the two subtypes of causes of coma?

A

Structural lesions, Diffuse disorders

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4
Q

What are some structural lesions that can cause coma?

A

tumor, stroke, intracranial bleed

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5
Q

What are the diffuse disorders that can cause coma?

A

hypothermia, hypoglycemia, drugs, postictal states, encephalopathy

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6
Q 
What are the eye opening Glasgow coma scale scores for:
to pain
spontaneously
no response
to speech
A

to pain 2
spontaneously 4
no response 1
to speech 3

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7
Q 
What are the verbal response Glasgow coma scale scores for:
Oriented
no response
inappropriate words
confused
incomprehensible sounds
A 
Oriented 5
no response 1
inappropriate words 3
confused 4
incomprehensible sounds 2
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8
Q 
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)
A 
flexion withdraw to pain 4
no response 1
moves to localized pain 5
abnormal flexion (decorticate) 3
obeys commands 6
abnormal extension (decorticate) 2
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9
Q

What GCS score is consistent with a comatose patient?

A

8 or less

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10
Q

What should be included in a basic neuro exam?

A

pupil response to light, extra ocular muscle reflexes, extremity gross motor response

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11
Q

What are normal pupil diameter?

A

3-4 mm

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12
Q

What is anascoria? Is is normal?

A

1mm difference in normal pupil diameter (one eye may be bigger or smaller)

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13
Q

Opioid or organophosphate intoxication, a focal pontine lesion or neurosyphilis is characterized by this pupil size?

A

Pinpoint 1mm

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14
Q

Diencephalon compression leads to which type of pupils?

A

small 2mm, but reactive to light

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15
Q

unresponsive midsize (5mm) pupils usually indicates what?

A

brainstem compression

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16
Q

Compression of this brain area leads to unresponsive midsize (5mm) pupils?

A

midbrain

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17
Q

Oculomotor nerve compression is indicated by which type of pupils?

A

fixed and dilated (7mm)

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18
Q

Besides oculomotor nerve compression, fixed and dilated (7mm) pupils may indicate what 2 things?

A

anticholinergic or sympathomimetic drug intoxication

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19
Q

Which cranial nerves can be assessed by extra ocular muscle function?

A

3, 4, 6

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20
Q

What is a normal oculocephalic reflex?

A

eyes deviate opposite the side the head is turned

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21
Q

What is oculocephalic reflex response would be expected in a comatose patient?

A

eyes follow head movement or stay midline

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22
Q

What is a normal oculovestibular reflex (cold caloric testing)?

A

Eyes move toward the ear the cold saline is injected into

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23
Q

What is a oculovestibular reflex (cold caloric testing)response would be expected in a comatose patient?

A

Eyes stay midline

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24
Q

Mild to moderate diffuse brain dysfunction above the diencephalon usually leaves the patient with what reactions to painful stimuli?

A

intact or semi purposeful reaction

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25
Q

What does a unilateral reaction to painful stimuli indicate?

A

one sided tumor or stroke

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26
Q

Does Diencephalon dysfunction lead to decorticate or decerebrate posturing?

A

decorticate

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27
Q

What patient movements are consistent with decorticate posturing?

A

flexion at the elbow, adduction of shoulder, extension of the knee, plantar flexion

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28
Q

Does more severe brain dysfunction lead to decorticate or decerebrate posturing?

A

decerebrate

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29
Q

What patient movements are consistent with decerebrate posturing?

A

elbow extension, internal rotation (pronation) of forearm, leg extension, plantar flexion

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30
Q

What type of posturing does pontine or medullary lesion result in?

A

no response to pain.

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31
Q

What should you always know about your patient coma before taking care of them?

A

the cause of the coma

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32
Q

If the cause of your patients coma is a TBI what should be avoided?

A

steroids, no hyperventilation for 24 hours after insult

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33
Q

What medication should be avoided in TBI?

A

ketamine

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34
Q

What neuromuscular blocker increases ICP?

A

succ

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35
Q

What is permanent cessation of total brain function and must involve coma of an irreversible cause?

A

brain death

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36
Q

What are criteria to determine brain death?

