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Fall 20' Advanced Pr. II > Neuroanatomy (exam 1) > Flashcards

Neuroanatomy (exam 1) Flashcards

1
Q

The brain receives what % of cardiac output?

A

15%

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2
Q

The brain receives how many ml of blood per 100 g of brain tissue per min?

A

50-65 mL

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3
Q

Does hypothermia increase or decrease CBF?

A

Decreases CBF

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4
Q

Does hyperthermia increase or decrease CBF?

A

Increases CBF

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5
Q

Does CBF increase or decrease with age?

A

Decreases with old age

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6
Q

What is the most powerful factor to increase CBF?

A

CO2

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7
Q

True or False: A doubling of CO2 doubles CBF?

A

True

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8
Q

HTN causes a right or left shift of the autoregulation curve?

A

Rightward shift

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9
Q

Metabolically what occurs so that CO2 can cause an increase in CBF?

A

CO2 combines with water to form carbonic acid which forms Hydrogen.
The H-‘s are what cause vasodilation of cerebral vessels (causing an increase in CBF)

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10
Q

The Brain uses O2 at a near constant rate, if CBF becomes insufficient to supply the needed amount of O2 what happens?

A

vasodilation occurs and CBF increases (known as autoregulation)

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11
Q

Both CO2 and O2 can cause an increase in CBF but which one is the most powerful factor?

A

CO2 is the most powerful factor.

O2 as hypoxia is a potent stimulus.

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12
Q

The cerebral blood flow is maintained fairly stable for a MABP of ?

A

50-150 (60-160)

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13
Q

autoregulation shifts to the left with what perfusion problems?

A

hypoperfusion / cerebral ischemia

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14
Q

autoregulation shifts to the right with what problem?

A

chronic HTN

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15
Q

*Arteries that form the circle of Willis?

A

2 carotid and 2 vertebral arteries - which merge to form the Circle of Willis at base of brain.

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16
Q

Three major components of the Intracranial contents?

A

Brain
CSF
Blood

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17
Q

What are astrocytes and their function?

A

star-shaped non-neuronal cells that support and protect neurons as well as provide nutrition.

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18
Q

Electrical stimulation of excitatory glutaminergic neurons leads to?

A

increase in intracellular calcium ion and vasodilation of nearby arterioles.

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19
Q

Does arterial or venous BP fluctuate greatly?

A

arterial

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20
Q

People with hypoperfusion/ cerebral ischemia, autoregulation is shifted to the left or right?

A

left

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21
Q

Autoregulation is by 2 separate mechanisms, what are the two mechanisms?

A

Responses to mean blood pressure changes

Responses to pulsatile pressure (perfusion pressure– for example…decreased during CPB)

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22
Q

When MAP rises acutely during strenuous exercise what happens so that vascular hemorrhage does not occur?

A

SNS constricts the large and intermediate-sized brain arteries enough to prevent the high pressure from reaching the smaller brain blood vessels. Thus, preventing vascular hemorrhages.

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23
Q

Give me an example of global ischemia and focal ischemia?

A 
Global = cardiac arrest
Focal = localized stroke
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24
Q

What is Penumbra?

A

an area of moderate ischemia peripheral to an area of greater ischemia, the penumbra area has compromised blood flow.

(immediate revascularization can save neurons in the penumbra)

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25
Q

most sensitive area of the brain for hypoxia/ischemia?

A

hippocampus (area for recent memories)

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26
Q

What is tPA used for?
window of use?
contraindications?
risk/side effects?

A

clot buster, reperfusion of an ischemic area of the brain.

3 hour window of use.

contraindications: hemorrhagic stroke, recent surgery.

Risks/side effects: cerebral hemorrhage

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27
Q

target glucose for treatment of cerebral ischemia?

A

target 180 mg/dl

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28
Q

Treatments for epilepsy?

A

Benzodiazepine

Barbiturates

Anti-epileptic (phenytoin)

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29
Q

What are most strokes caused by?

A

arteriosclerotic plaques that occur in one or more of the feeder arteries to the brain.

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30
Q

Most common arteries affected by Hemorrhagic strokes?

A

Middle Cerebral Artery

Posterior Cerebral Artery

Midbrain arteries

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31
Q

Entire capacity of cerebral cavity enclosing brain and spinal cord is about how much in mL?

A

1600-1700mL

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32
Q

CSF alone is how many mL?

A

150mL

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33
Q

Rate of CSF formation is about how much per day?

