T3 - Neuro Disease Assessment Flashcards
What is the first step in managing patients with neurological disorders before anesthesia?
Conduct a thorough assessment, including reviewing the patient’s history, symptoms, and neurological deficits.
What should be included in the diagnostic evaluation of patients with neurological disorders before anesthesia?
Review imaging and neurological testing results to understand the extent of the neurological condition.
Why is it important to review the patient’s current drugs and treatments before anesthesia?
To assess potential drug interactions, side effects, and their impact on anesthesia.
What should be considered when assessing the potential risks and benefits of various anesthetic options?
Factors such as the patient’s neurological condition, comorbidities, and the type of surgery should be evaluated.
How can the patient’s condition be optimized before anesthesia?
Implement preoperative measures such as medication adjustments, neurological interventions, and addressing any modifiable risk factors.
Why is clear preoperative documentation important in patients with neurological disorders?
It ensures that all relevant factors, including the patient’s history, diagnostic findings, medication review, and chosen anesthetic plan, are documented with a rationale.
What is Multiple Sclerosis (MS)?
MS is a progressive autoimmune disorder characterized by the demyelination of central nerve fibers.
What is the typical onset age for Multiple Sclerosis?
MS typically begins between the ages of 20 and 40.
What are the risk factors associated with Multiple Sclerosis?
Risk factors include being female, having a first-degree relative with MS, Epstein-Barr virus (EBV) infection, other autoimmune disorders, and smoking.
What are the common symptoms of Multiple Sclerosis?
Symptoms include motor weakness, sensory disorders, visual impairment, and autonomic instability. Symptoms vary depending on the site of demyelination.
What factors can trigger exacerbations of Multiple Sclerosis?
Triggers include stress, elevated temperatures, and the postpartum period.
What is the typical disease course of Multiple Sclerosis?
MS is characterized by periods of exacerbations and remissions.
Is there a cure for Multiple Sclerosis?
No, there is no cure for MS. However, it can be managed with corticosteroids, immune modulators, and targeted antibodies.
What is the first step in preanesthetic considerations?
Assess existing deficits in the patient’s condition.
What should be considered if the patient has respiratory compromise?
Consider pulmonary function tests to assess respiratory function.
Which laboratory tests are typically ordered before anesthesia?
CBC with platelets, basic metabolic panel (BMP), and optionally liver function tests (LFT) if the patient is on Dantrolene or Azathioprine.
Why is close attention to glucose and electrolytes necessary before anesthesia?
Steroids may impact glucose and electrolyte levels, so monitoring is crucial.
When should preoperative steroids be considered?
Consider preoperative steroids in patients with long-term steroid use.
Why is temperature management critical before anesthesia?
An increase in body temperature can precipitate exacerbations of Multiple Sclerosis symptoms.
What are the acceptable anesthetic options for patients with Multiple Sclerosis?
General anesthesia (GA), regional anesthesia (RA), and peripheral nerve blocks (PNBs) are acceptable options.
Why should Succinylcholine be avoided in multiple sclerosis patients?
Succinylcholine may induce hyperkalemia and should be avoided in patients with Multiple Sclerosis.
What is Myasthenia Gravis (MG)?
MG is an autoimmune disorder characterized by antibodies generated against N-Ach-R’s at skeletal motor endplates.
Which type of muscle does MG affect?
MG primarily affects skeletal muscle, not smooth or cardiac muscle.
What are the common symptoms of MG?
Symptoms include muscle weakness exacerbated by exercise, cranial nerve involvement (especially ocular symptoms like diplopia and ptosis), and bulbar involvement leading to respiratory insufficiency and aspiration risk.
What is common in Myasthenia Gravis patients related to the thymus?
Thymic hyperplasia is common in MG patients, and approximately 90% of patients improve after thymectomy.
What factors can exacerbate symptoms of Myasthenia Gravis?
Symptoms can be exacerbated by pain, insomnia, infection, and surgery.
What are the treatment options for Myasthenia Gravis?
