Neurological Diseases in Anesthesia (Part 1) Flashcards
__________________ is modulated by Cerebral Metabolic Rate (CMR), Cerebral Perfusion Pressure (CPP), PaCO2, PaO2, drugs and intracranial pathologies.
Cerebral Blood Flow
CBF is ____ml/____g brain tissue per minute
- 50 ml/100g
Cerebral Blood Flow (CBF) is _____ ml/min
- 750ml/min
What percentage % of CO goes to Cerebral Blood Flow (CBF)?
- 15%
Neural tissue (brain + spinal cord), blood, and CSF are all components of the _____________________ .
Intracranial and spine vault
The Intracranial & Spinal vault is enclosed by ………..
- dura mater
- bone
Under normal conditions, brain tissue, intracranial CSF and intracranial blood have a combined volume of ________ .
- 1200-1500 ml
What is a normal ICP
- 5-15 mmHg
____________________ is any increase in one component of intracranial volume must be offset by decrease in another component to prevent an elevated ICP.
Monroe - Kellie Hypthesis
Hemostatic Mechanisms can increase MAP to support CPP despite increase in ICP. When these compensations fail, it results in?
Cerebral Ischemia
What is shown in this graph?
Monroe- Kellie Hypothesis
The intracranial vault is considered ________________.
- compartmentalized
________ barriers seperate the brain contents
Meningeal barriers
Name (2) Meningeal Barriers
- Falx cerebri
- tentorium cerebelli
Name the dura that seperates the 2 cerebral hemispheres
- falx cerebri
Name the dura that lies rostal to the cerebellum and marks the border btw supratentorial and infratentorial cerebelli
- tentorium cerebelli
Increases in contents of one region of the brain causes regional _____ in ICP , and in extreme instance, the contents can herniate into a ________ __________.
- increases
- different compartments
Herniation syndromes are categorized based on
- region of brain affected.
Name the Herniation:
* Herniates Hemispheric contents under the falx cerebri
* compressing branches of the anterior cerebral artery
* creates a midline shift
Subfalcine Herniation
Name the herniation:
* Herniation of supratentorial contents past the tentorium cerebelli
* brainstem compression in a rostal to caudal direction
Trantentorial Herniation
_____________ Herniation can cause AMS, defects in gaze and occular reflexes, hemodynamic and respiratory compromise and death.
Transtentorial
Name the Herniation:
* subtype of transtentirial herniation
* uncus hernates over the tenrorium cerebelli
* Results in ipsilateral oculomotor nerve dysfunction
Uncal Herniation
_____________ Herniation symptoms are pupillary dilation, ptosis, lateral deviation of affected eye, brainstem compression and death.
Uncal
Herniation of the ________________ can occur d/t elevated infratentorial pressure, causing cerenellar structure to herniate through the foramen magnum.
cerebellar tonsils
Hernaition of the ____________________can cause medullary dysfunction, cardiorespiratory instability and death.
cerebellar tonsils
Subfalcine causes a _________ shift.
*midline shift
Transtentorial Brain Hernation causes a ____________ down
- subrtentoial down
Cerebellar Herniation shifts contents through _________ ___________.
- formen magnum
Traumatic herniation can cause herniation out of ____________ cavity
- cranial
Tumors, Hematomas, blood in CSF and infections can all cause an ________ ICP
Increased
Tumors lead to an _____________ ICP with their size, _______ surrounding brain tissue and by __________ CSF flow.
- Increased
- edema
- obstructing
How can blood in CSF cause an increase ICP
- ex: Subarachnoid hemorrhage
- lead to obstruction of CSF reabsorption
- granulations
Name (2) Infections that can cause an increased ICP
- meningitis
- encephalitis
Elevation of head, hyperventilation, CSF drainage, hyperosmotic drugs, diuretics, corticosteroids, cerebral vascostricting anesthetics (propofol) and surgical decompression can call cause a ______________ ICP.
Decreased
Elevation of the Head decreases ICP by _______ jugular venous outflow.
- encouraging
hyperventilation causes a decrease in ICP by __________ PaCO2.
- lowering PaCO2
Name (1) way to drain CSF to decrease ICP
- External ventricular drain (EVD)
How can hyperosmotic drugs cause a decrease in ICP?
- increase osmolarity
- draws fluid across BBB
How can corticosteroids cause a decrease in ICP?