A

500-600mL/day

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34
Q

What is Coup, Contrecoup, and coup contrecoup?

A

Coup = contusion on the same side as the impact injury.

Contrecoup = injury to the opposite side as the site of injury.

Coup contrecoup = injury at the site of trauma and the opposite side of the brain.

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35
Q

What structure is responsible for drainage or reabsorption of CSF?

A

Arachnoid Villi

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36
Q

Normal CSF pressure in children is?

Adults?

A 
children = 3-7.5
adult = 4.5-13.5

Just need to know that children is less than adults.

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37
Q

What is normal ICP?

A

less than or equal to 20

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38
Q

What is the main cause of death after head injury?

A

Elevated ICP

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39
Q

Intracranial pressure curve, what does point 3 and 4 tell you?

A

At point 3, focal ischemia occurs. At point 4, global ischemia occur

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40
Q

Sustained elevation of ICP leads to?

A

brain herniation

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41
Q

Normally increases in volume (ICP) are initially well compensated, what points on the Intracranial pressure curve would this be?

A

1 and 2

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42
Q

*What is Cushings Triad?

A

increase ICP leads to reflex increase in MAP (hypertension), decrease in HR (bradycardia) and irregular respiration.

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43
Q

Intracranial Hypertension would be defined as?

A

ICP greater than 20 mmHg

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44
Q

What are some causes of intracranial hypertension?

A

mass lesion
hematoma
head trauma

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45
Q

herniation of the brain due to increased ICP will occur through what two structures?

A

tentorial notch

foramen magnum

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46
Q

Intracranial hypertension will cause what to occur on the same side of the mass?

A

cranial nerve three compression on the ipsilateral side = fixed dilated pupil to the same side as the mass (also cushings triad)

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47
Q

Chronic intracranial hypertension will cause?

A

papilledema

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48
Q

Treatment of intracrainial hypertension?

A

ABCs

Intubation plus hyperventilation

Maintain PCO2 level 25-30ish mmHg

Mannitol

Sedation

Steroids

Slowly wean from ventilator

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49
Q

Glasgow coma score, tell me what each number range means?

A

Severe brain injury defined as 7 or less

Moderate injury = 8-12

Minor injury = > 13

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50
Q

Two techniques to monitor ICP today? (explain)

A

1…intraventricular (requires cannulation of ventricular frontal horn)

2…intraparenchymal (often held in place by bolt screw)

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51
Q

An increase in ICP can reduce what?

A

CBF

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52
Q

Cerebral blood flow and BP is maintained pretty constant over a wide MABP, what would that range be?

A

50-150

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53
Q

What does CPP measure?

A

Cerebral Perfusion Pressure (CPP)- Is actually what is measured as a surrogate for Cerebral Blood flow under conditions where stats are rapidly changing (i.e. ill person with increased ICP and possible herniation in progress)….

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54
Q

What measurement is the difference between MAP and the greater of ICP or CVP?

A

CPP

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55
Q

equation for CPP is?

A

MABP - ICP or CVP (whichever is greater)

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56
Q

What should the CPP range be, and what do the ranges mean?

A

CPP Goal- Maintain above 50-55

CPP < 40 considered critical

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57
Q

Difference between communication and non-communicating Hydrocephalus?

A

Communicating: Caused by blockage of fluid flow around base of brain or by blockage of arachnoidal villi
Fluid collects on the outside of brain and some collects inside the ventricles

Non-Communicating:Caused by block in aqueduct of Sylvius
Volumes of lateral and 3rd ventricle increase greatly

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58
Q

BBB is permeable to?

A

Water
CO2
O2
Most lipid-soluble substances

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59
Q

BBB is slightly permeable to?

A

Electrolytes: Na+, Cl, K+

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60
Q

BBB is impermeable to?

A

Plasma proteins

Non-lipid-soluble large molecules

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61
Q

What can cause the BBB to be more permeable? (like a break in the barrier)

A 
Microwaves
Radiation
Trauma
Hypertension
Infection
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62
Q

What typically causes Brain Edema?

A

Usual cause is increased capillary pressure or damage to capillary wall that makes the wall leaky to fluid.

Starts a vicious cycle: edema decreases blood flow, causing ischemia, then more edema

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63
Q

Most of the Brains energy is supplied as what? and how long will that supply last?

A

Glucose

only a 2 minute supply of glucose stored as glycogen in the neurons.

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64
Q

Most common first degree brain tumor is?

