Neuro Diseases Flashcards
1
Q
What are the main categories of neurological diseases?
A
Neurological Diseases, Genetic Disorders, Degenerative Disorders, Cerebral Vascular Disorders, Congenital Brain Diseases, Traumatic Brain Injury, Seizure Disorders.
2
Q
What is cerebral blood flow (CBF) modulated by?
A
cerebral metabolic rate, cerebral perfusion pressure (CPP), arterial blood carbon dioxide (PaC02), arterial blood oxygen (Pa02), various drugs, and intracranial pathologies.
3
Q
What is the normal CBF rate?
A
Approximately 50 mL/100g brain tissue per minute, totaling 750 mL/min which is 15% of cardiac output.
4
Q
What does the Monro-Kellie hypothesis state?
A
Any increase in one component of intracranial volume must be offset by a decrease in another component to prevent elevated ICP.
5
Q
Whats does the intracranial and spinal vault contain?
A
neural tissue (brain &spinal cord)
blood
CSF
6
Q
What is normal ICP?
A
5-15mmHg
7
Q
Normal volume of intracranial and spinal vault
A
1200-1500mL
8
Q
What are the common causes of increased intracranial pressure (ICP)?
A
- Tumors
- Intracranial hematomas
- Infections (meningitis or encephalitis)
- Blood in the CSF
- Edema in surrounding brain tissue.
9
Q
What are the methods to decrease ICP?
A
- Elevation of the head
- Hyperventilation
- CSF drainage
- Hyperosmotic drugs
- Diuretics
- Corticosteroids
- Surgical decompression.
10
Q
What is Multiple Sclerosis (MS)?
A
A progressive, autoimmune demyelination of central nerve fibers, typically onset age 20-40.
11
Q
What are common symptoms of Multiple Sclerosis?
A
- Motor weakness
- Sensory disorders
- Visual impairment
- Autonomic instability.
12
Q
What triggers exacerbations in Multiple Sclerosis?
A
- Stress
- Elevated temperatures
- Postpartum period.
13
Q
What is Myasthenia Gravis?
A
An autoimmune disorder characterized by antibodies against nicotinic acetylcholine receptors at the skeletal motor endplate.
14
Q
What are common symptoms of Myasthenia Gravis?
A
- Muscle weakness, exacerbated with exercise
- Ocular symptoms (diplopia, ptosis)
- Bulbar involvement.
15
Q
What is Lambert Eaton Syndrome?
A
An autoimmune disorder characterized by antibodies against voltage-gated calcium channels, reducing Ca++ influx and therefore ACh release at the neuromuscular junction.
16
Q
What are the symptoms of Lambert Eaton Syndrome?
A
- Progressive limb-girdle weakness
- Dysautonomia
- Oculobulbar palsy.
17
Q
What is LES commonly associated with?
A
Small cell lung carcinoma
18
Q
What is the main treatment medication for LES?
A
3-4 diaminopyridine (K+channel blocker)
19
Q
Special anesthetic considerations for LES?
A
VERY sensitive to ND-NMB and D-NMB, prefer RA over GA
20
Q
What is Muscular Dystrophy?
A
A hereditary disorder of muscle fiber degeneration caused by breakdown of the dystrophin-glycoprotein complex.
21
Q
What is the most common and severe form of Muscular Dystrophy?
A
Duchenne Muscular Dystrophy.
22
Q
Who does Duchenne MD affect?
A
Only boys, onset 2-5 y, wheelchair-bound by 8-10 y
23
Q
S/S of Duchenne MD
A
muscle wasting, kyphoscoliosis, long bone fragility, respiratory weakness, EKG changes, elevated CK
24
Q
Special Anesthetic Considerations for Duchenne MD
A
EKG/ECHO
Hypermetabolic syndrome-have MH cart ready
Consider low dose Rocc and TIVA
RA >GA
25
Hypermetabolic Syndrome
similar to MH, triggered by succs and VA in Duchenne MD
-can lead to rhabdo, hyperkalemia, vfib, cardiac arrest
26
Myotonic Dystrophies
Characterized by myotonia, triggered by stress and cold, no cure
27
Types of Myotonic Dystrophies
Myotonic dystrophy-->most common
Myotonia congenita: milder, only skeletal muscles
Central Core: rare, core cells lack mitochondrial enzymes
28
Special Anesthetic Considerations for Myotonic Dystrohpies
Keep Warm
Avoid Succs b/c fasciculations trigger myotonia
29
Considerations for Dementia
Medical PoA
Aspiration Risk (full stomach)
Increased risk for Delirium (consider TIVA)
Look at home meds
30
What are the three major dementia syndromes?
