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Critical Care I > Neurosurgery Lecture > Flashcards

Neurosurgery Lecture Flashcards

1
Q

SCALP pneumonic for what all the scalp consists of

A 
Skin
Connective tissue
aponeurosis
loose connective tissue
periosteum
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2
Q

Brain anatomy terms

A 
Scalp
Skull
Dura mater
Arachnoid
Pia
Brain (Gray matter and white matter)
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3
Q

what brain anatomy has nerve endings

A

scalp and Dura

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4
Q

Intraparenchymal means what

A

in the brain area

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5
Q

extraaxial

A

inside of scalp but outside of brain tissue

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6
Q

breast milk does what to brain

A

myelinates neurons and gives you white matter

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7
Q

myelin and brain tissue in relation to seizures

A

myelinated tissue is not as excitable

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8
Q

neonates and gray matter/white matter

A

does not have as much white matter. colostrum has cholesterol which helps to myelinate the brain to develop the white matter

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9
Q

brain stem is made up of how many parts

what are they

A

3
midbrain
pons
medulla

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10
Q

supratentorial

A

above posterior fossa

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11
Q

drooling, not managing secretions - from a neuro stand point, what part of the brain should you think about

A

think brain stem

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12
Q

how many ventricles do you have

A

4

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13
Q

CSF is being absorbed through what layer of the brain

A

arachnoid

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14
Q

80% of the CSF is produced where

A

Choroid plexus (in the 3rd ventricle)

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15
Q

part of brain controls balance or movement (coordination)

A

cerebellum

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16
Q 
lobe that controls
personality
motor
emotions
problem solving 
reasoning
A

frontal lobe

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17
Q

lobe that controls

sensory

A

parietal lobe

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18
Q

lobe that controls
hearing
language
speech

A

temporal lobe

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19
Q

lobe that controls

vision

A

occipital lobe

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20
Q

CN in midbrain

A

3 -oculomotor

4 - trochlear

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21
Q

CN pons

A

5 - trigeminal
6- abducens
7- facial
8- vestibulocochlear

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22
Q

CN medulla

A

9- glossopharyngeal
10- vagus
11 - accessory

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23
Q

definition of brain death by the American academy of neurology (AAN) in 1995 and updated in 2010

A

“irreversible cessation of all functions of the entire brain, including the brain stem”

each facility will have their criterion

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24
Q

cant call Brain death if there is

A
  • contribution of depressant drugs
  • hypothermic
  • metabolic/endocrine disturbance
  • breathing on own

-patient condition must be compatible with irreversible brain damage

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25
Q

Brain death tests

A

pupil response
corneal reflex
vestibulo-ocular reflex (ear drum must be intact - inject cold water into ear while some one is holding the eyes open…eyes will shoot over to opposite side and produce nystagmus) (Dolls eyes test)
gag reflux (If intubated must be at the carina)
motor response (Train of 4 (TOF)) (needs to be central ie) sternal rub)
resp movements

each institution varies on who, repetition/timing

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26
Q

labs needed prior to neurosurgery

A

CBC (H&H and platelets - needs to be 100,000) - Hgb (10), HCT (30)
Coags (pt/inr/ptt)
BMP/Chem10 (sodium, potassium, BUN, creatinine)
type and screen

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27
Q

an impact, penetration or rapid movement of the brain within the skull that results in altered mental state

A

Traumatic brain injury

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28
Q

an insult to the brain, not of a degenerative or congenital nature, but caused by external physical force that may produce a diminished or altered state of consciousness

A

Traumatic brain injury

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29
Q

GCS associated with mild TBI

A

13-15 (brief change in mental status/consciousness)

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30
Q

GCS associated with moderate TBI

A

10-12

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31
Q

GCS associated with severe TBI

A

9 and below - extended period of unconsciousness or memory loss…death

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32
Q

results when the brain moves rapidly within the skull (coup - impact and contrecoup - non-impact (physiological due to force))

A

Traumatic brain injury

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33
Q

what lab that there are studies with brain injury

serial ____ levels

A

lactate

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34
Q

Changes in ionic fluxes after TBI

what’s going on

A

body is trying to repair itself

sodium and potassium will be depleted

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35
Q

when does frontal sinus develop

A

7-10 years old

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36
Q

sagittal view is

A

side view

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37
Q

when you see a bleed on a CT - bright white vs dull white

A

bright white is clotted blood, dull is fresh- still bleeding

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38
Q

when have a TBI, still have swelling. What electrolyte is important to follow and make sure they are keeping up?

