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Neuro Diseases in Anesthesia Flashcards

1
Q

What is the cerebral blood flow rate?

A

50 mL/100 g brain tissue/min or 750 mL/min

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2
Q

The brain gets what % of CO?

A

15%

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3
Q

What are the 3 components in the cranium?

A
  1. Tissue (Brain + Spinal Cord)
  2. Blood
  3. CSF
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4
Q

What is the combined volume of the brain, blood and CSF?

A

1200-1500 mL

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5
Q

What is normal ICP?

A

5-15 mmHg

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6
Q

What does the Monroe-Kellie hypothesis state?

A

Increase in one component of intracranial volume must be offset by a decrease in another to prevent elevated ICP

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7
Q

If ICP increases, what happens to MAP?

A

MAP increases to maintain CPP

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8
Q

What is the name of the dura that separates the 2 cerebral hemispheres?

A

Falx Cerebri

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9
Q

What is the name of the dura that separates the supratentorial (Cerebrum) and infratentorial (cerebellum) spaces?

A

Tentorium Cerebelli

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10
Q

Herniation against the falx cerebri is called what? And what branch of artery does it compress causing midline shift?

A

Subfalcine Herniation
Compresses the ACA

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11
Q

Herniation of the cerebrum against the tentorium cerebelli compresses the _____ downwards is what kind of herniation?

A

Transtentorial Herniation
Compresses the brainstem downwards

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12
Q

This type of herniation causes the uncus (medial portion of the temporal lobe) to herniate over the tentorium cerebelli and cause herniation through foramen magnum?

A

Uncal Herniation

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13
Q

What type of ocular problems do we see in uncla herniation?

A

Ipsilateral oculomoter nerve dysfunction, Pupillary dilation, ptosis, lateral deviation of the affected eye

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14
Q

Does hyper or hypoventilation decrease ICP?

A

Hyperventilation

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15
Q

Which drug class, used to decrease ICP can decrease swelling and enhance the integrity of the BBB?

A

Corticosteroids

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16
Q

What affect does propofol have on cerebral bloodflow?

A

Propofol is a cerebral vasoconstrictor that decreases CRMO2 and CBF

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17
Q

_________ is an autoimmune dx that causes demyelination of ___ ____ fibers

A

Central nerve

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18
Q

Female, 1st degree relative, Epstein Barre virus, smoking are risk factors for what disease?

A

Multiple sclerosis

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19
Q

What causes a MS exacerbation?

A

Stress
Temperature swings
Post-partum

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20
Q

Symptoms of MS?

A

Vary dramatically:
1. Motor weakness/Sensory disorders
2. Visual impairment
3. Autonomic instability (HR, Postural Hypotension)

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21
Q

Treatment for MS?

A

Corticosteroids & IVIG

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22
Q

With an MS patient, what medications would cause you to check certain labs?

A

Dantrolene & Azothioprine
-Check LFT’s

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23
Q

What drug for MS causes bone marrow suppression?

A

Azothioprine

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24
Q

Do MS patients have up or down regulated n-Ach receptors at the end plate?

A

Up-regulated Ach receptors

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25
Q

What diseases would you consider stress-dose steroids for?

A
  1. MS
  2. MG
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26
Q

What NMB do you avoid with MS patients?

A

Succs, up-regulated n-Ach-R can cause hyperkalemia

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27
Q

What are symptoms common in MG?

A
  1. Muscle weakness
  2. Ocular Symptoms: Diplopia & Ptosis
  3. Bulbar involvement: laryngeal/pharyngeal weakness
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27
Q

What disease generates Antibodies against n-Ach-R?

A

Myasthenia gravis

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28
Q

What is common in 10% of MG patients?

A

Thymic hyperplasia (90% patients improve after thymectomy)

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29
Q

What are exacerbation triggers for MG?

A

Stress-Related Factors
1. Insomnia
2. Pain
3. Surgery
4. Infection

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30
Q

What is the treatment for MG?