Treatment may include acetylcholinesterase inhibitors (Pyridostigmine), immunosuppressive agents, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).
How does thymectomy affect Myasthenia Gravis?
Over 90% of patients improve after thymectomy.
What is the first step in preanesthetic considerations for Myasthenia Gravis?
Assess existing deficits in muscle strength and respiratory function.
What should be considered if there is respiratory compromise?
Consider pulmonary function tests to evaluate respiratory function.
How should respiratory function be optimized before anesthesia?
Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.
What precaution should be taken with neuromuscular blocking agents (NMBs)?
Reduce NMB dosage to avoid prolonged muscle weakness and respiratory depression.
Why should caution be exercised with opioids in Myasthenia Gravis patients?
Use opioids cautiously to avoid respiratory compromise, especially in patients with compromised respiratory function.
How do acetylcholinesterase (Ach-E) inhibitors affect neuromuscular blocking agents and local anesthetics?
Ach-E inhibitors may prolong the effects of Succinylcholine and ester local anesthetics.
Which laboratory tests are typically ordered before anesthesia in Myasthenia Gravis patients?
Order CBC, BMP, and optionally LFT (if on Azathioprine) to monitor glucose and electrolyte levels.
When should preoperative steroids be considered in Myasthenia Gravis patients?
Consider preoperative steroids in patients with long-term steroid use to prevent adrenal insufficiency.
What should be discussed with Myasthenia Gravis patients before surgery?
Counsel patients on the increased risk of needing postoperative respiratory support or ventilation until fully recovered from anesthesia.
What is Eaton-Lambert Syndrome?
Eaton-Lambert Syndrome is a rare autoimmune disorder characterized by autoantibodies against voltage-gated calcium channels, leading to reduced calcium influx and decreased acetylcholine release.
What is a significant association of Eaton-Lambert Syndrome?
More than 60% of cases are associated with small cell lung carcinoma.
What are the common symptoms of Eaton-Lambert Syndrome?
Symptoms include progressive limb-girdle weakness, dysautonomia, oculobulbar palsy, and may resemble those of Myasthenia Gravis.
How is Eaton-Lambert Syndrome treated?
Treatment options include
- Selective potassium channel blockers like 3,4-diaminopyridine, acetylcholinesterase inhibitors, immunosuppressive agents such as Azathioprine, steroids, plasmapheresis, and intravenous immunoglobulin (IVIG).
What is the first step in preanesthetic considerations for Eaton-Lambert Syndrome?
Assess existing deficits in muscle strength and respiratory function.
What should be considered if there is respiratory compromise?
Consider pulmonary function tests to evaluate respiratory function.
How does Eaton-Lambert Syndrome respond to neuromuscular blocking agents?
Eaton-Lambert Syndrome is very sensitive to both non-depolarizing and depolarizing neuromuscular blocking agents, with significantly higher sensitivity to non-depolarizing agents compared to Myasthenia Gravis.
What should be done to optimize respiratory function before anesthesia?
Optimize respiratory function to reduce the risk of respiratory compromise during and after anesthesia.
Why should extreme caution be exercised with neuromuscular blocking agents and opioids?
Exercise extreme caution with neuromuscular blocking agents and opioid dosing to prevent respiratory compromise.
What should be discussed with Eaton-Lambert Syndrome patients before surgery?
Counsel on risks for needing post-op resp support until fully recovered from anesthesia
What is Muscular Dystrophy?
Muscular Dystrophy is a hereditary disorder characterized by muscle fiber degeneration due to breakdown of the dystrophin-glycoprotein complex, leading to myonecrosis, fibrosis, and increased skeletal muscle membrane permeability.
How many types of Muscular Dystrophy are there?
There are six types of Muscular Dystrophy, each with its own characteristics and genetic mutations.
What is the most common and severe form of Muscular Dystrophy?
Duchenne Muscular Dystrophy is the most common and severe form, occurring only in boys with onset typically between 2-5 years of age. Patients are usually wheelchair-bound by age 8-10 and have an average lifespan of around 20-25 years due to cardiopulmonary complications.