A

sodium

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39
Q

what age is it that they have a better chance of the other parts of the brain taking over those functions

A

younger than 7 y.o.

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40
Q

general changes in brain function, such as confusion, amnesia, loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions and disruptions in perception, psychomotor skills and behavior.

A

altered mental status

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41
Q

Pediatric decreased mental status differentials

A 
acute demyelinating encephalomyelitis (ADEM)
fever
electrolyte disturbance
sepsis/meningitis
Respiratory
head injury
hydrocephalus
abscess of brain
seizure
ruptured AVM/aneurysm
narcotics
benzo
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42
Q

focal brain injury is a

A

contusion

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43
Q

2 types of diffuse brain injury

A

concussion

DAI (direct axonal injury)

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44
Q

types of hemorrhages

A

epidural
subdural
subarachnoid
intracerebral (in brain tissue)

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45
Q

4 major causes of brain injury

A

falls
MVA
bicycle accident
child abuse

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46
Q

what does intraparenchymal hemorrhage mean

A

bleeding inside the brain

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47
Q

where is bleeding for a subdural hemorrhage

A

between the arachnoid mater and dura mater - irritates the brain faster, may cause seizures faster

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48
Q

where is bleeding for a subarachnoid hemorrhage

A

bleeding in the subarachnoid space

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49
Q

where is bleeding for epidural hemorrhage

A

between the dura mater and the skull

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50
Q

if bleeding does not clear during LP (from tube 1 to tube 4)

A

subarachnoid hemorrhage

if it clears its a dirty lp

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51
Q

subarachnoid hemorrhage think what on differential causes

A

subarachnoid hemorrhage

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52
Q

what type of bleed is confined by sutures

A

subdural

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53
Q

where does blood accumulate in an epidural

A

between skull and dural membrane

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54
Q

what artery tear is most common cause of epidural hematoma

A

middle meningeal artery

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55
Q

R pupil is fixed and dilating, what side of the brain is the bleed

A

R

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56
Q

clotted blood, up to 48 hours (subdural hematoma classification)

A

acute

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57
Q

2-3 days to 2-weeks, clot lyses (subdural hematoma classification)

A

subacute

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58
Q

> 3 weeks, fluid mass (subdural hematoma classification)

A

chronic

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59
Q

stroke - what is the hour time frame to be able to see on MRI

A

immediately

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60
Q

narcotic use in head injury - pros and cons

A

decrease agitation and pain so the blood pressure and ICP doesn’t increase

works as a CNS depressant by slowing down neural activity in the brain and body (PNS)

downside - no effect on cerebral metabolic rate of oxygen (CMRO2) or cerebral blood flow but they have been reported to increase ICP in some cases

CNS depressants

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61
Q

cautious alert to think about for when you are ordering benzos for treating seizure (What should you be double checking before giving a benzo for seizure

A

treating a seizure with benzo has major effects on the CNS. Are you treating a seizure? or could this be posturing?

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62
Q

Benzos and ICP

A

no effect on ICP

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63
Q

downside of Benzos

A

have a coupled reduction in cerebral metabolic rate of oxygen and cerebral blood flow and no effect on ICP

CNS depressant

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64
Q

what stage of sleep has highest ICP

A

REM

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65
Q

normal ICP ranges

A

1-15mm Hg

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66
Q

causes of increased ICP

A

trauma (contusion, EDH, SDH), infection, neurosurgery/neurosurgical procedures, overdose of/toxic reactions from meds, disease that affect nervous system, stroke, hydrocephalus (malfunctioning shunt/ETV)