A

AchE inhibitors: Pyridostigmine, Azathiaprine, Steroids, PLEX, IVIG

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31
Q

Should your MG patient take or hold their Pyridostigmine the morning of surgery?

A

Take pyridostigmine

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32
Q

Ach-E inhibitors may prolong what 2 drugs?

A

Succs
Ester LA’s

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33
Q

Should you increase or decrease paralytic dose for MG patients?

A

Decrease paralytic to avoid prolonged muscle weakness

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34
Q

What patients might need post-op Ventilation support?

A
  1. MG
  2. EL Syndrome
  3. Myotonias
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35
Q

What disease creates antibodies against pre-synaptic VG Ca++ channels?

A

Eaton-Lambert syndrome

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36
Q

What pathology is E-L Syndrome associated with?

A

Small-cell lung carcinoma

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37
Q

What are symptoms of EL Syndrome?

A
  1. Progressive limb-girdle weakness
  2. Dysautonomia (BP and GI)
  3. Oculobulbar palsyT
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38
Q

Treatment for EL Syndrome?

A

3,4 Diaminopyridine (K+ channel blocker that increases circulating Ach levels)

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39
Q

Patients with what disease are VERY sensitive to depolarizing and Non-depolarizing NMB?

A

E-L syndrome (already Ach deficit at synapse)

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40
Q

Are EL Syndrome pt. or MG patients more sensitive to Non-depolarizing NMB?

A

EL syndrome are more sensitive

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41
Q

What type of anesthesia is the preferred route for EL patients?

A

Regional - Reduce paralytic and opioid doses

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42
Q

What gene is affected in Muscular dystrophy?

A

Dystrophin-glycoprotein complex

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43
Q

Why is the lifespan of DMD patients 20-25 years?

A

Cardiopulmonary complications

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44
Q

Symptoms of DMD?

A
  1. Muscle wasting without sensory abnormalities
  2. Kyphoscoliosis
  3. Long-bone fragility
  4. Respiratory Weakness
  5. Frequent pneumonia
  6. EKG changes
  7. Elevated CK levels due to muscle breakdown
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45
Q

What is at trigger for hypermetabolic syndrome in DMD?

A

Succs & Volatiles

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46
Q

DMD are susceptible to _______ ______ which leads to rhabdomyolysis, Inc. K+, V-fib

A

Hypermetabolic Syndrome

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47
Q

What type of anesthesia is preferred for DMD?

A

Regional is preferred
Low-Dose Rocuronium and TIVA for GA

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48
Q

What is myotonia?

A

Prolonged contraction after muscle stimulation

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49
Q

What is myotonic Dystrophy and where do you see muscle wasting?

A

Most common myotonia
Wasting in:
1. Face
2. Masseter
3. Hands
4. Pre-tibial muscles
5. Maybe laryngeal and diaphragm

50
Q

20% of myotonic dystrophy patients have what cardiac complication?

A

mitral valve prolapse

51
Q

What is myotonia congenita?

A

mild form of myotonia, involving only the skeletal muscles

52
Q

What is central core disease? and hallmark symptom?

A

Rare type of myotonia where core muscles lack mitochondrial enzymes
-Proximal muscle weakness & scoliosis

53
Q

What are all myotonias triggered by?

A

Stress & cold temperature

54
Q

What medications are symptoms of myotonias managed by?

A
  1. Quinine
  2. Procainamide
  3. Steroids
55
Q

What are anesthesia considerations for myotonias?

A
  1. GI hypomotility
  2. Keep patients warm
  3. Look at thyroid and glucose
  4. Avoid Succs (Fasciculations)
56
Q

What patients are treated as full stomachs?

A

Dementia patients

57
Q

What is the preferred anesthetic for dementia patients?

A

Regional Anesthesia

58
Q

What is the biggest risk for parkinson’s?

A

Advanced Age

59
Q

Parkinson’s pathophysiology?