A

Astrocytoma

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65
Q

Do first degree brain tumors commonly or rarely undergo metastasis?

A

rarely

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66
Q

What type of prognosis and expectancy does astrocytoma have?

A

grave prognosis and less than 1 year life expectancy.

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67
Q

2nd most common first degree brain tumor? (arise from arachnoid cells external to the brain, slow growing)

A

Meningloma

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68
Q

Tumor found in the 4th ventricle, can cause hydrocephalus, poor prognosis, what is this tumor called?

A

Ependymoma

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69
Q

tumor that is relatively rare and slow growing?

A

oligondendroglioma

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70
Q

Most common prolactinoma, causes tunnel vision, hyper or hypo pitutarism can result?

A

Pituitary adenoma

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71
Q

3rd most common first degree tumor with schwann cell origin?

A

Schwannoma

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72
Q

What nerve is an acoustic schwannoma tumor localized to?

A

VII nerve

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73
Q

What test is diagnostic for seizures?

A

EEG

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74
Q

What type of seizure does not cause a loss of consciousness?

A

Focal (partial) seizure arise from discrete region, no loss of consciousness

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75
Q

causes of tumors in children, adults, and elderly?

A

Children- genetic, infection (febrile), trauma, congenital, metabolic

Adults- tumors, trauma, stroke, infection

Elderly- stroke, tumor, trauma, metabolic, infection

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76
Q

What is the major goal in neurosurgical anesthesia?

A

to provide adequate tissue perfusion to brain and spinal cord so that regional metabolic demand is met and to provide adequate surgical conditions (“a relaxed brain”)

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77
Q

In general IV anesthetics do what to CMR and CBF

where most inhalation anesthetics cause what change to CMR and CBF?

A

IV anesthetics decrease cerebral metabolic rate (CMR) and CBF in parallel fashion….

Most inhalational anesthetics decrease CMR with an increase in CBF (cerebral vasodilation)

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78
Q

What CANNOT not be recommended in patients who have experienced stroke?

A

hyperventilation

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79
Q

Hypercapnia is what?

A

high CO2

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80
Q

what is hypocapnia?

A

low CO2

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81
Q

what CO2 concentration can dilate vessels in the normal area of the brain but not in the damaged (ischemic) area?

A

high or hypercapnic

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82
Q

what is intracerebral steal?

A

“stealing from the poor”

when blood flow is shunted away from an ischemic area to a normal blood flow area of the brain.

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83
Q

what CO2 concentration can divert blood flow from the normal area of the brain to an ischemic area?

A

low or hypocapnic

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84
Q

what is “reverse” cerebral steal/Robin hood effect?

A

“stealing from the rich to give to the poor”

when blood is diverted from a normal area of the brain to an ischemic area.

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85
Q

How can you induce the “steal” phenomena?

A

pharmacologically with anesthesia (not hyperventilation)

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86
Q

Anesthesia alters ICP through changes in what?

A

CBV (which appear to be proportional to changes in CBF, thus in ICP)

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87
Q

Intracerebral steal VS. reverse steal?

A

intracerebral = blood flow away from ischemic area.

reverse = blood flow to ischemic area

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88
Q

How are the smaller blood vessels in the brain protected when MAP rises acutely? (ultimately protecting against vascular hemorrhage)

A

SNS constricts the large and intermediate-sized brain arteries enough to prevent the high pressure from reaching the smaller brain blood vessels. Thus, preventing vascular hemorrhages.

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89
Q

Sensory CN are?

A

I olfactory, II optic, VIII vestibulocholear

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90
Q

Motor CN are?

A

III occulomotor, IV trochlear, VI abducen, XI accessory, XII hypoglasal

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91
Q

What 4 large arteries merge to form the circle of Willis?

A

2 carotid and 2 vertebral arteries.

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92
Q

—— is the basic functional cell of the CNS?

A

Neuron

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93
Q

Sensory or Motor neuron has multiple dendritic processes and constitutes the majority of the CNS.

A

Motor

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94
Q

What cell lines the roof of the 3rd and 4th ventricles of the brain and central spinal cord. They also form the choroid plexus which secretes CSF?

A

Ependymal cells

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95
Q

These cells develop into large macrophages that phagocytize neuronal debris?

A

Microglia cells

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96
Q

Forms the myelin sheath of axons in the brain and spinal cord and are capable of mylenating more than one axon?

A

Oligodendrocyte cells

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97
Q

This cell forms the myelin sheath of peripheral nerves?

