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933: Assessment & Specialty Techniques > Neurological Quiz > Flashcards

Neurological Quiz Flashcards

1
Q

What are the THREE MAJOR risk factors to identify those at risk of stroke?

A
  1. Hx of previous stroke/TIA
  2. Advanced age (none given)
  3. Renal disease
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2
Q

Give some of the ELEVEN predictors of perioperative stroke:

A
  1. atrial fib
  2. MI within the last 6 months
  3. heart failure
  4. prior cardiac intervention
  5. Acute OR chronic renal failure
  6. currently on dialysis
  7. COPD
  8. Smoker
  9. Hemiplegia
  10. DM
  11. Female
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3
Q

What type of surgery has the highest risk of stroke?

A

Cardiac surgery:

  • – 2 or 3 valves (9.7%)
  • – Mitral valve (8.8%)
  • – combined CABG and valve replacement (7.4%)
  • – aortic valve replacement (4.4%)
  • – CABG (3.8%)
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4
Q

What is the goal when monitoring cerebral saturation?

A

Do not let it drop by more than 20%

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5
Q

What is MoyaMoya syndrome?

A

BV leak and create “smoke” on scan

narrowing of distal internal carotid arteries and its proximal branches

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6
Q

MoyaMoya may be associated with which 2 other diseases?

A

sickle cell

neurofibromatosis

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7
Q

What are the two therapies included in MoyaMoya treatment?

A
  1. antiplatelet agents

2. revascularization

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8
Q

Preanesthetic evaluation in patient with a history of stroke:

A
  1. cause and timing of previous stroke
  2. symptoms
  3. residual effects

*get an ECHO / review any imaging of head & neck

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9
Q

When pre-evaluating a patient with a history of stroke, auscultate and palpate what?

A

carotid arteries; for bruits

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10
Q

Why should hemiparesis patients not be administered succ?

A

↑ in receptors; can cause an increase in K

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11
Q

What are the anesthetic considerations of a stroke?

A
  1. Is patient on antiplatelet therapy?
  2. Can therapy be stopped with or without bridging?
  3. high risk patients include:
    • Stroke/TIA within the last 3 months
      - genetic predisposition
      - CHA2DS2VASC Score >2
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12
Q

The presence of a carotid bruit is indicative of atherosclerosis?

A

NO; but it should prompt a more focused exam

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13
Q

In patients having cardiac surgery, what is a significant risk factor for stroke?

A

pre-existing cerebrovascular disease

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14
Q

Anesthetic considerations of a carotid bruit / carotid endarterectomy surgery?

A

Patient will NOT have “train tracks”; large hemodynamic variability expected

  • surgery requires significant head/neck manipulation
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15
Q

What is the gold standard for imaging diagnosis of a carotid bruit/atherosclerosis?

A

carotid arteriography

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16
Q

What is an acceptable first-line study for a carotid bruit/atherosclerosis?

A

carotid duplex imaging

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17
Q

When a patient has dementia; what is the MOST IMPORTANT consideration?

A

get a CLEAR baseline

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18
Q

Dementia is a neurocognitive disorder characterized by a decline in what 4 things?

A
  1. memory
  2. language
  3. problem-solving
  4. cognitive skills
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19
Q

What are the THREE most common causes of dementia?

A
  1. Alzheimer disease (60-80%)
  2. Vascular dementia (10%)
  3. Parkinson disease
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20
Q

Alzheimer diseases affects one in ___ over the age of 85

A

1 in 3

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21
Q

Alzheimer disease affects one in ___ under the age of 65

A

9

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22
Q

What are TWO cognitive exams that screen for dementia?

A
  1. Montreal Cognitive Assessment (MoCA)

2. Mini-Cog

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23
Q

What are anesthetic considerations of dementia?

A

dementia meds may interact

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24
Q

How will cholinesterase inhibitors affect anesthesia?

A

prolong effects of Succ & increase pulmonary complications

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25
Q

Gingko biloba can increase what?

A

bleeding risk

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26
Q

What are TWO medications that should be avoided when a patient has dementia?

A
  1. benzodiazepines

2. antihistamines

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27
Q

How is Parkinson disease defined?

