neurosurgery

Question 1

CSF:

1. what is production in ml/min?
2. what is production in ml/day?
3. is volume in child larger or smaller than in an adult?
4. what 3 meds have a transient decrease in CSF production? (A, F, C)

Answer 1

1. 0.35 ml/min
2. 500 ml/day
3. smaller
4. acetazolamide, furosemide, corticosteroids

Question 2

ICPs:

1. full term neonate range mmHg?
2. children < what mmHg?
3. increases in what are first sign of increased ICP? (HC)

Answer 2

1. 2-6 mmHg
2. < 15
3. head circumference

Question 3

CBF:

1. what is normal cerebral blood flow in ml/100g/min?
2. what % of CO goes to the brain?
3. there is a linear increase of CBF with arterial CO2 or O2?
4. PaO2 < what increases CBF exponentially?
5. PaO2 < what increases CBF 4 fold?

Answer 3

1. 100 ml/100g/min
2. 25%
3. CO2
4. < 50
5. < 15

Question 4

cerebral metabolic oxygen rate:

1. what is it in children? (ml/100g/min)
2. is CMRO2 higher or lower in children than adults?
3. in one word describe CBF’s relationship with CMRO2? (L)

Answer 4

1. 5 ml/100g/min
2. higher
3. linear

Question 5

increased ICP signs:

1. what are 4 classic signs? (P, PD, H, B)
2. what are 3 chronic ICP signs? (H, I, N)
3. what time of day are classic signs especially bad?

Answer 5

1. papilledema, pupil dilation, hypertension, bradycardia
2. HA, irritability, nausea
3. morning

Question 6

these are 4 things that increase risk of VP shunt complications:

1. younger or older age?
2. prematurity or full term?
3. increase or decrease number of previous revisions?
4. longer or shorter time to first revision?

Answer 6

1. younger age
2. prematurity
3. increase
4. shorter

Question 7

pts with increased ICPs are considered a full stomach and get RSI because they are at risk for what 2 things? (V, PA)

Answer 7

vomiting, pulmonary aspiration

Question 8

VP shunt anesthesia:

1. avoid what induction med?
2. premed in these pts can increase what 2 things?
3. to maintain CPP with induction, prevent an increase in what pressure and prevent what other thing?
4. what is the most stimulating part of the procedure?
5. can you give these peds succs?
6. what physical state do we want for this procedure? (A)

Answer 8

1. ketamine
2. CO2, ICP
3. increase ICP, hypotension
4. tunneling of the catheter
5. yes
6. akinesia

Question 9

what is the most common neuro disorder?

Answer 9

epilepsy

Question 10

antiseizure medications:

1. they cause an upregulation of what enzymes?
2. enhanced metabolism of what 2 types of meds?
3. valproic acid and carbamazepine cause abnormalities in what systems function?
4. keppra can cause extreme what behavior in peds? (A)

Answer 10

1, P450

2. MRs, opioids
3. hematologic
4. agitation

Question 11

MRI

1. are eeg leads safe in MRI?
2. prepare to give what dose range of lorazepam for post-procedure seizures?
3. do pts with a VP shunt need to have it be reprogrammed after an MRI?
4. consider what inhaled VA for pts with frequent seizures and recent epilepsy?

Answer 11

1. no
2. 0.5-1 mg/kg
3. yes
4. isoflurane

Question 12

vagal nerve stimulator:

1. left or right vagus nerve?
2. device automatically activated for how many seconds every how many minutes?
3. are bradycardia and other SEs common with this device?
4. may be necessary to deactivate it during surgery so it doesn’t interact with what surgery device and to prevent the repeated motion of what?

Answer 12

1. left
2. 30 seconds q 5 minutes
3. no
4. bovee, vocal cords

Question 13

seizure threshold:

1. what 2 things lower the seizure threshold? (H, M)
2. what 3 things raise the seizure threshold? (A, IA, B)
3. what 3 drugs don’t affect the seizure threshold? (O, N, MR)

Answer 13

1. hyperventilation, methohexital (0.25-0.5 mg/kg)
2. anticonvulsants, inhaled anesthetics, benzodiazepines
3. opioids, N2O, muscle relaxants

Question 14

hemispherectomy:

1. what is the #1 anesthesia concern with hemispherectomy?
2. what 3 things need to be discussed with the surgeon? (P, NM, PL)

Answer 14

1. massive blood loss

2. positioning, neuromonitoring, postop location

Question 15

brain tumors:

1. early increase in ICP d/t obstructed what?
2. what are 5 presenting symptoms? (EMV, I, L, CNP, A)

Answer 15

1. CSF flow

2. early morning vomiting, irritability, CN palsies, ataxia

Question 16

posterior fossa tumor resection:

1. what is the position for this procedure?
2. brainstem manipulation can cause acute changes in what and what other c/v thing?
3. posterior fossa syndrome develops what weird hour range after surgery?
4. what are the 6 signs of posterior fossa syndrome? (M, SD, D, DMM, CNP, EL)
5. does posterior fossa syndrome resolve on its own?

