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Neurosurgery overview 2 Flashcards

1
Q

Head injuries can include

A

deceleration injuries: coup & contrecoup lesions
skull fracture
-linear: subdural or epidural hematomas
-basilar: CSF rhinorrhea, pneumocephalus, and cranial nerve palsies- Battle’s sign, Racoon/Panda eyes
depression: brain contusion

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2
Q

Primary brain injuries include

A 
biomechanical effect of forces on the brain at time of insult- no treatment, continues to evolve
contusion
concussion
laceration
hematoma
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3
Q

Secondary brain injuries include

A

represents complicating processes related to primary injury- minutes, hours, days after primary injury
intracranial: hematoma, increased ICP, seizures, edema, vasospasm

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4
Q

Prehospital management for head injury includes

A

starts at the accident site
CAB
stabilize prior to transport
GCS <9: level 1 trauma center

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5
Q

Airway considerations for a head injury include

A

assume C-spine injury until otherwise proven radiographically
in-line stabilization
intubate early
full stomach precautions
awake FOI if difficult airway is anticipated
blind nasal intubation is CONTRAINDICATED in presence of basilar skull fracture

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6
Q

Anesthetic considerations for head injury include

A 
hypotension
bradycardia
maintain HCT >30%
seizure prophylaxis
DIC may be seen with severe head injuries; treat with platelets, FFP, cryoprecipitate as necessary
pituitary dysfunction: diabetes insipidus, SIADH
patient remains intubated
fluid management?
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7
Q

Nonfunctioning pituitary tumors are

A

non-secretory

  • arise from growth of transformed cells of anterior pituitary
  • generally well tolerated until 90% of gland is non functional
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8
Q

Functioning pituitary tumors are

A 
secretory
-Cushing's disease (ACTH)
- acromegaly (GH)
prolactinomas (prolactin)
TSH adenomas (TSH)
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9
Q

Intraoperative considerations for pituitary tumors include

A

transsphenoidal approach necessitates HOB elevated 10-20 degrees
oral RAE or reinforced ETT
avoid hyperventilation: reductions in ICP result in retraction of pituitary into the sella tursica, making surgical access difficult
potential for mass hemorrhage as the carotid arteries lie adjacent to the suprasellar area
mouth and throat pack: placed to absorb glottic blood and minimize postoperative vomiting of blood
avoid positive airway pressure upon extubation

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10
Q

Preoperative evaluation for the patient with a pituitary tumor includes

A 
visual field evaluation
s/s increased ICP
endocrine labs
electrolytes
steroids?
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11
Q

Postoperative management considerations for the patient with a pituitary tumor include

A

DI is common and is usually self-limiting (resolves within 7-10 days)- treat with vasopressin or DDAVP
SIADH

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12
Q

______ is the leading cause of intracranial hemorrhage

A

cerebral aneurysm

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13
Q

Cerebral aneurysm is commonly located in

A

the anterior Circle of Willis

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14
Q

With a cerebral aneurysm, the aneurysm fills with

A

blood and can rupture, spilling blood into the subarachnoid space, creating a SAH

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15
Q

Cerebral aneurysms can lead to

A

permanent brain damage, disability, or death

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16
Q

Unruptured cerebral aneurysm symptoms include

A 
headache
unsteady gait
visual disturbances (loss, diplopia, photophobia)
facial numbness
pupil dilation
drooping eyelid
pain above or behind eye
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17
Q

Ruptured cerebral aneurysm symptoms include

A 
sudden, extremely severe HA
N/V
LOC, prolonged coma
focal neuro deficits
hydrocephalus
seizure
s/s of increased ICP
18
Q

Describe considerations with vasospasm as it relates to ruptured cerebral aneurysm

A 
causes ischemia or infarction
exact mechanism not known
accounts for 14% of M/M
digital subtraction angiography is the gold standard for diagnosis
use calcium channel blockers
19
Q

With rebleeding with a rupture cerebral aneurysm

A

rebleeding follows initial SAH peaks seven days post incident
major threat during delayed surgery
accounts for 8% of M/M
antifibrinolytic therapy

20
Q

Treatment for vasospasm includes

A

triple H therapy (goal is to treat ischemia with an increased CPP)
hypertension- SBP 160-200 mmHg
hemodilution- Hct 33% provides balance between O2 carrying capacity and viscosity
hypervolemia- aggressive IV infusion of colloids & crystalloids for CVP >10 mmHg or PCWP 12-20 mmHg

21
Q

The rationale for vasospasm treatment includes

A

intended to increase CBF in brain areas that become ischemic due to intense vascular narrowing
normally, increased CBF would not result from increased BP, however with vasospasm the vascular bed becomes passive
therefore increasing CPP by increased volume or by systemic administration of vasoactive drugs may reverse symptoms of cerebral ischemia