A

lack of spontaneous movement
lack of cranial nerve reflexes and function
Positive apnea test

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37
Q

Along with lack of cranial nerve function, what other test must be done?

A

0.04mg/kg Atropine with failure of HR to increase by 5bpm

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38
Q

How is an apnea test performed?

A

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.

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39
Q

What does a positive apnea test mean?

A

No spontaneous respiratory effort is made during the apnea test.

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40
Q

What is a potent stimulus for ventilation?

A

hypercarbia

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41
Q

What are some “other” brain death tests?

A

isoelectric EEG, absence of CBF on doppler, angiography

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42
Q

During organ donation are we more concerned about the donor or recipient?

A

recipient

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43
Q

Neurogenic shock, DI, 3rd spacing, and pharmacologic management lead to what in the brain dead patient?

A

hypotension

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44
Q

How is HoTN in brain death patients preferably managed?

A

aggressive fluids and inotropes.

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45
Q

What are the preferred inotropes in managing HoTN in brain dead patients?

A

Dopamine and Dobutamine

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46
Q

What is third line treatment for HoTN for organ donation patients?

A

Epi

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47
Q

Why is Epi avoided in the patient is donating their heart??

A

causes catecholamine induced cardiomyopathy

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48
Q

Should dysrhythmias be shocked for the patient donating their organs?

A

No. Pace or treat with drugs.

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49
Q

What can PEEP lead to?

A

barotrauma, decreased CO, hypoxemia

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50
Q

Hypovolemia, hypotension, hyperosmolarity, and electrolyte abnormalities in brain dead patients is typically caused by what?

A

DI

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51
Q

What is the preferred treatment of DI in brain death patients?

A

Desmopressin 1-4mcg

Vasopressin is another treatment

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52
Q

If vasopressin must be used to treat DI what other medication should be given to prevent end organ ischemia?

A

NTP

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53
Q

What is the rule of 100’s for managing brain dead patients?

A

SBP > 100
Urine output > 100
PaO2 > 100
Hgb > 100 g/L

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54
Q

What type of stroke is most common?

A

ischemic

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55
Q

Stroke is most common in what gender? Up until which age then odds are the same/

A

Males

Age 75

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56
Q

what tests are used to diagnose and determine monitoring in stroke?

A

noncontrast CT, angiography, doppler

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57
Q

What test is used to determine ischemic or hemorrhagic stroke?

A

noncontrast CT

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58
Q

What is a sudden vascular related focal neurological deficit that resolves within 24 hours.

A

TIA

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59
Q

What is the most significant risk factor for acute ischemic stroke?

A

systemic HTN

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60
Q

What medication is used as initial therapy and prevention of recurrent stoke?

A

ASA

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61
Q

The mass expanding effects of stroke peaks after how many days after onset and should be prevented?

A

two days

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62
Q

Large hemispheric stroke may be characterized by what?

A

middle cerebral artery syndrome

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63
Q

What is middle cerebral artery syndrome?

A

Edematous infarcted tissue compresses anterior & posterior cerebral arteries resulting in seconding infarctions

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64
Q

Infarction of which brain area results in basilar artery compression and brainstem ischemia?

A

cerebellum

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65
Q

What is the mortality rate with cerebellum and middle cerebral artery syndrome?

A

80%

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66
Q

what is the treatment of cerebellum and middle cerebral artery syndrome?

A

craniotomy and surgical decompression

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67
Q

Is ventilatory drive affected by ischemic stroke?

A

No

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68
Q

What causes ventilatory drive to be affected by ischemic stroke?

A

massive hemispheric or medulla infarction

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69
Q

What is common immediately post ischemic injury?

A

HTN

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70
Q

Immediately post ischemic injury what is the blood pressure goal?

A

maintain below 220/120

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71
Q

After revscularization of ischemic injury what is the blood pressure goal?

A

below 180/105

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72
Q

To maintain appropriate intravascular volume, cardiac output, and CPP what should be initiated after ischemic injury?

A

HHH therapy: HTN, hypervolemia, hemodilution

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73
Q

During ischemic stroke abnormal glucose levels leads to what?