* Alzheimer's (70%)
* Vascular dementia (25%)
* Parkinson's (5%).
31
What are common symptoms of Parkinson's Disease?
* Skeletal muscle tremor
* Rigidity
* Akinesia.
32
What is the role of dopamine in Parkinson's Disease?
Dopamine suppresses overstimulation of the extrapyramidal motor system.
33
Biggest Risk Factor for Parkinsons
Advanced age
34
Special Considerations for Parkinsons
- Continue PO levodopa to avoid w/d which can lead to chest wall rigidity
- Avoid reglan, phenothiazines, butyrophenones, demerol if on MAOi
-DBS may need to be disabled
35
What are common symptoms of brain tumors?
* Increased ICP
* Papilledema
* Headache
* Altered mental status
* Mobility impairment.
*Vomiting
*Autonomic Dysfucntion
*Seizures
36
What are the types of astrocytomas?
*Gliomas
*Pilocytic astrocytomas
* Anaplastic astrocytomas
* Glioblastoma Multiforme.
37
Least aggressive astrocytoma?
Highest mortality?
Glioma
Glioblastoma Multiforme
38
Meningioma
Usually benign, arise from dura or arachnoid tissue
39
What are the preanesthesia considerations for patients with neurological disorders?
* Assess existing deficits
* Review imaging and neurological testing results
* Evaluate risks/benefits of anesthetic options.
40
What is the average lifespan for a patient with Duchenne Muscular Dystrophy?
Approximately 20-25 years due to cardiopulmonary complications.
41
What should be avoided in patients with Myasthenia Gravis during anesthesia?
Succinylcholine, as it may induce hyperkalemia.
42
True or False: Hyperventilation can help decrease ICP.
True because it lowers PaCO2
43
What is the effect of corticosteroids in the management of increased ICP?
They decrease swelling and enhance the integrity of the blood-brain barrier.
44
Fill in the blank: The triad of symptoms in Parkinson's Disease includes tremor, rigidity, and _______.
Akinesia.
45
What are Pituitary Adenomas?
Noncancerous tumors with varying subtypes
## Footnote
Surgical removal through transsphenoidal approach or open craniotomy is usually curative.
46
What are Acoustic Neuromas?
Benign schwannomas involving the vestibular component of CN VIII within the auditory canal
- have auditory defecits
## Footnote
Good prognosis with resection and/or radiation.
47
What is the prognosis for Metastatic Carcinomas?
Generally less favorable outcomes
## Footnote
Symptoms and origins can vary widely.
48
What are the key components of preanesthesia consideration for brain tumors?
* Review history & physical
* Inquire about previous therapies
* Assess presenting symptoms & neurological deficits
* Monitor glucose levels if on steroids
* Use anticonvulsants for supratentorial lesions
* CBC, BMP, EKG
* CT/MRI
* Pre-op steroids & antiseizure meds per surgeon
* Mannitol for intracranial pressure
49
What does CVA stand for?
Cerebral Vascular Accident
50
What is the leading cause of death and disability worldwide?
Stroke
51
What are the two main causes of strokes?
* Ischemia (88% of cases)
* Hemorrhage (12% of cases)
52
What supplies blood to the brain?
* Internal carotid arteries
* Vertebral arteries
53
What is an Ischemic CVA?
Occlusion of a vessel that perfuses a region of the brain, causing brain cell necrosis
54
What is a Transient Ischemic Attack (TIA)?
Sudden focal vascular neurologic deficit that resolves within 24 hours
55
What percentage of patients who experience a TIA will subsequently suffer a stroke?