A

Loss of dopamine-containing neurons from the pars compacta of the substantia nigra with intracytoplasmic inclusion

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28
Q

What is the “hallmark finding” of Parkinson disease?

A

Lewy bodies

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29
Q

What causes the classic s/s of Parkinson disease?

A

unopposed action of acetylcholine in extrapyramidal motor system

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30
Q

What are 4 s/s of Parkinson disease?

A

bradykinesia/slow movement
rigidity
tremor
postural instability

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31
Q

Parkinson patients have a high incidence of: (2)

A

dysphagia*

respiratory dysfunction*

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32
Q

What are 4 anesthetic considerations of Parkinson disease?

A
  • continue medications
  • reduced fasting vs aspiration risk?
  • Avoid meperidine and dopaminergic antagonists
  • NDMB have little impact
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33
Q

What kind of cautery is preferred in patients with deep brain stimulators?

A

bipolar cautery.

keep grounding pad as far as possible from stimulator

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34
Q

What medications should be avoided in patients with parkinson disease?

A

benzodiazepines
antihistamines
MEPERIDINE
DOPAMINERGIC ANTAGONISTS

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35
Q

What is Myasthenia Gravis?

A

antibodies attack post-synaptic acetylcholine receptors

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36
Q

What is usually the presenting symptom of myasthenia gravis?

A

proximal muscle weakness;

alleviated with rest, exacerbated with activity

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37
Q

What is treatment for myasthenia gravis?

A 
Pyridostigmine: first line therapy [Acetylcholinesterase inhibitor]
Glucocorticoids
Immunosuppressive agents
IVIG
Thymectomy
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38
Q

What is pyridostigmine?

A

acetylcholinesterase inhibitor

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39
Q

Will edrophonium help or hurt myasthenic crisis? Why or why not?

A

helps, will increase the amount of acetylcholine in the synaptic cleft

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40
Q

Will edrophonium help or hurt a cholinergic crisis? Why or why not?

A

NO! there is already too much acetylcholine triggering

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41
Q

Should elective surgery be done in patients with myasthenia gravis?

A

yes, it is safe if patient is stable and well controlled

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42
Q

What can be used to optimize myasthenia gravis patients when emergency surgery is necessary?

A

plasma exchange

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43
Q

What amount of NMBD should be given to patients with myasthenia gravis?

A

LESS! effect is INCREASED (antibodies act as NMB molecules)

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44
Q

Is the effect of succinylcholine increased or decreased in patients with myasthenia gravis?

A

effect of succinylcholine is reduced, but duration is prolonged [patient will have decreased acetylcholinesterase activity due to treatment medications]

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45
Q

What is the scoring system to predict post op ventilatory support in MG patients?

A

duration of MG >= 6 years = 12 points
Hx chronic resp dz = 10 points
Pyridostigmine dose >750mg/day = 8 points
vital capacity <2.9L = 4 points

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46
Q

What medications should be given to MG patients preoperatively?

A
  • glucocorticoids

- aspiration prophylaxis

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47
Q

What is multiple sclerosis?

A

autoimmune demyelinating disease of the brain & spinal cord

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48
Q

Two considerations for patients with multiple sclerosis

A
  1. keep them warm

2. maintain good pain management

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49
Q

Will multiple sclerosis have any altered regulation of their acetylcholine receptors?

A

Yes, UPregulation

Will have increased response to succinylcholine
Will have decreased response to NDMB

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50
Q

What is muscular dystrophy?

A

muscle wasting and weakness

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51
Q

MD is linked to which gene?

A

recessive mutation in the dystrophin gene on the X chromosome

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52
Q

What are the two most common forms of MD?

A

Duchenne and Becker

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53
Q

4 perioperative complications that can occur when a patient has muscular dystrophy

A
  1. rhabdomyolysis
  2. hyperkalemia
  3. Malignant hyperthermia
  4. cardiac arrest
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54
Q

Patients with muscular dystrophy will all eventually develop _____. Because of this, preoperatively MD patients should all have __ & ___.

A

cardiomyopathy

ECG & ECHO

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55
Q

What kind of lung disease occurs with MD?