A

Schwann cells

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98
Q

electrical stimulation of excitatory glutaminergic neurons leads to increase in ?

A

intracellular calcium ion and vasodilation of nearby arterioles.

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99
Q

Rate of CSF formation is constant, this makes what really important?

A

This makes drainage or reabsorption by arachnoid villi important!

100
Q

blockage of CSF drainage or reabsorption by the arachnoid villi can be caused by?

A

tumor
hemorrhage
infection

101
Q

what are the three signs of cushing’s triad?

A
  1. Irregular respiration
  2. Bradycardia
  3. hypertension
102
Q

VAE is most often associated with what procedure?

A

posterior fossa procedures in the sitting position.

103
Q

Intraoperative goals if a patient is suspected to have or does have a venous air embolism?

A
  1. inform the surgeon immediately.
  2. discontinue nitrous, increase 02 flows.
  3. modify the anesthetic.
  4. Have the surgeon fluid the surgical field.
  5. provide jugular vein compression
  6. aspirate the right atrial catheter.
  7. provide cardiovascular support.
  8. change the patients position.
104
Q

most sensitive / noninvasive for VAE?

A

TEE

105
Q

*Onset of insult when monitoring with evoked potentials would look like what?

A

decrease in amplitude and increase in latency

106
Q

When an evoked potential changes what must you do?

A

you must assess the physiologic, anesthetic, and surgical environment to determine what has contributed to the change.

107
Q

What does diffuse ischemia look like when monitoring evoked potentials?
What does mechanical injury or localized ischemia look like?

A

slow loss of response amplitude with an increase in latency = diffuse ischemia

fast losses of amplitude with minimal latency changes = mechanical injury or localized edema.

108
Q

Medication commonly used for evoked potentials is opioids, why?

A

cause only mild depression of all responses

109
Q

volatile anesthetics and N20 produces what kind of evoked potential changes?

A

decrease in amplitude and increase in latency

110
Q

most commonly monitored evoked potential is?

A

SSEP

111
Q

What evoked potential is used during CEA?

A

Cortical SSEP

112
Q

What medication is acceptable to use with SSEP but not ok to use with MEP?

A

NMB are acceptable with SSEP

113
Q

A change in SSEP corticol amplitude is most sensitive indication of what?

A

ischemia

114
Q

SSEP can be used to monitor ischemia from what all factors?

A 
VASOSPASM
retractor pressure
hypotension
clipping
hyperventilation
115
Q

If SSEP is used during spinal cord surgery what can it identify?

A

mechanical or ischemic insult when they result in alteration or loss of transition through surgical field.

116
Q

What evoked potential is used extensively for monitoring during surgery involving posterior fossa?

A

ABR (auditory brainstem responses)

117
Q

When are visual evoked potentials used?

A

during craniofacial procedures, pituitary surgery, and surgery in the retrochiasmatic visual tracts and occiptal cortex.
(considered less useful in surgery)

118
Q

What evoked potential is very common in spinal surgery?

A

MEPs bc it has a very good correlation with post-op outcome.

119
Q

Preferred form of anesthetic delivery when using MEP?

A

TIVA is preferred

(propofol with or without ketamine in combination with opioids) discuss with surgeon.

120
Q

Name the CN 1-12

A 
1 olfactory
2 optic
3 oculomotor
4 trochlear
5 trigeminal
6 abducens
7 facial
8 auditory
9 glossopharyngeal
10 vagus
11 spinal accessory
12 hypoglossal
121
Q

Most common CN monitored during surgery is?

A

Facial nerve (CN 7)

122
Q

stimulation of what two CN will cause CV changes?

A

CN IX and X

123
Q

stimulation can cause potentially harmful head movement (sternocleidomastoid and trapezius activation)

A

CN XI

124
Q

What CN monitoring is becoming common in skull base and anterior neck procedures?

A

X vagus nerve

125
Q

Best choice muscle relaxant (during induction) for head injury with HTN and disturbed autoregulation?

A

Nondepolarizing neuromuscular relaxants do not appear to have clinically significant direct effects on CBF or CMRO2, provided MAP is not altered after administration

Rocuronium 1 mg/kg

126
Q

How do IV anesthetics change CMR and CBF?

A

IV anesthetics decrease cerebral metabolic rate (CMR) and CBF in parallel fashion

127
Q

How do inhalational anesthetics change CMR and CBF?