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67
Q

signs symptoms of Increased ICP

A

lethargy/change in LOC
bradycardia
HTN
unequal pupils (esp if one is not reactive at all)

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68
Q

ICP mgmt

A 
decompressive craniectomy (most invasive)
pentobarbital coma
EVD 
Mannitol/hypertonic saline
sedatives, paralytics, hyperventilation
general measures (least invasive)
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69
Q

why would you give 23% mannitol/hypertonic saline vs 3%

A

less volume

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70
Q

ICP general measures

A

elevate HOB (enhances venous outflow)

Loosen C-collar (if present), keep neck midline which enhances venous outflow, prevents “kinking”

maintain euvolemia

avoid hypotension

control pain/agitation

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71
Q

CSF production vs CSF absorption

A

not consistent over time and among individuals

Production not affected by ICP

but as ICP increases (usually >14cm H20) -> absorption increases

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72
Q

most common etiologies for hydrocephalus

A 
intraventricular hemorrhage (IVH) of newborn
chiari II (myelomeningocele)
aqueductal stenosis
post infectious
tumors
congenital brain malformations
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73
Q

types of hydrocephalus

A

obstructive

Communicating

over-production

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74
Q

what type of hydrocephalus can bacterial meningitis cause

A

communicating Hydrocephalus (HCP)

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75
Q

flow of CSF is blocked along one or more of the narrow pathways connecting the ventricles

A

Obstructive hydrocephalus

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76
Q

occurs when the flow of CSF is blocked after it exits from the ventricles

A

communicating hydrocephalus

77
Q

mongolian spot, hair, tissue are all what type of markers

A

cutaneous

78
Q

what age should you have head circumferences

A

2 years and younger

79
Q

hydrocephalus signs/symptoms

A

abnormal enlargement of head

AF (anterior Fontenelle) tense/bulging when child is sitting up and quiet

scalp appears thin and glistening

scalp veins prominent

separated suture lines

vomiting, sleepiness, irritability, sunsetting eyes

seizures

difficulty feeding

80
Q

position child should be in when checking fontanelle

A

upright

81
Q

what week gestation is the germinal matrix max size

A

23 weeks (2.3mm)

82
Q

common mistake with assessing eye movement tracking

A

signs without sound

83
Q

what week gestation is the germinal matrix 1.15mm

A

32 weeks

84
Q

what week gestation is the germinal matrix involuted

A

36 weeks

85
Q

what week gestation is the germinal matrix gone

A

39 weeks

86
Q

what grade (intracranial hemorrhage)

hemorrhage limited to subpendymal matrix

A

grade 1

87
Q

toddler specific hydrocephalus s/s

A

if sutures not closed, head enlargement

sutures closed -s/s increased ICP

HA, vomiting, nausea, blurred or double vision, irritable, tired

balance problems, delayed walking, talking, poor coordination

loss of previous abilities

seizures

88
Q

eye signs for hydrocephalus

A

setting sun (Parinaud’s syndrome)

nystagmus
VI nerve paresis

89
Q

higher risk time frame for infection with shunt

A

6 months after insertion or manipulation of any sort

90
Q

a small catheter is passed into a ventricle of the brain. A pump is attached to the catheter to keep the fluid away from the brain. Another catheter is attached to the pump and tunneled under the skin, behind the ear, down the neck and chest and into the peritoneal cavity. The CSF is absorbed in the peritoneal cavity

A

Ventriculoperitoneal shunt (VP shunt)

91
Q

a typical shunt infection lowers IQ by how many points

A

10

92
Q

testing for meningitis in an shunted pt

A

still need to

93
Q

labs for shunt infection

A

CRP
Procalcitonin
CSF esosinophilia (>7% suggests infection)

94
Q

procalcitonin is an inflammatory marker that checks for what

A

bacterial infection

95
Q

what inflammatory marker checks for viral infection

A

CRP

96
Q

what hour marker does vancomycin reach steady state

A

24 hour

97
Q

when do you start drawing vanc trough levels

A

24 hour mark
so if you are vanc q 8 draw 30 min prior to 3 rd dose

if you are vanc q 6 hours draw 30 min prior to 4th dose

98
Q

what vanc trough level do you want to maintain for shunt infection treatment

A

> 15-20

10-15 without shunt

99
Q

other than shunt placement for treatment of hydrocephalus (surgical)