1/3
56
Time from onset to thrombolytic intervention
<90 minutes
57
What is the initial treatment for Ischemic stroke?
PO Aspirin is often recommended
58
What is the time window for administering IV or intra-arterial tissue plasminogen activator (TPA)?
3-4.5 hours post onset
59
What are the categories of causes for Ischemic stroke according to the TOAST classification?
* Large artery atherosclerosis
* Small vessel occlusion
* Cardioaortic embolic
* Other etiology
* Undetermined etiology
60
What is a Hemorrhagic CVA?
Bleeding inside the cranial vault that impairs perfusion of the brain
61
How much more likely is a Hemorrhagic stroke to cause death compared to an Ischemic stroke?
4 times more likely
62
What are the two most reliable predictors of outcome in Hemorrhagic strokes?
* Blood volume
* Change in level of consciousness (LOC)
63
What are the subtypes of Hemorrhagic strokes based on the location of blood?
* Intraparenchymal hemorrhage
* Epidural hematoma
* Subdural hematoma
* Subarachnoid hemorrhage
* Intraventricular hemorrhage
64
What is the conservative treatment for Hemorrhagic stroke?
* Reduction of ICP
* BP control
* Seizure precautions
* Monitoring
65
What is the surgical treatment for Hemorrhagic stroke?
Evacuation of the hematoma
66
Conservative treatment for hemorrhagic CVA
reduction of ICP, BP control, seizure precautions, monitoring
67
How long until an elective case can be performed after starting a new anticoagulant for thrombus?
3 months
68
Special Pre-OP Considerations for cerebrovascular disease
-Baseline neuro
-Route cause of CVA
-Aline
69
What should be done if a patient is on anticoagulants for CVA prophylaxis?
Consult prescriber to establish protocol
70
What are the imaging studies used for cerebrovascular disease pre-op?
* Carotid U/S
* CT/MRI of head & neck
* Echocardiogram
71
How often is surgery performed before rupture in Cerebral Aneurysms?
1/3
Majority are not diagnosed before rupture
72
Risk Factors for cerebral aneurysms
HTN
Smoking
Female
Oral contraceptives
Cocaine
73
What are the symptoms of a ruptured Cerebral Aneurysm?
* Headache
* Photophobia
* Confusion
* Hemiparesis
* Coma
74
What is the recommended intervention time frame following a rupture of a Cerebral Aneurysm?
Within 72 hours for best outcomes
75
Main pre-op goal for cerebral aneurysm
control BP-avoid rupture
76
What is Triple H?
Hypertension(main initial treatment), hypervolemia, hemodilution
Used to manage post-SAH vasospasms
77
Post-SAH vasospasms
risk of vasospasms 3-15 days post SAH due to free hgb triggering inflammatory mediators which reduce NO, increasing endothelin 1=vasoconstriction
78
What does AMV stand for?
Arteriovenous Malformation
79
What is the main characteristic of Arteriovenous Malformation?
Arterial to venous connection without intervening capillaries that creates am area of high flow, low resistance shunting that is believed to be congenital
80
Chiari Malformation
congenital displacement of the cerebellum that is treated with surgical decompression
Progressively worse Types 1-4
81
Tuberous Sclerosis
AKA Bourneville Disease
Genetic disease causing benign hematomas, angiofibromas, and other malformations that occur anywhere in the body
82
Presentation of Tuberous Sclerosis
-Lesions of the brain: cortical tumors and giant cell astrocytes
-tumors of oropharynx, heart, lungs, liver, kidneys
- seizure disorders and mental retardation
83
Anesthesia Considerations for Tuberous sclerosis
airway compromise
-cardiac and/or kidney involvement
84
Von Hippel-Lindau Disease
Genetic disease process involving formations of benign tumors of the CNS, eyes, adrenals, pancreas and kidneys
- may have pheochromocytoma (high Mg, HTN
- be aware of possible spinal tumor-limited NA
85
Neurofibromatosis
A genetic disorder of the nervous system that causes tumors to form on the nerves in the body anywhere at anytime
- NO CURE
86
Types of Neurofibromatosis
Type 1 (most common)
Type 2
Schwannomatosis (rare)
87
Special Considerations of Neurofibromatosis
increased ICP, airway issues, scoliosis, possible pheochromocytoma
- Avoid NA d/t high liklihood of spinal tumors
88
What is Hydrocephalus?