- decrease swelling
- enhances integrity of the BBB
These seven components are part of a _____________ Assessment:
* basic pathology for neurological disorder
* pt’s history, symptoms and baseline deficits
* imaging and available neurological results
* pts current drug and treatments
* evaluate risks/benefits of various anesthetic options
* pre-op optimize patients condition prior to anesthesia
* clear pre-op documentation and rational for anesthesia pains
Neurologic
Name the cause of Multiple Sclerosis
- No know cause
___________ ___________ is a progressive, autoimmune demyelination of central nerve fibers.
Multiple Sclerosis (MS)
Onset of MS
- 20 -40 years
Name (5) Risk Factors for Multiple Sclerosis
- female
- 1st degree relative
- Epstein-Barr Virus (EBV)
- other Autoimmune disorders
- smoking
Multiple Sclerosis is characterized by periods of _______ and _________.
exacerbation and remissions
Name (3) Triggers for Multiple Sclerosis (MS)
- stress
- elevated temps
- postpartum periods
Symptoms of ______ __________:
* motor weakness
* sensory disorders
* visual impairments
* autonomic instabolity
* symptoms vary d/t site of demyelination
Multiple Sclerosis
There is no ________ for Multiple Sclerosis, but it can be treated with corticosteroids, ________________, and targeted antibodies.
- No Cure
- immune modulators
MS Pre-Op Considerations
- existing deficits
- PFT
- CBC, BMP, LFT
- Pre-Op Steroids
Why is temperature management important for MS?
- increase in body temp can exacerbate MS symptoms
Name (3) Anesthesia options for MS
- GA
- RA
- PNB
You want to avoid ________ in MS patients because of induced hyperkalemia d/t ____ N-ach receptors
- Succinylcholine
- upregulation N-ach receptors
____________________ is an autoimmune disorder with antibodies generated against N-ACH Receptors at skeletal muscle endplates.
Myasthenia Gravis
Myasthenia Gravis affects ________ muscles and is ________ with exercise.
- Skeletal Muscles
- Exacerbated with exercise
Myathenis Gravis can cause ________ and ________ when it involves the Ocular Nerve
- diplosia
- ptosis
Laryngeal/pharyngeal weakness, Repiratory insufficency and aspiration can occur with ________ involvement of Myasthenia Gravis?
Bulbar
Thymic-hyperplasia is common in ____% of MG
10%
Myasthenia Gravis Symptoms are exacerbated by
- pain
- insomnia
- infection
- surgery
Myasthenia Gravis can be treated with Ach-E ________ (pyridostigmine), immunosuppressive drugs, steroids, ______________ and IVIG.
- Ach-E inhibitors (pyridostigmine)
- plasmapheresis
Name (2) Types of Medications you need to use with caution in patient’s w/ MG
- Paralytics: prolonged respiratory compromise
- Opioids: Respiratory compromise
What medication that you give an MG patient that will prolong Succinycholine and Ester LA’s?
- Ach-E inhibitors
What do you need to counsel MG patients on before they have surgery?
- increased risk of needing post-op Respiratory support/ventilation
____________________ is a disorder that causes developement of antibodies against VG calcium channels.
Eaton-Lambert Syndrome
________ ________ can cause progressive limb-girdle weakness, dysautonomia, and oculobulbar palsy.
Eaton- Lambert
> 60% of Eaton-Lambert cases area associated with
- small cell lung carcinoma
What Neurologic Disease is treated with:
* Selective K Channel blocker (3-4 diaminopyridine)
* Ach-E inhibitors
* immunologics (Azathiprine)
* steroids
* plasmapheresis
* IVIG
Eaton-Lambert
Name the Lab that you need to check for any patient who is taking the immunologic Azathioprine
LFTs
Name the medications that Lambert-Eaton Syndrome patient’s are very sensitive
- Non-depolarizing NMB
- Depolarizing NMB
more sensitive to ND-NMB than MG pts
Extreme caution needs to be use with what (2) classifications of medications with Lambert-Eaton patients?
- Parlytics
- opioids
What do you need to councel your Eaton Lambert Patients on before surgery?
- Need of post-op respiratory support until fully recovered from anesthesia
Name the prefered anesthesia for Lambert Eaton patients
- Regional > General
Muscular Dystrophy is a hereditary disorder of muscle fiber degeneration caused by the ________ of dystrophin-glycoprotein complex.
- breakdown
_________________ can lead to myonecrosis, fibrosis and skeletal muscle membrane permeability.
Muscular Dystrophy
How many types of Muscular Dystrophy exist?
- 6 types
Name the most common and severe form of Muscular Dystrophy
- Duchenne MD
Summarization of Duchenne MD:
* boys
* onset ____ years
* wheelchair bound by ____ years
* dead by ____ d/t cardiopulmonary complications
- onset 2-5 years
- wheelchair bound by 8-10
- dead by 20-25 d/t cardiopulmonary complications
Symptoms of _________________ include:
* progressive muscle weakness w/out motor/sensory abnormalities
* kyphoscoliosis
* long bone fragility
* respiratory weakness
* frequent pneumonia
* EKG changes
Muscular Dystrophy
Reason for an increased serum creatine kinase in MD patients.