A

Degeneration of dopaminergic fibers of basal ganglia

60
Q

______ suppresses overstimulation of the extrapyramidal motor system

61
Q

In parkinson’s, motor neurons become _____

A

Over stimulated

62
Q

What is the Parkinson’s triad?

A
  1. Skeletal muscle tremor
  2. Rigidity
  3. Akinesia
63
Q

Treatments for Parkinson’s

A
  1. Levodopa
  2. Anticholinergic
  3. MAO-I
  4. Deep-Brain stimulator
64
Q

Should levodopa be continued or discontinued in pre-op

A

Levodopa should be continued to avoid chest wall rigidity

65
Q

When assessing parkinson’s patients pre-op, pay attention to the degree of

A

Respiratory compromise

66
Q

Which drugs do we avoid in parkinson’s patients?

A
  1. Reglan
  2. Phenothiazines
  3. Butyrophenones
67
Q

If your patient is on an MAO-I, what drug should we avoid?

68
Q

Which type of cautery is preferred to avoid interaction with deep brain stimulators?

69
Q

What is the most common CNS glial cell?

A

Astrocytes

70
Q

Which astrocytoma is the least aggressive that is primarily tumors and found in young adult with new onset ________

A

Glioma; new onset seizures

71
Q

Which astrocytoma is found in young adults/children, benign and has good outcomes when resected

A

Pilocyctic Astrocytoma

72
Q

Which astrocytoma is poorly differentiated and usually evolves into a glioblastoma?

A

Anaplastic astrocytoma

73
Q

Which astrocytoma is a high mortality that requires surgery and chemo with short life expectancy?

A

Glioblastoma multiforme

74
Q

Which benign brain tumor arises from dura and arachnoid tissue and has good prognosis?

A

Meningioma

75
Q

Which tumor is non-cancerous and fixed via transsphenoidal or open crani methods?

A

Pituitary adenoma

76
Q

Which involves benign schwannomas involving vestibular component of CN 8 in the auditory canal?

A

Acoustic neuroma; good prognosis with resection

77
Q

What is characteristic of a metastatic carcinoma?

A

Varies in origin and symptoms
-Outcomes are less favorable

78
Q

What % of strokes are ischemic/Hemorrhagic?

A

Ischemic - 88%
Hemorrhagic - 12%

79
Q

Brain blood supply is fed via

A
  1. Internal carotid arteries
  2. Vertebral arteries
80
Q

What is a symptom of occluded ACA?

A

Contralateral leg weakness

81
Q

What is a symptom of occluded MCA?

A

Aphasia
Contralateral hemiparesis
Contralateral vision deficit

82
Q

What is a symptom of occluded Basilar?

83
Q

What is a symptom of occluded Vertebral artery?

A

Ataxia
Crossed sensory deficit

84
Q

What is a symptom of occluded PCA?

A

Contralateral visual deficit
Contralateral hemiparesis

85
Q

When does a TIA resolve and what fraction will suffer a stroke after?

A

24 hours; 1/3

86
Q

What imaging is required to distinguish ischemia from hemorrhage?

A

Non-contrast CT

87
Q

Ischemic stroke prognosis depends on the time from ________ to _______

A

Onset to thrombolytic intervention

88
Q

What are the 5 TOAST categories for ischemic stroke classification?

A
  1. Large artery atherosclerosis
  2. Small vessel occlusion
  3. Cardioarotic embolic
  4. Other etiology (hypercoagulable)
  5. Undetermined
89
Q

What is the initial treatment for CVA?

A

PO aspirin

90
Q

When does TPA need to be initiated if within the criteria?

A

3-4.5 hrs post symptom onset

91
Q

The 2 most reliable predictors of outcome after hemorrhagic stroke is:

A
  1. Blood volume
  2. Degree of change in LOC
92
Q

Blood within the brain is a:

A

Intraparenchymal hemorrhage

93
Q

If a patient wants to have a hernia repaired 2 months after starting anticoagulation for a thrombus, should you delay or continue the case?