A

restrictive lung disease d/t the inability to create adequate negative pressures

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56
Q

What is an important study to determine the severity of restrictive lung disease in the presence of MD?

A

pulmonary function studies.

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57
Q

What are the indications for NIPPV & cough assist training for a patient with MD?

A

FVC <50% & ineffective cough

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58
Q

What are the indications for NIPPV & cough assist training for a patient with MD?

A

FVC <50% & ineffective cough

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59
Q

What is Lambert-Eaton Syndrome?

A

autoantibodies attacking the pre-synaptic VG calcium channels (no vesicles to membrane) = ↓ release of acetylcholine by pre-synaptic neuron

60
Q

What 3 medications and 1 therapy is included in the treatment of Lambert-Eaton Syndrome?

A
  • 3,4-diaminopyridine
  • pyridostigmine
  • IVIG
  • plasmapheresis
61
Q

What is the presenting symptom of Lambert-Eaton syndrome & what is their pattern of weakness?

A

proximal weakness in the pelvic & truncal areas;

weakest in the morning, strength improves throughout the day.

62
Q

What are 5 anesthetic pre-op considerations/evaluations of patients with Lambert-Eaton syndrome?

A
  1. progressive proximal weakness
  2. altered gait
  3. stiff, aching muscles
  4. ASSESS for pharyngeal weakness
  5. Evaluate spirometry & pulmonary function tests; <2.9L may indicate need for postoperative ventilation
  • continue medications
  • patient’s will be SENSITIVE to NMB - avoid if possible
  • AVOID HYPERTHERMIA
63
Q

What is the incidence of aneurysms?

A

3.2%, 0.25% will rupture → 10% dead before hospital, 5% dead w/n 30 days

64
Q

What are 2 surgical methods of managing/treating an aneurysm?

A
  1. microvascular clipping

2. endovascular coiling

65
Q

What are some of the disorders associated with aneurysms?

A
  1. Marfan syndrome
  2. Ehler-Danlos Syndrome
  3. Pseudoxanthoma elasticum
  4. Coarch of the aorta
  5. bicuspid aortic valve
  6. Autosomal dominant polycystic kidney disease
  7. pheochromocytoma
66
Q

What is an AVM?

A

triangle of abnormal vessels, referred to as a nidus

67
Q

What is the typical presentation of an AVM?

A

hemorrhage, seizures, neurological deficits

68
Q

What are 3 treatment options of an AVM?

A

endovascular embolization
stereotactic radiosurgery
surgical removal

69
Q

What is the most common electrolyte abnormality in aneurysm and AVM? Why?

A

hyponatremia d/t cerebral salt wasting or SIADH

70
Q

Other than hyponatremia, what are other common electrolyte abnormalities in aneurysm and AVM?

A

hypokalemia
hypocalcemia
hypomagnesemia

71
Q

What can cause myocardial dysfunction when repairing/treating an aneurysm or AVM?

A

catecholamine release =
cardiac dysrhythmias
prolonged QT
T wave abnormalities

72
Q

What can cause myocardial dysfunction when repairing/treating an aneurysm or AVM?

A

catecholamine release =
cardiac dysrhythmias
prolonged QT
T wave abnormalities

73
Q

What is the leading cause of acute autoimmune neuromuscular paralysis?

A

Guillian barre

74
Q

What 4 infections are associated with development of Guillian Barre?

A

campylobacter jejuni
Epstein-Barr virus
mycoplasma pneumoniae
cytomegalovirus

75
Q

What are the first 4 signs of Guillian Barre?

A

pain
numbness
paresthesia
weakness in limbs, extending up

76
Q

Diagnosis of Guillian Barre requires what?

A

a lumbar puncture

77
Q

Diagnosis of Guillian Barre requires what?

A

a lumbar puncture

78
Q

What 3 things should be avoided if possible in patients with Guillian Barre?

A
  1. NMB
  2. endotracheal intubation
  3. mechanical ventilation
79
Q

If a patient has Guillian Barre can they receive regional anesthesia?

A

Yes, generally considered safe.

80
Q

Are local anesthetic requirements altered in patients with Guillian Barre?