Excessive accumulation of CSF causing increased ICP and ventricular dilatation
89
What are the surgical treatments for Hydrocephalus?
* Ventriculoperitoneal (VP) shunt (ventricle to peritoneum)
* Endoscopic third ventriculostomy (ETV) (lateral ventricle to R atrium, peritoneal space, or pleural space)
90
Hydrocephalus treatment mainly consist of?
diuretics (furosemide and acetazolamide)
91
What is the Glasco Coma Scale used for?
To categorize the severity of Traumatic Brain Injury
92
What are the primary and secondary injuries in Traumatic Brain Injury?
* Primary injury occurs at time of insult
* Secondary injuries include neuroinflammation, cerebral edema, hypoxia, anemia, electrolyte imbalances, and neurogenic shock
93
What is penetrating or non penetrating TBI based on?
breech of dura
94
What is the main preop consideration with TBI?
Do not delay emergency surgery
95
What seizure medications may require higher doses of hepatically cleared medications?
Phenytoin
Tegretrol
Barbituates
- They are enzyme inducers
96
What is a seizure?
Transient, paroxysmal, synchronous discharge of neurons in the brain
97
What is Epilepsy?
Recurrent seizures due to congenital or acquired factors
98
What should we be aware of for intubation post seizure?.
RSI w/cricoid pressure
99
What should be reviewed during pre-anesthesia for patients with seizure disorders?
Source of seizures and control level
100
Falx Celebri
a reflection of dura that separates the cerebral hemisphrere
101
Tentorium Cerebelli
a reflection of dura that lies rostral to the cerebellum and separates the supratentorial and infratentorial spaces
102
Subfalcine Herniation
Herniation against the falx cerebri; often compressing branches of the anterior cerebral artery, creating a midline shift
103
Transtentorial Herniation
Herniation of the supratentorial contents against the tentorium cerebelli, compressing the brainstem in a rostral to caudal direction
104
Uncal Herniation
a subtype of transtentorial herniation, where the uncus (medial portion of temporal lobe) herniates over the tentorium cerebelli
105
MS Risk Factors
Female
1st degree relative
EBV
Smoking
ABI disorders
NO CURE
106
Special Considerations for MS
- Avoid Succs
- Temperature management- variations can trigger exacerbation
107
Why is bulbar involvement of MG relevant?
respiratory weakness, aspiration risk
108
Exacerbation triggers of MG
pain, insomnia, infection, surgery
109
What medication should MG patients take the morning of surgery?
Ach-E inhibitors (pyridostigmine)
110
Special Considerations for MG
- reduce paralytic dosage
-caution with opioids
- Ach-E prolong succs and Ester LA
- may need ventilation post-op
111
Clinical Features of Anterior Cerebral artery occlusion
contralateral leg weakness
112
Clinical Features of middle Cerebral artery occlusion
-contralateral hemiparesis and hemisensory defecit
-Aphasia
-Contralateral visual field defect
113
Clinical Features of Posterior Cerebral artery occlusion
-Contralateral visual field defect
-contralateral hemiparesis
114
Clinical Features of Penetrating Arteries occlusion
-contralateral hemiparesis
-contralateral hemisensory defecit
115
Clinical Features of basal artery occlusion
oculomotor deficits and/or ataxia w/crossed sensory and motor deficits
116
Clinical Features of vertebral Cerebral artery occlusion
lower cranial nerve deficits and/or ataxia with crossed sensory deficits
117
Hunt and Hess Classification
Grading of aneurysm for prognosis based on neurological finding
-0-5 progressively worse mortality
118
World Federation of Neurologic Surgeons Grading System
Grading of aneurysm for prognosis based on GCS and major focal deficit
-0-5 progressively worse
119
Spetzler- Martin AVM grading
Grading system of AVM based on size, eloquence, and pattern of drainage and used to predict outcome of surgery and neurologic deficit