A

most inhalationals decrease CMR with an increase in CBF (cerebral vasodilation)

128
Q

How do anesthetic agents change the affect of ICP?

A

by changing the rate of production and reabsorption of CSF/

129
Q

Hyperventilation and head trauma, what is correct and incorrect?

A

Hyperventilation can rapidly control intracranial HTN, but prolonged and extreme hypocapnia (low CO2) from hyperventilation can result in a marked decrease in CBF in pts with head trauma (another reason it is C/I in CVA).

Only short duration of mild to moderate hyperventilation (hypocapnia) should be initiated (other pharmacologic/surgical intervention should be performed to control critical intracranial HTN)

130
Q

“BEST” inhaled anesthetic for NEURO patients would be?

A

Isoflorane

131
Q

cerebral vasodilators (capable of increasing ICP) usually depress metabolism EXCEPT for

A

N20

132
Q

Why does N20 have restricted use in neurosurgical procedures?

A

N/V incidence among other properties

133
Q

When N20 is added to volatile anesthetics it increases both what and what?

A

CBF and CMR

134
Q

What gas has no direct vasodilating effect as well as the most dramatic increase in CBF and ICP when administered alone?

A

N20

135
Q

Other name for Isoflurane?

A

Forane

136
Q

What has Isoflurane been reported to do to whole brain metabolism?

A

reduce whole brain metabolism by half.

potent cerebral metabolic depressive effects.

137
Q

Which gas has the only property to increase ICP mildly but can be prevented with hypocapnia?

A

Isoflurane

138
Q

Which gas has the disadvantage of compound A renal toxicity?

A

Sevoflurane

139
Q

What is the other name for Sevo?

A

Ultane

140
Q

What surgical situation can make sevo undesirable to use?

A

prolonged anesthesia for neurosurgery with preexisting renal disease.

141
Q

Which two gases may have neuro-protective effects similary to Iso? One is proven clinically and one is not…

A

proven clinically = Des

not proven clinically = Sevo

142
Q

Why is ketamine a unique IV anesthetic?

A

increases both CBF and CMR while all other IV anesthetics decrease both. (also increases ICP)

(synthetic opioids are a possible exception, may slightly increase ICP)

143
Q

what IV anesthetic has the effect to keep ICP the same or slightly increase?

A

synthetic opioids

144
Q

True or False

IV anesthetics decrease CBF and CMR due to vasoconstriction?

A

False, - Decrease in CBF by most is a result of reduced cerebral metabolism secondary to cerebral functional depression… not due to vasoconstriction

145
Q

Does etomidate have CV side effects, does it change CMRO2, and what are it’s adverse effects?

A

does not have CV side effects.

decreases CMRO2 like barbs

Adverse effects: adrenocortical suppression & frequent occurrence of involuntary muscle activity and seizure activity – use with great caution with pt having history of seizures

146
Q

Should propofol be used in children?

A

Prolonged use may cause systemic acidosis and progressive cardiac failure and even death in children…use of prolonged infusion in children is UNJUSTIFIED

147
Q

Propofol has dose related decreases in what and what?

It also decreases what else?

A

dose related decreases in CBF and CMR02.

Also decreases ICP

148
Q

What all does ketamine increase?

A

increases CBF, CMRO2, and ICP.

149
Q

the markedly increase in ICP by ketamine can be blocked or attenuated by what?

A

induced hypocapnia, thiopental, or benzos

150
Q

What does Versed do to ICP?

A

decrease or no change to ICP

151
Q

Which is better at maintaining hemodynamic stability, versed or thipental?

A

Versed

152
Q

Flumazenil and pts with impaired intracranial compliance?

A

Flumazenil (antagonist) also antagonizes effects of benzo of CBF, CMRO2, and ICP – use cautiously when reversing sedation in pts with impaired intracranial compliance

153
Q

What opioid is used in neurosurgery with satisfactory results more so than any other?

A

Remifentanil which is fast on and fast off.

alfentanil can also be used over fentanyl and sufentanil

154
Q

Succinylcholine and use with neuro patients?

A

elevates ICP, may be prevented or decreased with pretreatment with NDMR.

Induced hyperkalemia is another concern with neuro patients and Sch. use

155
Q

When would it be o.k. to use Sch in a neuro case?

A

emergency situation (full stomach/RSI/ difficult airway) with NDMB for defasciculating dose.

156
Q

Histamine release by some NMB is an issue with neuroanesthesia patients, why?