A

cranial morcellation

100
Q

what type of bleed

“thunderclap headache/worst headache of life”

A

subarachnoid and can be intraventricular as well

101
Q

star of death pattern on CT

A

aneurysm

102
Q

work up for aneurysms

A

Labs
CTA or MRA/MRV
may get diagnostic angiogram as well

103
Q

Treatment for aneurysms

A

usually involves clipping or open case

TIGHT BLOOD PRESSURE CONTROL WITH ARTERIAL LINE

High risk for stroke

High risk for vasospasm ->leads to stroke

104
Q

Post aneurysm how many days are critical risk for stroke, in ICU

A

21 days

105
Q

clinical presentation of brain injury - shift/herniation

A

progressive loss of consciousness

coma

irregular breathing

resp arrest

irregular pulse

cardiac arrest

loss of all brainstem reflex (blink, gag, pupillary reaction to light)

106
Q

hydrocortisone and Decadron -whats better for treating adrenal insufficiency

A

hydrocortisone

107
Q

tumor that grows slow

A

benign

108
Q

tumor that grows fast

A

malignant

109
Q

what type of tumor does chemo and radiation target

A

targets mitosis

malignant

110
Q

posterior fossa tumors - what CN deficits

A

Primarily V, VI, VII, VIII

V - ptosis, moves mandible chewing

VI - eyes cant abduct

VII - facial palsy

VIII - balance and hearing

111
Q

amount of contrast they use for a contrasted CT (Isovue300)

A

2cc/kg: max of 100cc

> 50kg - max of 100cc
75kg - case dependent, may choose to use Isovue 370

112
Q

imaging that demos intracranial vessels in 2D/3D

A

CTA (Computed Tomography Angiography)

113
Q

gold standard for evaluating
Vessel occlusion/stenosis
aneurysm/AVM
Abnormal tumor circulation

A

Angiography

114
Q

why are they ordering an MRI

A

stroke

evaluation of ETV (CINE)

Tumor/post surgery

AVM/aneurysm

Non-bony items

Ligamentous injury

Brain anatomy (any plane)

115
Q

MRI vs CT

A

no radiation with MRI

more detailed for MRI

116
Q

isotonic IV solution

what is it?
what does it do to the cells?
what does it do to the vascular volume?

A

NS

nothing to cells
increases volume

117
Q

hypertonic saline

what is it?
what does it do to the cells?
what does it do to the vascular volume?

A

3%

so this adds sodium to the vascular
pulls water out of the cells into the vascular

shrinks cells
increases vascular volume

118
Q

hypotonic saline

what is it?
what does it do to the cells?
what does it do to the vascular volume?

A

.45%

this pulls water from the vascular to the cells

enlarges cells

119
Q

what color is blood and bone on a CT

A

White

120
Q

What color is tissue on CT

A

black

121
Q

decreased density on a CT means…

A

presence of surrounding edema

122
Q

increased density on a CT means…

A

tumors with high nuclear to cytoplasmic ratio

123
Q

CT Head with contrast will show what

A

areas of increased vascularity and breakdown of blood -brain barrier

124
Q

A standard plane for Brain CT is selected to avoid excessive radiation to the ______

A

lens of the eye (retina)

125
Q

Isovue 300: Contrast max dose rules

A

2cc/kg: max of 100cc
>50kg: max of 100cc
>75kg: case dependent, may choose to use Isovue 370

This is what they have to give to get a contrast study. If they have had one contrasted study, must wait 24 hours to get another study

126
Q

Does MRI use Radiation

A

no

127
Q

imaging type characterized by altered attenuation

A

CT

128
Q

Imaging type characterized by signal intensity

A

MRI

129
Q

what color is air and bone on MRI

A

black

130
Q

What is the stronger/more detailed MRI magnet

A

3T

131
Q

Renal precautions for MRI contrast

A

MRI Gadolinium can not be dialyzed
If GFR <60 (stage 3 or 4 renal disease, no gadolinium)