Answer 16

1. prone with head flexed
2. BP, arrhythmias
3. 24-107 hours
4. mutism, speech disturbances, dysphagia, decreased motor movement, CN palsies, emotional lability
5. yes

Question 17

anesthesia for posterior fossa tumor resection:

1. want to provide an anesthesia that ensures what 2 things? (I, NM)
2. prepare for what 3 things during maintenance of this procedure? (MBL, V, AHC)
3. want an immediate what on extubation?
4. what 2 meds can facilitate a smooth emergence? (HDN, P)
5. what 2 things do you want to control during induction?

Answer 17

1. immobility, neuromonitoring
2. massive blood loss, VAE, acute hemodynamic changes
3. neuro exam
4. high dose narcotics, precedex
5. BP, ICP

Question 18

craniopharyngiomas:

1. what are 3 common things seen in these pts? (GF, VI, EA)
2. look for signs of what? (H)
3. what might these pts need to maintain normal hemodynamics?
4. if not see preop, what is usually seen postop in these pts?

Answer 18

1. growth failure, visual impairment, endocrine abnormalities
2. hypothyroidism
3. corticosteroids
4. diabetes insipidus

Question 19

transphenoidal tumor resection:

1. treat what adenomas?
2. is a lot of blood loss seen with this procedure?
3. should you be prepared for a lot of blood loss?
4. is ICP a problem with this procedure?
5. why don’t you want to give these pts mannitol?
6. monitor UO because what is a possibility?
7. ensure what level is appropriate and give what if it isn’t?

Answer 19

1. pituitary
2. no
3. yes
4. no
5. pulls the tumor away from the surgeon
6. DI
7. cortisol, hydrocortisone

Question 20

neurofibromatosis:

1. is type 1 central or peripheral?
2. is type 2 central or peripheral?
3. type 1 is associated with other whats? (T)
4. type 2 is associated with what neurofibromatosis? (BAN)
5. gliomas of what pathway are seen in these pts?
6. what are 2 presenting symptoms of these gliomas? (VC, P)
7. what are 2 late findings of these gliomas? (II, HD)

Answer 20

1. peripheral
2. central
3. tumors
4. bilateral acoustic neurofibromatosis
5. optic
6. visual changed, proptosis
7. increased ICP, hypothalamic dysfunction

Question 21

cerebral hemisphere tumors:

1. what % of intracranial tumors?
2. more likely than other tumors to present with what 2 things? (S, FD)
3. what tumors can cause hydrocephalus by obstructing CSF flow and increasing CSF production? (CP)

Answer 21

1. 25%
2. seizure, focal deficits
3. choroid plexus

Question 22

AVMs:

1. large malformation manifest as what in early infancy?
2. smaller malformation can be see as what 2 things? (S, S)
3. AVMs of what 2 vessels manifest as congestive heart failure? (PCA, VOG)
4. what is the most common presentation of an AVM?
5. what is the mortality % associted with this presentation?

Answer 22

1. CHF
2. seizure, stroke
3. posterior cerebral artery, vein of galen
4. intracranial hemorrhage
5. 25%

Question 23

AVM treatment:

1. what are the 2 options for deep AVMs? (E, R)
2. what are the 2 options for superficial AVMs? (E, E)
3. can a pt have a combo of embolization and then resection?

Answer 23

1. embolization or radiation
2. excision vs emobilzation
3. yes

Question 24

aneurysms:

1. children with what 2 conditions have an increased incidence of them? (COTA, PKD)
2. remain generally what in peds?
3. if they rupture in childhood, they are generally what?

Answer 24

1. coarctation of the aorta, polycystic kidney disease
2. silent
3. fatal

Question 25

aneurysm anesthesia: 1. control what to prevent aneurysm rupture and surgical site bleeding? 2. want what 2 parts of anesthesia smooth? 3. is intraop hypotension advised in small children? 4. is intraop hypotension advised in peds with increased ICP? 5. what should you be prepared for? 6. anesthesia plan should entail a plan for emergent what?