A

Histamine can reduce CPP b/c of the increase in ICP caused by cerebral vasodilation and the decrease in MAP.

histamine = increased ICP and decreased CPP, MAP.

157
Q

Atracurium and use with neuro-anesthesia patients?

A

clinical dose appears to have no significant effect on CBF, CMRO2, or ICP. However, high doses have potential release of histamine (so give slowly).

158
Q

What is laudanosine?

A

Metabolite of atracurium (laudanosine) has been reported to cross BBB and cause seizures

159
Q

Does cisatracurium produce or release laudanosine?

A

Produces and releases LESS laudanosine and histamine than atracurium

160
Q

Vecuronium and neuro-anesthesia?

A

does not induce histamine release, nor does it change B/P or HR (often preferable)

161
Q

Rocuronium and neuro-anesthesia?

A

rapid onset with lack of adverse activity such as histamine release, may be preferable to Sch. during RSI

162
Q

what dose of lidocaine to prevents circulatory changes and an elevation of ICP during tracheal intubation, endotracheal suctioning, or after application of pin-type skull clamp or skin incision in patient undergoing craniotomy

A

1.5mg/kg

163
Q

name an agonist that is a potent cerebral vasoconstrictor?

A

alpha agdrenergic agonist

164
Q

dexmedetomidine (prexedex) in small doses does what to CBF, MABP, and ICP?

A

DECREASES CBF, MABP, and ICP

165
Q

because of precedex having a quick onset and offset without resp. depression it may be advantageous for what procedure?

A

awake crani

166
Q

autoregulation is impaired with what types of anesthetics and is NOT impaired with what anesthetics?

A

autoregulation is impaired with volatile anesthetics, especially at high concentrations, also by/with level of paCO2.

autoregulation is preserved by IV anesthetics even if used with hypocapnia.

167
Q

pts with intracranial space occupying lesion will usually have what impaired?

A

autoregulation, so much so that sudden changes in blood pressure can produce ischemia or brain edema.

168
Q

what are barbiturates known to do in a patient with focal ischemia (stoke)?

A

neuro-protective properties

169
Q

Barbiturates are a - Favorable drugs provided that CV stability is maintained. However, prolonged use results in accumulated effects (slow metabolism)…other IV agents may be more appropriate, what drug would this be?

A

propofol

170
Q

Most appropriate fluid for maintenance in neuro patient under general anesthesia?

A

Normal Saline

171
Q

should dextrose solutions be infused for patients at risk for an ischemic event?

A

NO! unless for the treatment or prevention of hypoglycemia.

172
Q

As a general rule what to types of IV fluids should be avoided in the neuro patient?

A

hypo-osmolar and dextrose containing solutions.

173
Q

Fluid administered during craniotomy can be what types?

A

iso-osmolar crystalloid / usually LR or NS

174
Q

True or False:

Ideally, IV fluid be administered at rate to increase CO but avoid excessive fluid resuscitation

A

False,

Ideally, IV fluid be administered at rate to MAINTAIN CO but avoid excessive fluid resuscitation

175
Q

What type of drug is Mannitol?

A

osmotic diuretic - most commonly administered hyperosmolar solution.

176
Q

infusions of Mannitol may initially cause what? but then the end result should be what?

A

During infusion it may increase ICP transiently (vasodilation of cerebral vessels in response to sudden increase to increased osmolality) and then it may (should) decrease ICP by movement of water from brain interstitial and intracellular spaces into vasculature - end result

177
Q

Rapid IV dose of mannitol would be?

A

0.25-1 g/kg

178
Q

hetastarch and use in neurosurgery?

A

limited use in neurosurgery due to sporadic cases of cerebral hemorrhages being reported

179
Q

what is the “do not exceed” dose for dextrans?

A

Do not exceed 20 ml/kg if 24 hours

180
Q

what two volume replacements are not recommended due to coagulopathy in a patient with head injury?

A

hetastarch and dextran

181
Q

OVERALL what solution is the first choice volume resuscitation of trauma pts with head injuries?

A

isotonic crystalloid solution

fresh whole blood would be nice, but most blood banks do not have this available

182
Q

trauma patient with head injury, what is the ideal resuscitaion with hypovolemia and ongoing blood loss?

A

Fresh whole blood!

but few blood banks have this available.

183
Q

NS is good choice for replacement bc it is inexpensive and it can be give with PRBC, but if large volumes of NS are given for resuscitation what could occur?

A

possible to develop hyperchloremic acidosis.