A

usually they are decreased.

81
Q

What are 2 classifications of seizures?

A

focal [originate from one point]

general [arise from both hemispheres

82
Q

For the treatment of seizures, what are 3 treatment options other than antiepileptic monotherapy?

A
  1. adrenal corticotropic hormone
  2. corticosteroids
  3. ketogenic diet
83
Q

History of a patient with seizures should focus on: (6)

A 
type of sz
triggers
frequency
most recent seizure
current medication regimen and if they are compliant
prior anesthetic history
84
Q

What medication should be given in the OR for a seizure?

A

Propofol.

Ativan will linger (Benzos will enhance sedative effects)

85
Q

What medication should be given in the OR for a seizure?

A

Propofol.

Ativan will linger (Benzos will enhance sedative effects)

86
Q

What is the most common type of intracranial tumor?

A

Meningioma (36%)

87
Q

Gliomas account for what percentage of intracranial tumors?

A

24%

88
Q

What type of cell do gliomas arise from?

A

astrocytes d/t anaplasia

89
Q

Which type of glioma has the poorest prognosis, and what is the median survival?

A

multiforme; 14 months

90
Q

Pre-op testing for a patient with a neurological tumor will include what?

A

electrolytes (glucose)
complete blood counts
blood type and cross
ECG

91
Q

What is the theory discussing ICP?

A

Monroe-Kelley Doctrine

92
Q

At what ICP can cerebral ischemia occur?

A

50-60mmHg

93
Q

What is included in Cushing’s triad?

A

hypertension (severe)
bradycardia
irregular respirations

94
Q

Pre-op diagnostic testing for a patient with elevated ICP will include..?

A

Complete blood counts
electrolytes (hyponatremia r/t cerebral salt wasting)
osmolality
ECG (neurogenic myocardial ischemia)
Continue medications (steroids, anticonvulsants)

95
Q

Mild TBI = what GCS score?

A

13-15

96
Q

Moderate TBI = what GCS score?

A

9-12

97
Q

Severe TBI = what GCS score?

A

<8

98
Q

To minimize secondary injury r/t TBI, AVOID

A

hypotension (SBP <90mmHg)
hypoxia (PaO2<60mmHg)
hyperpyrexia

99
Q

To minimize secondary injury r/t TBI, AVOID

A

hypotension (SBP <90mmHg)
hypoxia (PaO2<60mmHg)
hyperpyrexia (↑ temp)

100, 100, 100
SpO2 100
SBP >100
HR <100

100
Q

What is goal ICP and CPP?

A

ICP <20mmHg

CPP 50-70mmHg

101
Q

Treatment of elevated ICP

A

HOB 30-45
head midline
hyperosmolar or hypertonic solution

102
Q

Mannitol dosing in TBI

A

1g/kg with repeating Q6H 0.25g/kg

103
Q

Goal serum osmolality & serum sodium in TBI

A

<360 and <160mg/dL

104
Q

Pre-op testing for TBI patient

A

metabolic profile
complete blood counts
PT, INR
Toxicology

105
Q

What are the two diagnosis criteria of autism?

A

social communication deficits

social interaction deficits with repetitive patterns of behavior

106
Q

What 5 components may autistic persons exhibit?

A
  1. intellectual disability (IQ<70)
  2. anxiety, panic, ODD
  3. self-injury
  4. attention deficit
  5. fine and gross motor problems
107
Q

Withdraw of autistic medications can result in (4):

A

dystonia, dyskinesia, delirium, psychosis

108
Q

What are the two descriptions used for pain?

A

Noxious / Protopathic

Non-noxious / Epicritic

109
Q

What is nociception?

A

the neural response to traumatic or noxious stimuli

110
Q

When do pain perceptions begin to disappear?

A

after 40 years old

111
Q

What is chronic pain associated with in the CNS pain pathway?

A

central sensitization (modulation)

112
Q

What is somatic pain?

A

acute pain that is either superficial or deep

113
Q

What is superficial pain?

A

skin, subQ, mucous membranes: well localized, sharp, prickling, throbbing, burning

114
Q

What is deep pain?