A

tissue acidosis and injury

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74
Q

What medication and dose is used to prevent DVTs following ischemic stroke?

A

heparin 5000 SQ

75
Q

What is the preferred anesthetic for ischemic stroke diagnostic testing?

A

sedation, not general

76
Q

Cardiac, neurologic, vascular, and radiologic procedures of heart/major arteries carry the highest risk of what?

A

perioperative stroke

77
Q

Perioperative stroke has ___ times increase in 30 day mortality following surgery?

A

8

78
Q

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?

A

perioperative stroke

79
Q

Elective sx should be delayed how long following stroke to allow for return of autoregulation?

A

9 months

80
Q

What should be suspected if mental status does not improve as expected following anesthesia?

A

Perioperative stroke

81
Q

The hallmark of this disease is progressive stenosis of intracranial blood vessels with secondary development of anastomotic capillary network?

A

moyamoya

82
Q

What disease can be characterized by a cluster of abnormal blood vessels?

A

moyamoya disease

83
Q

How is moyamoya disease diagnosed?

A

angiography

84
Q

Affected arteries of moyamoya disease have a ___ intima and a ____ media.

A

thick intima

thin media

85
Q

Patients with moyamoya disease have increased incidence of what?

A

cerebral aneurysms

86
Q

What are common initial findings of moyamoya disease in children?

A

symptoms of ischemia

87
Q

What are common initial findings of moyamoya disease in adults?

A

hemorrhagic complications

88
Q

What medications are common in treating moyamoya disease?

A

anticoagulants and vasodilators

89
Q

What treatment of moyamoya disease is not super effective but it is treatment option?

A

Bypass by direct anastamosis of superficial temporal artery to middle cerebral artery

90
Q

What medication should you ensure is discontinued before taking a patient with moyamoya disease back to the OR?

A

anticoagulants

91
Q

What ventilatory dynamic should be avoided in moyamoya disease?

A

hypocapnia

92
Q

What should be avoided during induction of a patient with moyamoya disease?

A

HoTN or HTN

93
Q

What is a necessary monitor for moyamoya disease?

A

A-line

94
Q

In a patient with moyamoya disease, avoided factors that cause cerebral vaso______?

A

vasoconstriction

95
Q

How is HoTN in moyamoya disease best treated?

A

dopamine or ephedrine

96
Q

What is a congenital displacement of the cerebellum, four types, treated with surgical decompression and enlargement of foramen magnum?

A

Chiari malformation

97
Q

Which type of chiari malformation is characterized by cerebellar tonsils over cervical spinal cord?

A

1

98
Q

Which type of chiari malformation is characterized by downward displacement of vermis?

A

2

99
Q

Which type of chiari malformation is characterized by cerebellum into an occipital encephalocele?

A

3

100
Q

Which type of chiari malformation is characterized by cerebellar hypoplasia without displacement?

A

4

101
Q

People with type 2 chiari malformations typically have this intraoperative complication?

A

significant blood loss

102
Q

Signs of what are present in 50% of people with chiari malformations?

A

syringomyelia

103
Q

What are benign lesions occurring throughout the body including the brain?

A

Tuberous sclerosis

104
Q

What are complications of tuberous sclerosis?

A

intellectual disability, seizures, and facial angiofibromas

105
Q

What is the most common cardiac dysrhythmia caused by tuberous sclerosis lesions?

A

WPW

106
Q

What is a familial disease characterized by benign retinal angiomas, hemangioblastomas, visceral tumors, and CNS tumors?

A

Von hippel-lindau disease

107
Q

Where does Von-Hippel Lindau typically occur?

A

Cerebellum

108
Q

What is a common complication of Von-Hippel Lindau disease?

A

Pheochromocytoma

109
Q

What type of anesthesia should be avoided in Von-Hippel Lindau disease? why?

A

Neuraxial, spinal lesions

110
Q

What is a condition involving tumors that grow in the nervous system primarily of Schwann cell?

A

Neurofibromatosis

111
Q

What are the three types of neurofibromatosis?

A

Nf 1, NF 2, schwannomatosis

112
Q

What type of neurofibromatosis consist of neurons, fibroblasts and collagen?