What are the common symptoms of Muscular Dystrophy?
Symptoms include progressive muscle wasting without motor/sensory abnormalities, kyphoscoliosis, long bone fragility, respiratory weakness, frequent pneumonia, and EKG changes.
What laboratory findings would be elevated in muscular dystrophy as a result of muscle wasting?
Serum creatine kinase levels are often elevated due to muscle wasting and damage.
What is myotonia?
Myotonia is a prolonged contraction after muscle stimulation, commonly observed in several muscle disorders.
What is the most common form of myotonia?
Myotonic Dystrophy is the most common form of myotonia, typically manifesting in the 20-30s with muscle wasting in the face, masseter, hand, and pre-tibial muscles. It may also affect pharyngeal, laryngeal, and diaphragmatic muscles, and can lead to cardiac conduction abnormalities. Approximately 20% of patients have mitral valve prolapse.
What is Myotonia Congenita?
Myotonia Congenita is a milder form of myotonia characterized by skeletal muscle involvement while smooth and cardiac muscles are spared.
What is Central Core Disease?
Central Core Disease is a rare condition where core muscle cells lack mitochondrial enzymes, leading to proximal muscle weakness and scoliosis.
What triggers myotonias, and how are the symptoms managed?
Myotonias are triggered by stress and cold temperatures. Symptoms are managed with medications such as Quinine, Procainamide, and steroids, although there is no cure for these conditions.
What laboratory tests should be considered pre-anesthesia for myotonic dystrophies?
Pre-operative EKG and echocardiogram should be performed to evaluate for cardiomyopathy.
How should neuromuscular blockade be approached in patients with Myotonic Dystrophies?
Exercise caution with non-depolarizing neuromuscular blockers, and ensure careful monitoring throughout the procedure.
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What syndrome, similar to Malignant Hyperthermia, can be seen with succinylcholine and volatile anesthetics?
Hypermetabolic Syndrome can occur, leading to life-threatening hyperkalemia and arrhythmias, particularly with succinylcholine use.
Why should succinylcholine and volatile anesthetics be avoided in patients with Myotonic Dystrophies?
Succinylcholine and volatile anesthetics can exacerbate instability of the muscle membrane, leading to complications.
What should be assessed regarding cardiac and pulmonary function pre-anesthesia?
Assess the extent of cardiac and pulmonary abnormalities through thorough evaluation, including auscultation of breath and heart sounds for abnormalities.
How does GI hypomotility impact the risk of aspiration?
GI hypomotility increases the risk of aspiration, necessitating careful management to mitigate this risk.
What endocrine abnormalities in MD should be considered pre-anesthesia?
Assess thyroid and glucose levels due to the high risk of endocrine abnormalities in patients with Myotonic Dystrophies.
Why is it important to keep MD patients warm pre-anesthesia?
Keeping patients warm helps to avoid flares of symptoms associated with Myotonic Dystrophies.
What should be done to optimize respiratory status pre-anesthesia in MD patients?
Optimize respiratory status to reduce the risk of postoperative respiratory weakness, a common complication in patients with Myotonic Dystrophies.
Why should depolarizing (Succs) neuromuscular blockers and opioids be used cautiously in MD patients?
Depolarizing neuromuscular blockers should be avoided because fasciculations can trigger myotonia. Caution should also be exercised with opioids.
What laboratory tests should be considered pre-anesthesia?
Consider CBC (Complete Blood Count), BMP (Basic Metabolic Panel), PFTs (Pulmonary Function Tests), and CK (Creatine Kinase) levels.
What are the three major dementia syndromes?
The three major dementia syndromes are Alzheimer’s (70%), Vascular dementia (25%), and Parkinson’s (5%).
What assessment should be conducted regarding cognitive function?
Assess the level of cognitive dysfunction in patients with dementia.
How should informed consent and decision-making be approached?
- Patient may not be able to give informed consent, look to medical PoA
- Investigate any advanced directives for medical decision-making
What evaluations should be conducted pre-operatively?