184
Q

how much potassium does LR contain?

A

4 mEq of potassium

185
Q

No single IV solution is best suited for pt at risk for intracrainial HTN but the use of what solution is widely accepted?

A

iso-osmolar crystalloids

186
Q

Tell me why the BBB has such low permeability?

A

due to “tight junctions” that join the endothelial cells of the brain’s tissue capillaries.

187
Q

Intracranial tumors, the majority of adult 1 degree tumors are — and the majority of childhood 1 degree tumors are —?

A

adult = SUPRA-tentorial

child = INFRA-tentorial

188
Q

Most prudent approach to CEA maintenance is?

A

NORMOcapnia

189
Q

What remains the “gold standard” of choice for stroke prevention?

A

CEA

190
Q

To increase CPP during carotid cross clamping what will you have to do?

A

induce HTN

191
Q

If a patient has good collateral flow then what would you maintain their blood pressure at?

A

normal pre-op range may be acceptable or increase to 20% above normal.

192
Q

Pts. with poor collateral flow may need an increase of blood pressure ? how much above baseline?

A

20-30%, discuss with surgeon.

193
Q

how much does CBF change for ever 1 mm Hg change in PaCO2?

A

CBF 1-2 ml/ 100g / min

194
Q

carotid arteries provide what % of cerebral blood flow? vertebral arteries are what %?

A

carotid arteries provide 80% and vertebral arteries provide 20%

195
Q

CEA, open artery exposure causes firing down the myelinated A-type and C-type fibers of the —- nerve to the nucleus tractus solitaris?

A

glossoharyngeal

196
Q

Open CEA creates a carotid chemo-response that overall causes onset of what?

A

Overall, causes onset of tachycardia and severe hypertension and thus increases in afterload and myocardial oxygen demand

197
Q

Pts. to have Carotid Angioplasty stents are medicated with what two meds 3-5 days prior to procedure?

A

ASA and clopidogrel

198
Q

If a carotid stent is to be placed stystemic heparin is given IV and then what test is performed?

A

ACT which should be confirmed at about 2x baseline value.

199
Q

what typically occurs after carotid cross-clamping?

A

HTN- be prepared to treat.

200
Q

When is the heparin administered for CEA?

A

Before carotid cross-clamping the heparin is administered.

201
Q

How long after Heparin administration do you notify the surgeon?

A

3 min.

202
Q

CEA you want a deep emergence or quick emergence?

A

quick emergence, important to assess neurological function quickly

203
Q

What would be considered a desired stump pressure?

What stump pressure would correlate with cross-clamp intolerance?

A

desired = greater than 50/60

stump pressure less than 25 mm Hg correlates with cross clamp intolerance. (inadequate CPP)

204
Q

What is the gold standard for imaging evaluation with AVMs?

A

DSA

205
Q

A patient presents with an AVM, is this an emergent surgery?

A

No, unless there is a rupture. They are usually scheduled and delayed.

206
Q

Frontal lobe controls?

A

personality

207
Q

Parietal lobe controls?

A

movement of the arms and legs

208
Q

Temporal lobe controls?

A

speech, memory, and understanding

209
Q

Occipital lobe controls?

A

vision

210
Q

Cerebellum controls?

A

walking and coordination

211
Q

Ventricles control?

A

secretion and cerebrospinal fluid

212
Q

The brainstem controls?

A

the pathway for all basic functions of the body, (HR, respiration)

213
Q

Best anesthetic plan for large tumor resection under SSEP and MEP monitoring?

A

Propofol is most commonly used when SSEP and MEPs are being monitored

(remember SSEP can use NMB but not MEP)

214
Q

Laplace gas law states?

A

states that the tension within the wall of a sphere filled to a particular pressure depends on the thickness of the sphere. Consequently, even at a constant pressure, the tension within a filled sphere can be decreased simply by increasing the thickness of the sphere’s wall.

215
Q

Boyles law

A

a law stating that the pressure of a given mass of an ideal gas is inversely proportional to its volume at a constant temperature.

216
Q

What should be avoided in patients who have ischemic cerebrovascular disease?

A

prolonged hyperventilation (discuss with surgeon)

217
Q

mild decreases in temp. can do what for a neuro patient?

A

provide neuroprotective effects.

218
Q

What is triple H therapy typically used for?

A

vasospasm following aneurysmal subarachnoid hemorrhage

219
Q

What is Triple H therapy simply?