A

Delay the case

94
Q

If a patient wants to have a breast augmentation repaired 4 months after starting anticoagulation for a thrombus, should you delay or continue the case?

A

Continue the case

95
Q

What is the guideline for elective cases and new anticoagulation for thrombus?

A

No elective cases within 3 months

96
Q

If your patient is on anticoagulation for CVA prophylaxis, what should you do?

A

Consult the prescriber to see if risks of stopping outweigh benefits of surgery

97
Q

What should high risk patients on warfarin be put on to bridge the gap until warfarin can be resumed?

A

Short acting anticoagulation (Heparin)

98
Q

As anesthesia providers, what should we assess pre-op for CVA patients?

A

Root cause of CVA
Imagine

99
Q

What are symptoms of an aneurysm?

A
  1. Headache
  2. Photophobia
  3. confusion
  4. Hemiparesis
100
Q

Intervention for aneurysm should be performed within ____ hrs of rupture for best outcome

101
Q

In Post-SAH Vasospasm, ______ ___ triggers inflammatory mediators which reduce __________ and increases _________ leading to ________

A

Free-hgb; nitric oxide; endothelin-1; vasoconstriction

102
Q

What is triple H therapy?

A
  1. Hypervolemia
  2. Hypertension
  3. Hemodilution
103
Q

Interventional treatments for SAH Vasospasm are

A

Direct injection of vasodilators and balloon dilation

104
Q

AVM is a connection without capillaries that creates an area of _____ ______ shunting

A

High flow, Low resistance

105
Q

Where are majority of AVM’s?

A

Supratentorial

106
Q

What is the name of the AVM grading scale?

A

Spicer Martin Grading system

107
Q

What is a chiari malformation Type 1

A

Displacement of the cerebellum downward thru the foramen magnum

108
Q

Type 2 Chiari malformation?

A

Downward of cerebellum associated with Myelomeningocele

109
Q

What are symptoms of Chiari malformation?

A

H/A that extends to shoulders/arms
Visual disturbances
Ataxia

110
Q

What are anesthesia interventions for chiari malformation?

A

Hyperventilate to decrease ICP

111
Q

Tubular sclerosis patients present with

A

Mental retardation and seizure disorders

112
Q

Tubular sclerosis is characterized by

A

Lesions “everywhere”: Brain, Kidney, Skin, Eye, Lungs, heart, Face

113
Q

Von Hippel Lindau Disease is characterized by tumors of the CNS, Eyes, Adrenals, Pancreas and kidneys. it can be differentiated from TS by presence of

A

Pheochromocytoma

114
Q

What are anesthesia considerations for Von Hippel Lindau Disease

A

Exaggerated HTN (Pheochromocytoma)

115
Q

What type of anesthesia is better for Von Hippel Lindau Disease

A

General
-Regional anesthesia limited d/t potential spinal tumor

116
Q

Anesthesia considerations for Neurofibromatosis?

A
  1. Increased ICP
  2. Airway issues
  3. Scoliosis
  4. Possible pheochromocytoma
117
Q

What are the diuretic tx for hydrocephalus?

A

Furosemide, Acetazolamide (decreases CSF production)

118
Q

You should intubate if GCS is less than

119
Q

What should you refrain from in TBI surgery?

A

Refrain from OGT/NGT due to potential for basilar skull fracture

120
Q

Which drugs are enzyme inducers?

A

Phenytoin
Tegretol
Barbiturates

121
Q

Seizure patients on certain meds need higher doses of

A

hepatically cleared medications

122
Q

If you have to intubate post seizure, whats the plan?

A

RSI with cricoid pressure

123
Q

What can transiently cause a seizure?

A
  1. Hypoglycemia
  2. Hyponatremia
  3. Hyperthermia
  4. Intoxication

Assessment (10 decks)

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