A

neurofibromas

113
Q

What type of neurofibromatosis consist almost entirely of Schwann cells?

A

schwannomas

114
Q

Which type of neurofibromatosis tend to encase the parent nerve?

A

neurofibromas

115
Q

Which type of neurofibromatosis displaces the parent nerve?

A

schwannomas

116
Q

Which type of neurofibromatosis spares the parent nerve during resection?

A

schwannomas

117
Q

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

A

NF1

118
Q

What complication of neurofibromatosis may complicate airway management?

A

laryngeal neurofibromas, cervical spine deformities

119
Q

What is the most common cause of dementia in patients over 65, 4th most common cause of death in patients over 65?

A

Alzheimers

120
Q

What is a chronic neurodegenerative disorder resulting from diffuse amyloid rich plaques and neurofibrillary tangles?

A

Alzheimers

121
Q

What age separates early and later onset alzheimers?

A

60

122
Q

Which type of Alzheimers occur from missense gene mutations?

A

early onset

123
Q

Which type of Alzheimers appears to have less of a genetic role?

A

late onset

124
Q

What does the cognitive impairment from alzheimers consist of?

A

memory loss, apraxia (inability to perform purposeful actions), aphasia (cant understand or produce speech), and agnosia (cant interpret or recognize things)

125
Q

Treatment of this disease involves cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and glantamine) and Memantine (NMDA antagonist)?

A

alzheimers

126
Q

What is the anesthetic consideration of people with alzheimers taking cholinesterase inhibitors?

A

Cholinesterase inhibitors can result in the prolongation of succinylcholine and resistance to nondepolarizing agents

127
Q

What is the neurodegenerative disorder with loss of dopaminergic fibers normally present in the basal ganglia?

A

Parkinsons

128
Q

What is the most important risk factor for Parkinson’s?

A

age

129
Q

What does the dopamine depletion in Parkinsons lead to?

A

reduced inhibition and unopposed stimulation by acetylcholine

130
Q

What is the Classic triad of symptoms in parkinsons?

A

skeletal muscle tremor, rigidity, akinesia

131
Q

Where does rigidity of Parkinson’s first appear?

A

proximal muscles of the neck

132
Q

Facial immobility, pill rolling, diaphragmatic spasms, dementia, and depression are also frequent are signs of which disease?

A

parkinsons

133
Q

What may be the first sign of parkinsons?

A

absence of arm swinging while walking, absence of head rotation when moving the body

134
Q

What is the most common medical management of Parkinsons?

A

Levodopa and Carbidopa

135
Q

Dyskinesia, psychiatric disturbances, increased HR and myocardial contractility, orthostatic hypotension, and N/V are common symptoms of this parkinsons medication?

A

levodopa

136
Q

What medications are used to control the side effects of levodopa?

A

selegilene and rasagiline, amantadine

137
Q

What medication should be avoided in a person with parkinsons?

A

demerol/meperidine

138
Q

Is levodopa stopped for a surgery?

A

No

139
Q

Interruption of which medication can result in skeletal muscle rigidity that impedes ventilation and abrupt loss of therapeutic effect?

A

levodopa

140
Q

Which mediations are used to antagonize the effects of dopamine in the basal ganglia?

A

droperidol and haloperidol

141
Q

What drugs are typically avoided during deep brain stimulator placement under sedation due to interference with microelectrode recordings?

A

GABA (-pam)

142
Q

What are potential complications of patient with parkinsons disease undergoing surgery?

A

air embolism, HTN, seizures

143
Q

How are seizures treated?

A

benzos, barbiturates, or propofol

144
Q

Which disease has marked atrophy of the caudate nucleus and a lesser degree the putamen and globus pallidus?

A

huntingtons

145
Q

This disease has deficiencies of acetylcholine, choline acetyltransferase and GABA in the basal ganglia?

A

huntingtons

146
Q

What are manifestations of Huntington’s?

A

progressive dementia, and choreoathetosis

147
Q

What is the first symptom of Huntington’s?

A

Chorea (uncoordinated muscle movements)

148
Q

What is treatment of Huntington’s aimed at?