If they are a dialysis pt, you cant do this…
There is another med for off label use (Ferumoxytol (Feraheme)

132
Q

Off label med as an alternative to Gadolinium for contrast for MRI in pt on dialysis

A

Ferumoxytol (Faraheme)

IV 2-5mg/kg (max reported dose: 510mg)

133
Q

for US (sonography) ______ stops the frequency beam completely

A

Bone

134
Q

Imaging type that uses high frequency sound

A

Ultrasound

135
Q

CTA and MRA

which imaging type requires contrast

A

CTA (Computed Tomography Angiography)

MRA (Magnetic Resonance Angiography) does not require contrast.

136
Q

what imaging type uses signals that demonstrate vessels, aneurysms, and AVM

A

MRA

137
Q

Imaging type that evaluates intra and extracranial vessels

  • Vessel occlusion/stenosis
  • Aneurysms/AVM
  • Abnormal tumor circulation

**This can be diagnostic and interventional

A

Angiography (Angiogram)

-catheter inserted into femoral artery and maneuvered up to carotid or vertebral origin (guidewire/image intensifier)

Iodinated contrast used

138
Q

After an AVM that has ruptured and pt has stabilized, 7 days later what are you looking to do imaging/interventional

A

MRA to view

Angiogram to intervene

139
Q

why do you want to use MRI instead of CT for stroke protocol

A

It takes a min of 6 hours to be able to see a stroke on CT, but can take 12 hours to show

140
Q

If your worried about a head bleed, what do you order?

A

CT Head without contrast

141
Q

what does MRI evaluate

A 
Stroke
Evaluation of ETV (CINE)
Tumor/post surgery
AVM/aneurysm
Non-bony items
Ligamentous injury
Brain anatomy (any plane)
142
Q

stroke protocol vs Rapid MRI

A

Stroke protocol - T1, T2

Rapid - T2 only

143
Q

what imaging is used to evaluate vessel injury/abnormality but uses less radiation than angiography

A

CTA

144
Q

what imaging is used to

  • evaluate blood supply to/from region
  • evaluate anatomy of vessels looking for stenosis, occlusion, dissection
A

MRA/MRV

145
Q

What imaging is the gold standard for aneurysm/AVM

A

Angiogram

146
Q

what are the risks with MRI

A

sedation risks

if kidney problem - metals in contrast

147
Q

How is an MRI diff then CT

A

MRI is less radiation

MRI is more detailed….the CT showed that something that was wrong but the MRI is going to give us more information

148
Q

Headache
subjective fever
Abdominal pain
Vomiting

What lab do you need to draw?
What are you looking for?

A

CBC

low platelets

ORDER CT! This is the start of alot of neuro bleeds….(remember sepsis case study)

This set of symptoms is very common for early symptom of a severe neuro problems

149
Q

Platelet requirement for neurosurgery to take pt to OR

A

100,000

150
Q

white matter is what

A

myelinated tissue

151
Q

myelin is made up of what

A

cholesterol

152
Q

white matter and gray matter

what is on outside and what is on inside of brain

A

White matter is inside

gray matter is outside

153
Q

cranial nerves that arise from the midbrain

A 
CN III (oculomotor)
CN IV (trochlear)
154
Q

cranial nerves that arise from the pons

A 
CN V (trigeminal)
CN VI (abducens)
CN VII (facial)
CN VIII (vestibulocochlear)
155
Q

cranial nerves that arise from the medulla

A 
CN IX (glossopharyngeal)
CN X (vagus)
CN XI (accessory)
156
Q

part of the brain that controls balance and coordination

A

cerebellum

157
Q

Part of brain that regulates basic body functions

A

Brainstem - breathing, digestion, heart rate, blood pressure, being awake and alert

158
Q

what cranial nerve is eyes moving side to side

A

6th

if your L eye does not move to the side then that is a L sided CNVI palsy

159
Q

what CN is eye conversion (when you have them follow finger follow to their nose)

A

4th

160
Q

What CN controls eyelid movement

A

3rd

161
Q

Brain death exams and problems with insurance

A

To declare someone brain dead, it requires 2 examinations. Sometimes there is a requirement for time in between the 2 exams. After 2nd one is done, pt is declared dead. Most insurance companies won’t pay after this. So if they change their mind…this can have significant implications.