- Muscle Wasting
________ syndrome can occur in MD patient when given succs and volatile anesthetics, that mimics Malignant Hyperthermia.
- Hypermetabolic Syndrome
Name the (4) conditions that Hypermetabolic syndrome can lead to
- rhabdomyolysis
- hyperkalemia
- Vfib
- cardiac arrest
How is Hypermetabolic Syndrome treated?
- Dantrolene
Name the preferred anesthesia for patients with Muscular Dystrophy and Duchenne
- Regional Anesthesia over General Anesthesia
If General Anesthesia has to be given to a patient with Muscular Dystrophy, what is your plan?
- TIVA and low dose rocuronium
Name the (4) Types of Myotonic Dystrophies
- Myotonia
- Mytonic Dystrophy
- Myotonia Congenita
- Central Core disease
_____________ is a prolonged contraction after muscle stimulation that is seen in several muscle disorders.
Myotonia
________________ ____________ is the most common type of myotonia and onsets in 20-30 years.
Myotonic Dystrophy
Myotonic Dystrophy Symptoms
- muscle wasting in face, masseter, hand and pre-tibial muscles
Name (3) specific muscle that Myotonic Dystrophy can affect
- Pharyngeal
- Laryngeal
- diaphragmatic muscles
____ % of Myotonic Dystrophy patients will have Mitral Valve Prolapse
20%
______________________ is a milder form that involves skeletal muscles only. It spares the smooth and cardiac muscles.
Mytonia Congenital.
________________ is very Rare and is characterizes by core muscles that lack mitrochondrial enzymes.
Central Cores Disease
Central Core Disease symptoms are _______ muscle weakness and ___________.
- Proximal muscle weakness
- scoliosis
Myotonias are triggered by ____________ and ___________ temperatures.
- stress
- cold temperatures
Treatment of Myotonic Dystrophyies
- No cure
- Quinine
- Procanamide
- Steroids
Anesthetic Considerations for Myotonic Dystrophies
- Cardiac and pulmonary abnormalities
- GI hypomotility -↑aspiration risk
- Keep pts warm
Myotonic Dystrophies are at a higher Risk for ________ abnormalities
- endocrine
- monitor thyroid and glucose levels
Why would you avoid Succinylcholine in Myotonic Dystrophies
- fasciculations trigger myotonia
Myotonic Dystrophy patients are at an increased risk of what post-op?
- Respiratory Weakness
Name (3) Major Dementia Syndromes
- Alzeheimers (70%)
- Vascular Dementia (25%)
- Parkinsons (5%)
Dementia patient’s might have issue giving consent for surgery. What should you look for in their charts?
- medical PoA
- Advance Directives
Name (3) medications a patient with Dementia might be on that can affect anesthetics
- AchE-I
- MAOI’s
- psych meds
Why would you consider a TIVA for Dementia patient’s?
- ↑risk for post-op delirium with general anesthesia
What are Dementia patient’s at a high risk for during intubation?
- Aspiration
What are we trying to avoid post-op by balancing anesthetics and opiods through Regional anesthesia or TIVA?
- Post-Op delirium
_________________ is a degeneration of dopaminergic fibers of basal ganglia.
Parkinsons Disease
_________ regulates extrapyramidal motor system, which is stimulated by ACH and inhibits excess stimulation.
Dopamine
The cause of Parkisons Disease is ______, but the biggest risk factor is _______ ____.
- Unknown Cause
- Advance age is the biggest risk factor
Skeletal Muscle tremors, rigidity and akinesia are the Triad of Symptoms associated with ___________________.
*Parkinsons Disease.
Motor neurons in Parkinson’s Disease are overstimulated and lack __________.
- lack Dopamine
Below are the classic symptoms of _____________.
* Rhythmic pill rolling
* facial rigidity
* slurred speech
* difficulty swallowing
* respiratory difficulty
* depression
* dementia
Parkisons
Treatment for Parkinson’s Disease includes ___________ (crosses BBB), anticholinergics, MAOIs and __________________.
- Levadopa (crosses BBB)
- Deep Brain stimulator
Parkinson’s Pre-anesthesia testing
- pulmonary compromise
- home meds
- labs w/ PFTs
- EKG and ECHO
Parkinson’s patient are at an increased risk of ___________ during intubation due to _________ and possible _______________
- aspiration
- dysphasia
- dementia
Name the Parkinson’s Medication that needs to be continued to avoid unstable extreme extrapyramidal effects such as chest wall rigidity
- PO Levadopa
Name (4) Medications to avoid in Parkinson’s patients.
- Reglan
- Phenothiazines
- Butyrophenones
- Demerol – if on MAOI
If your patient has a deep brain stimulator and cautery needs to be used, you should _________ the deep brain stimulator and use a ________ cautery.
- disable
- Bipolar cautery