Answer 25

1. blood pressure 2. induction, emergence 3. no 4. no 5. massive blood loss 6. craniotomy

Question 26

moyamoya disease: 1. progressive occlusion of what blood vessels? 2. primarily in what arteries near the circle of willis? 3. congenital forms can affect systemic arteries, especially which arteries? 4. TIAs progress to what and then what? 5. what therapy is used to medically manage moyamoya? 6. what is the surgical intervention for this disease? (PS)

Answer 26

1. intracranial 2. internal carotid arteries 3. renal 4. strokes, fixed neuro deficits 5. antiplatelet 6. pial synangiosis

Question 27

moyamoya anesthesia: 1. avoid changes in what? 2. maintain baseline what? 3. postop complications are strokes associated with what 2 things? (D, C) 4. these pts are admitted prior to surgery to ensure adequate what? 5. what is our main concern in these pts? 6. why do we want avoid hyperventilation and maintain normocapnia?

Answer 27

1. CBF 2. blood pressure 3. dehydration, crying 4. hydration 5. strokes 6. to ensure adequate CBF

Question 28

Neuro IR: 1. what MAC of gas if neuromonitoring? 2. what gtt is nice for this case d/t no postop pain? 3. pt must lay flat for how many hours without leg flexing? 4. what can be given at end of case to avoid wiggling in PACU and facilitating laying flat? 5. ensure what isn't covering the puncture site? 6. consider extubating deep?

Answer 28

1. half MAC 2. remi 3. 6 hours 4. fentanyl 5. diaper 6. deep

Question 29

encephalocele: 1. failure of what tube to close? 2. results in the head filled with what? 3. when are large encephaloceles diagnosed? 4. small encephaloceles can be seen inside where? 5. very large encephaloceles lead to difficulty with managing what?

Answer 29

1. neural 2. CSF 3. prenatally 4. nose 5. airway

Question 30

Meningocele and meningomyelocele: 1. associated with what allergy? 2. which one is CSF only? 3. which one is CSF and neural tissue? 4. associated with what malformation? 5. primary closure of meningomyelocele is performed first what of life?

Answer 30

1. latex 2. meningocele 3. meningomyelocele 4. arnold-chiari 5. days

Question 31

MM and anesthesia: 1. come to preop in what position? 2. careful fluid resuscitation to prevent return of what? 3. pt may have difficulties with what after a tight closure of a large defect? (B) 4. risk for what related to chiari malformation?

Answer 31

1. prone 2. fetal circulation 3. breathing 4. central apnea

Question 32

TBI phases: 1. primary injury is the damage that incurred at the time of what? (T) 2. secondary injury is the damage cause by what 2 processes leading to cerebral edema and elevated ICP? (I, E) 3. we aim to prevent which type of injury?

Answer 32

1. trauma 2. inflammatory, excitotoxic 3. secondary

Question 33

TBI airway: 1. GCS less than what we intubate? 2. what cervical level range do young children have greater movement? 3. what cervical level range after age 12 has maximal movement? 4. is there a survival advantage to intubating in the field vs bag masking? 5. what type of laryngoscopy is performed? 6. why avoid vigorous cricoid pressure in these pts?

Answer 33

1. < 9 2. C 1-3 3. C 3-5 4. no 5. in-line stabilization 6. can sublux the injury

Question 34

TBI treatment: 1. goal is to minimize intracranial what to prevent secondary injury? (H) 2. EVD controls ICP in what % of pts? 3. bolus with 3% saline and a continuous gtt at what ml/kg/hr to keep ICP < 20? 4. if using hypothermia, continue for > how many hours? 5. rewarming rate should be slower than what degrees per hour? 6. what is the most commonly used way to decrease ICP? 7. regional ischemia occurs at what weird % with a PaCO2 of 25-35? 8. is it possible to lower PaCO2 enough to impair O2 delivery and cerebral hypoxia?

Answer 34

1. hypertension 2. 87% 3. 0.1 - 1.0 ml/kg/hr 4. > 24 hours 5. 0.5 degrees/hr 6. hyperventilation 7. 59.4% 8. yes

Question 35

TBI and anesthesia agents: 1. all IV agents cause cerebral vasodilation or vasoconstriction? 2. all IV agents cause increase or decrease CMRO2? 3. all inhaled agents cause cerebral vasodilation or vasoconstriction? 4. all inhaled agents cause increase or decrease CMRO2? 5. is the IV agents effect coupling or decoupling? 6. is the inhaled agents effect coupling or decoupling?

Answer 35

1. vasoconstriction 2. decrease 3. vasodilation 4. decrease 5. coupling 6. decoupling

Question 36

propofol gtt is not used for sedation in ICUs because of what?

Answer 36

propofol infusion syndrome