A

decreasing chorea with Haloperidol

149
Q

Which medication used to treat Huntington’s depletes dopamine stores and which antagonizes dopamine stores?

A

haloperidol antagonizes

reserpine depletes

150
Q

People with Huntington’s are prone to what?

A

aspiration

151
Q

How to people with Huntington’s respond to paralysis?

A

Prolonged responses to succinylcholine due to decreased plasma cholinesterase activity and sensitive to nondepolarizers

152
Q

What is the autoimmune disease characterized by diverse inflammation, demyelination (leads to demyelination plaques), and axonal damage in the CNS?

A

multiple sclerosis

153
Q

Are peripheral or central nerves affected in multiple sclerosis?

A

CENTRAL

154
Q

What neurodegenerative disease has exacerbations and remissions with no cure?

A

multiple sclerosis

155
Q

How can we prevent exacerbation of multiple sclerosis symptoms in the OR?

A

preventing HYPERthermia

156
Q

Which treatment of MS can cause flu like symptoms for 24-48 hours?

A

interferon beta

157
Q

Factors increasing the risk of exacerbation MS in the postoperative period include:

A

infection, fever, and spinal anesthesia (questionable but best avoided)

158
Q

Are exacerbations of demyelination from MS seen with nerve blocks or epidural anesthesia?

A

No

159
Q

What mediation can cause exaggerated potassium release and should be avoided in MS patients?

A

succinylcholine

160
Q

What causes MS patient to have potential resistance for NDNMBs?

A

up regulation of acetylcholine receptors

161
Q

Patients with MS will likely need this type of medication in the OR due to long term management?

A

corticosteroids

162
Q

What are a transient synchronous discharge of groups of neurons in the brain?

A

seizures

163
Q

How are seizures classified?

A

loss of consciousness and regions of the brain affected

164
Q

What type of seizure has no loss of consciousness?

A

simple seizure

165
Q

A seizure with altered levels of consciousness is called what?

A

complex seizure

166
Q

A seizure that originates from limited neurons in a single hemisphere is called?

A

partial seizure

167
Q

This type of seizure activates neurons in both hemispheres?

A

generalized seizure

168
Q

Partial seizure that begins in one hemisphere and becomes generalized when it moves over to the other hemisphere and involves both is called what?

A

Jacksonian March

169
Q

What is epilepsy?

A

recurrent seizures resulting from congenital or acquired factors

170
Q

What medications treat seizures?

A

Phenytoin, Valproate, carbamazepine, barbiturates, gabapentin

171
Q

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?

A

Phenytoin

172
Q

What seizure medication produces hepatic failure?

A

valproate

173
Q

Side effects of this seizure medication include diplopia, leukopenia, hyponatremia, and altered hepatic metabolism of several other drugs?

A

Carbamazepine

174
Q

What is continuous seizure activity or more than one seizure occurring in succession without return to consciousness between?

A

status epilepticus

175
Q

If a patient is having status epileptics what do you want to rule out as a cause?

A

hypoglycemia

176
Q

What is a common sequalae of continued seizure activity?

A

Metabolic acidosis

177
Q

What is common following status epileptics?

A

hyperthermia

178
Q

What medication can activate epileptic foci and may be utilized during electrocortical mapping for surgical treatment of epilepsy?

A

Methohexital

179
Q

What two anesthetic agents have both been shown to cause epileptiform EEG activity in patients with known seizure history?

A

Alfentanil and Sevo

180
Q

Which NMB’s has a metabolite that is a proconvulsant? What is the metabolite? How does it cause seizures?

A

Atracurium and Cisatracurium. Laudanosine. Crosses the BBB.

181
Q

What medications used during electrocorticographic monitoring may be used to enhance epileptiform activity?

A

alfentanil, methohexital, or etomidate

182
Q

What might you see on the vent if your patient has a seizure?

A

increased EtCO2

183
Q

Cold saline on a open brain in awake patients prevents what?

A

somnolence

184
Q

What movements are common under general anesthesia if not paralyzed?

A

tonic clonic

Neuro Anesthesia (4 decks)

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