162
Q

There is only one organ that can be donated even if your cold and not producing urine

A

Cornea

163
Q

Shunt problem Neurosurgery will have to have what imaging first

A

CT

164
Q

CBC number requirements for Neurosurgery

A

must be at least
Hgb - 10
HCT - 30
platelets - 100,000

165
Q

surgical prep product info

A

Hibiclens is preferred
Chloraprep is flammable (hair catches fire)

Hibiclens is not safe for meninges so for LP needs to be iodine or chloraprep

166
Q

In a brain bleed situation, when is a reasonable time to re-scan if no changes

A

4-6 hours

167
Q

Bright or Dark

MRI - T1

A

Dark

168
Q

Bright or Dark

MRI-T2

A

Bright (white)

169
Q

The deeper in the brain the injury, the _______amount of force that caused it

A

Greater

170
Q

what type of bleed

accumulation of blood between skull & dural membrane

A

Epidural hematoma

171
Q

What is the most common cause of an epidural hematoma

A

Epidural hematoma

172
Q

unilateral pupil dilatation - 2 potential causes

A

compression of a 3rd nerve
think seizure or bleed
if it goes away…seizure….

173
Q

on CT there is a hematoma that is described as a well-defined mass, maintains boundaries within cranial sutures

A

Epidural hematoma

174
Q

collection of blood below dura but external to the brain and arachnoid membrane

A

Subdural hematoma

175
Q

Subdural hematoma classification:

clotted blood - up to 48 hours

A

Acute

176
Q

Subdural hematoma classification:

2-3 d to 2-3 wks, clot lyses

A

subacute

177
Q

Subdural hematoma classification:

>3 weeks, fluid mass

A

Chronic

178
Q

the displacement of brain tissue, cerebrospinal fluid and blood vessels outside the compartments in the head that they normally occupy

A

Herniation

179
Q

shaken baby syndrome is now called

A

Abusive head trauma

180
Q

other reasons for shaken baby symptomes

A

underlying hematologic or metabolic problem

181
Q

Osmotic therapy for ICP management with doses

A

Hypertonic saline
3% (3-5ml/kg)
23% (0.5.1ml/kg)

182
Q

what can decrease CSF production

A

infection

183
Q

Does Increased ICP affect CSF production

A

no, but as ICP increases (usually >14cm H20) absorption

184
Q

germinal matrix is at its max size at how many weeks gestation

A

23 weeks (2.3 mm)

at 32 weeks (1.15 mm)
Involuted at 36 weeks
Gone at 39 weeks

185
Q

hydrocephalus eye signs

A

Setting sun (Parinaud’s syndrome)
VI nerve palsy/paresis (means same as palsy) (can’t look up)
nystagmus (from pressure to the cerebellum)

186
Q

95% of shunt infections occur within the first ______ months of operation

A

3 (very unlikely in a fever in a child that had a shunt infection more than a year ago)

187
Q

Fever in a shunt pt …what labs need to be drawn

A

CBC
ESR
CRP

188
Q

Treatment in a pt with shunt infection

A

Broad spectrum abx (including vanc), replaced by organism specific antibiotics

Shunt needs to be replaced with an external ventricular drain (EVD) and a new shunt be replaced after CSF sterile

189
Q

Posterior Fossa Tumor Work up

A

MRI brain and spine w and w/o contrast

Start Dexamethasone: (symptomatic reasons- vasodemic edema): 0.25-0.5mg/kg/day divided q 6 hours

PPI

If decompensating due to HCP - may need EVD placement prior to OR/MRI

labs

Critical Care I (27 decks)

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