A

Hypervolemia, hypertensive, and hemodilution therapy “triple H therapy”

220
Q

Hypervolemia in triple H therapy means?

A

Increase fluid to CVP around 10 mm Hg or PAWP 12-20 mm Hg, may use colloids (albumin) as well as crystalloids, avoid hetastarch and dextran solutions

221
Q

HTN in triple H therapy means?

A

use vasopressors (dopamine, dobutamine, phenylephrine), titrate until signs of vasospasm reversal or to maximum of 160-200 mm Hg systolic in pt whose aneurysm has been clipped, if not clipped, increase systolic only to 120-150 mm Hg (HTN must be maintained until vasospasm has resolved)

222
Q

Hemodilution in triple H therapy means?

A

based on correlation of hematocrit and whole blood viscosity, as Hct and viscosity diminish, CVR decreases and CBF increases; 33% provides optimal balance b/w viscosity and O2-carrying capacity (some surgeons allow 27-30)

223
Q

Typically during deliberate hypertension in triple H therapy the systemic blood pressure is raised above baseline by what percentage?
(this would be in absence of some direct outcome measure such as resolution of ischemic symptoms or imaging evidence of improved perfusion)

A

30-40% above baseline

224
Q

What is the first line agent for deliberate hypertension?

A

Phenylephrine

225
Q

Surgery time and TPA administration?

A

TPA can’t be given within 2 weeks of surgery or trauma patient

226
Q

PCI should be perfomed in what time frame?

A

90 min.

227
Q

What is Trigeminocardiac reflex and what is the treatment?

A

Pts undergoing surgery may experience bradycardia caused by activation of the trigeminocardiac reflex.

Treatment is anticholinergics!

228
Q

Right sided cath. is typically performed for what reason?

A

diagnostic

229
Q

Left sided cath. is typically performed for what reason?

A

performed from brachial cut down or more commonly through femoral artery * BOARDS*

230
Q

what can you give to a patient who has contrast agent reactions? and when would you give them these meds?

A

treated with steroids, antihistamines and H2 blockers prior to the procedure (treat the night before and morning of)

231
Q

severe contrast induced reactions would be?

A

Cardic shock
Resp. failure
Cardiac arrest

232
Q

What are the irreversible anticoagulants?

A

ASA
clopidogril
(direct thrombin inhibitors are SLOWLY reversible)

233
Q

angioplasty with stenting almost inevitably will cause bradycardia… what will be done in order to prepare for this?

(inflation of the balloon can cause bradycardia)

A

could include placement of transcutaneous pacing leads (stimulation to carotid body stimulation).

atropine or glyco may also be used to mitigate the bradycardia

234
Q

What is NOT an indication for ablation?

A

If you are a street drug user (drug abusing life style)

know that not liking drug side/effects is a reason for ablation

235
Q

What is the advantage of using NEWER radiologic contrast media over old contrast media?

A

Newer = lower osmolor load and less neurotoxic

the lower osmolor load preserves intravascular volume in the event of an allergic crisis.

236
Q

Predicting factors for a protamine allergy?

A

NPH insulin allergy
prior vasectomy
(fish sperm allergy lol)

237
Q

40% of people’s SA node is not perfused by the R coronary artery but by which artery?

A

Left Circumflex artery

238
Q 
Posterior fossa surgery, of the meds below which would you avoid?
Benzos
antihypertensives
corticosteroids
fentanyl
A

fentanyl

239
Q

acute hyperventilation - what is going on with your potassium?

A

transient decrease in potassium (goes into cell)

240
Q

neuro patient should not be sedated without what in place first?

A

secure airway

241
Q

Trauma patients, what do you need to have cleared before you intubate?

A

C SPINE CLEARANCE

242
Q

Is there any difference in older and newer radiologic contrast media for causing anaphylactoid reactions?

A

NO

newer ones have lower osmolor loads and less neurtoxic

243
Q

what anticoagulant is primarily hepatic metabolism?

A

Argatroban

244
Q

what is the half life time for Lepirudin, bivalirudin, and synthetic derivatives?

A

40-120 minutes

245
Q

what is a negative about the anticoagulant Abciximab (Reopro) ?

A

increase likelihood of major bleeding due to long duration and potent effect.

246
Q

DTI and antiplatelet agents, do they have antidotes?

A

No

247
Q

When you are making a patient hypotensive on purpose what meds do we typically use?

A

nicardipine or sodium nitroprusside

Fall 20' Advanced Pr. II (3 decks)

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