A

muscles, tendons, joints, bones (dull, aching, not well localized)

115
Q

What is visceral pain?

A

dull diffuse, usually midline

116
Q

What are four common forms/causes of chronic pain?

A

musculoskeletal & visceral
lesions to nerves
lesions to central nervous system
cancer

117
Q

Pain travels from the periphery to the cerebral cortex via:

A

three neuronal pathways (1st, 2nd, 3rd order neurons)

118
Q

Failure to resolve pain results in:

A

occult inflammation and changes to the afferent pain pathway

119
Q

Persistent stimulation of the pain pathways leads to:

A

changes to the afferent nervous system & allodynia

120
Q

What are two locations of pain perception in the brain/CNS?

A

Sensory discriminators in the dorsal horn to the thalamus & sensory cortex

Affective motivators from the dorsal to limbic system and prefrontal cortex

121
Q

What are four diseases that cause neurologic pain?

A

shingles
sciatica
cluster headaches
trigeminal neuralgia

122
Q

If a patient has inflammation of the meninges, they may complain about..

A

pain with neck flexion & extension

123
Q

What is Brudzinski’s sign?

A

pain with resistance to motion (head flexion/extension) - indicative of inflammation of the meninges

124
Q

What is Kernig’s sign?

A

pain with resistance to knee extension - indicative of inflammation of the meninges

— Hip is bent 90degrees. Pain with trying to straighten leg

125
Q

What is trigeminal Neuralgia?

A

tic doulourex

jabbing pain lasting seconds in the maxillary & mandibular distributions of the trigeminal nerve

126
Q

Scale of motor function

A 
0/5 no muscle twitch with attempted movement
1/5 muscle twitch with no movement
2/5 movement along horizontal plane
3/5 movement against gravity
4/5 movement against slight resistance
5/5 movement against full resistance
127
Q

What do reflexes occur through?

A

activation of the stretch receptor that communicates with lower motor neurons in the anterior horn

128
Q

What are the two main types of reflexes?

A
  1. Deep tendon

2. superficial

129
Q

Reflex grading scale

A 
0/4 no resposne
1/4 diminished response
2/4 normal
3/4 increased
4/4 clonus
130
Q

Upper motor neuron disease will lead to what kind of spascitity?

A

rigid
(HYPER-REFLEXIA)
corticospinal tract

131
Q

Lower motor neuron disease will lead to what kind of spasticity?

A

flaccid
(HYPOREFLEXIA)
myopathies & spinal cord lesions

132
Q

What are FOUR reflexes?

A

Biceps
Brachioradialis
Patellar
Achilles

133
Q

Bicep tendon reflex is testing which nerve?

A

C5-6

134
Q

Brachioradialis reflex is testing which nerve?

A

Nerve roots C5-6

- observe for flexion at the elbow and supination of the forearm

135
Q

Triceps tendon reflex is testing for which nerve?

A

Nerve roots C6-8

- prompt contraction of the triceps tendon with extension of the elbow

136
Q

Patellar reflex is testing which nerve?

A

Nerve roots L2-4

- quadriceps contraction

137
Q

Achilles reflex is testing which nerve?

A

S1-2

- plantar flexion of the ankle

138
Q

What is babinski’s sign?

A

dorsiflexion of the big toe with fanning of the toes

139
Q

What is babinski’s sign assessing?

A

Nerve roots L5-S2

140
Q

What is the function of the cerebellum?

A

coordination between multiple systems

141
Q

What are three ways to test the cerebellar function?

A

finger to nose
heal to shin
Romberg test

142
Q

Stimulation at the carotid bulb will result in what?

A

bradycardia

143
Q

What is the most distal portion of the optic nerve that has dura?

A

the optic sheath

144
Q

As ICP increases, what change occurs at the optic sheath?

A

Dilation in the middle (measurable)

145
Q

What vital sign should be avoided, specifically in LEMS patients

A

Hyperthermia- will make weakness worse

146
Q

Who is at highest risk of having a stroke? What 3 factors

A
  • Stroke/TIA within the last 3 months
  • genetic predisposition
  • CHA2DS2VASC Score >2

933: Assessment & Specialty Techniques (3 decks)

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