22
Q

Endovascular coiling considerations include

A 
GETA with complete muscle paralysis
control CPP
minimal narcotic needs since minimally invasive
a-line preferred
minimal to no blood loss
heparin may be used for ACT 200-250
same postop concerns and with clipping
23
Q

Endovascular aneurysm coiling involves

A

detachable coil inserted into aneurysm
standard arteriogram is performed to locate aneurysm
catheter is passed, often through femoral vessels, and coil is advanced

24
Q

Advantages to endovascular aneurysm coiling includes

A

shorter stay, less anesthetic requirements, uncomplicated positioning, minimally invasive

25
Q

Complications of endovascular aneurysm coiling include

A

aneurysm rupture/subarachnoid hemorrhage- rapid transport to OR for clipping is necessary
vasospasm
CVA
incomplete coiling

26
Q

A cerebral aneurysm presenting to the operating room is most commonly treated by

A

microsurgical clip ligation
craniotomy approach; parent vessel giving rise to aneurysm is identified
aneurysm neck is isolated, and a clip is placed across the neck, excluding it from circulation
deep circulatory arrest may be necessary with giant aneurysms

27
Q

Goals of anesthesia for cerebral aneurysm intraoperative management include

A

maintain optimum CPP
decrease CPP rapidly if rupture occurs during surgical clipping
maintain transmural pressure (MAP-ICP)
decrease intracranial volume (blood and tissue); provide “slack” brain
minimize CMRO2

28
Q

Preinduction for the patient with cerebral aneurysm includes

A 
limit sedation (hypercapnia)
a-line
2 large bore PIVs
T&C 2-4 units PRBCs
remember HOB will be turned 90-180 degrees
29
Q

Induction for the patient with cerebral aneurysm includes

A

smooth induction- difficult airway, full stomach

aggressive BP & HR control- narcotics, BB, deepen anesthesia

30
Q

Describe maintenance for the patient with cerebral aneurysm

A

may use TIVA or anesthetic gases
temporary occlusion of a cerebral artery
maintain BP 15-20% below baseline to prevent vasospasm, decrease EBL and allow for better exposure & visualization
employ methods for cerebral protection and to reduce ICP if necessary

31
Q

Fluid management for the patient with cerebral aneurysm includes

A

run pt dry <10 mL/kg + UOP
expand blood volume with colloids
have PRBCs available
no GLUCOSE CONTAINING SOLUTIONS

32
Q

Describe control of BP for the patient with cerebral aneurysm

A

control of BP is critical to successful outcome of case
surgeon may ask for temporary increase in MAP to 80-100 mmHg to provide for collateral flow if a feeder vessel is clamped for a short period to allow for clipping of aneurysm
post clipping, MAP is usually kept at 80-100 mmHg

33
Q

Likely times of aneurysm rupture include

A

dural incision
excessive brain retraction
aneurysm dissection
during clipping or releasing of clip

34
Q

Treatment of intraoperative aneurysm rupture includes

A

immediate, aggressive fluid resuscitation and replacement of blood loss
propofol bolus for brain production, to decrease MAP, and decrease blood loss
decrease MAP to 40-50 mmHg (clevidipine, labetalol, esmolol)
surgeon may apply temporary clip on parent vessel to control bleeding, restore BP after clipping to improve collateral flow

35
Q

Arteriovenous malformation considerations include

A

AVM is congenital abnormality that involves a direct connection from an artery to a vein “nidus” without a pressure modulating capillary bed
-most common presentation intracranial hemorrhage*****

36
Q

Treatment for AVM includes

A

intravascular embolization, surgical excision or radiation

37
Q

Preoperative considerations for AVM include

A

same as with aneurysm

potential for significant blood loss is much higher (upwards of 3L)

38
Q

Cranial nerve decompression treats

A

disorders of cranial nerves such as trigeminal neuralgia, hemifacial spasm, & glossopharyngeal neuralgia
unilateral
usually caused by compression of a vascular structure

39
Q

Describe positioning for cranial nerve decompression

A

lateral, prone or supine

40
Q

Describe monitoring for cranial nerve decompression

A

facial nerve, brainstem auditory evoked response, EMG

41
Q

Describe anesthesia for cranial nerve decompression

A

TIVA
brain relaxation
PONV- multimodal

42
Q

Spinal cord surgeries include

A 
spinal cord stimulators- MAC
intrathecal pumps- asleep in lateral
scoliosis
ALIF/TLIF
ACDF

Advanced Principles 2 (42 decks)

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