Perform basic labs and pertinent tests/imaging to assess the patient’s medical condition.
What is the potential risk related to aspiration?
Patients with dementia may have an increased risk of aspiration due to a full stomach, necessitating careful management.
Why is it important to review pre-operative medications?
Review pre-operative medications, especially those that may affect anesthesia, such as acetylcholinesterase inhibitors, MAOIs, and psychotropic medications.
What is an increased risk post-operatively in patients with dementia?
Patients with dementia are at an increased risk of post-operative delirium, which should be carefully monitored and managed.
How should opioids be managed in patients with dementia?
Balance opioids to meet analgesic needs without exacerbating delirium. Regional anesthesia may be preferred to reduce opioid requirements.
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What is Parkinson’s disease characterized by?
Parkinson’s disease is characterized by the degeneration of dopaminergic fibers in the basal ganglia.
What is considered the biggest risk factor for Parkinson’s disease?
Advanced age is considered the biggest risk factor for Parkinson’s disease.
How does dopamine normally regulate the extrapyramidal motor system?
Dopamine regulates the extrapyramidal motor system by inhibiting excess stimulation, which is primarily driven by acetylcholine.
What are the main symptoms that comprise the triad of Parkinson’s disease?
The triad of symptoms in Parkinson’s disease includes skeletal muscle tremor, rigidity, and akinesia.
What are some treatment options for Parkinson’s disease?
Treatment options include
- Levodopa (which crosses the blood-brain barrier),
- Anticholinergics
- MAOIs (which inhibit dopamine degradation)
- Deep brain stimulation.
What are some other symptoms commonly associated with Parkinson’s disease?
Other symptoms include
- Rhythmic “pill rolling” tremors
- Facial rigidity
- Slurred speech
- Difficulty swallowing
- Respiratory difficulty
- Depression
- Dementia
Question: What is important to assess regarding Parkinson’s disease before anesthesia?
Assess the severity, with special attention to the degree of pulmonary compromise.
Why is it important to review a Parkinson’s patient’s home medications before anesthesia?
Many home medications may interact with anesthetic drugs, for example, MAOIs.
What basic preoperative tests should be done for Parkinson’s patients?
Basic labs along with Pulmonary Function Tests if there are respiratory symptoms.
When are an EKG and Echo indicated preoperatively for Parkinson’s patients?
An EKG and Echo are indicated if clinically indicated.
Why are Parkinson’s patients at an increased aspiration risk under anesthesia?
They are at an increased risk due to dysphagia and possible dementia.
Why must PO Levodopa be continued for Parkinson’s patients undergoing surgery?
To avoid unstable extreme extrapyramidal effects such as chest wall rigidity.
What medications should be avoided in Parkinson’s patients due to potential adverse interactions?
Avoid reglan, phenothiazines, butyrophenones, and demerol if the patient is on MAOIs.
What consideration should be taken regarding deep brain stimulators during surgery for Parkinson’s patients?
Deep brain stimulators may need to be disabled to avoid interaction with cautery.
: What type of cautery is recommended for use in Parkinson’s patients during surgery?
If cautery is used, bipolar is recommended.
What are the two main types of brain tumors?
Brain tumors may be primary or metastatic.
What is the etiology and severity of brain tumors?
Brain tumors have a wide etiology and varying severity.
What are gliomas and how common are they among brain tumors?
Gliomas are primary brain tumors and are the most common type, comprising approximately 45%.
How are many types of gliomas categorized?
Many types of gliomas are based on histologic cell-type and subclasses based on oncogenic mutations.
What are benign meningiomas and how often do they occur?
Benign Meningiomas account for about 15% of brain tumors and arise from dura or arachnoid tissue.
What are pituitary adenomas and their prevalence?
Pituitary adenomas are noncancerous, make up about 7% of brain tumors, and the majority are found on autopsy.
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What are metastatic carcinomas in the context of brain tumors?
Metastatic carcinomas account for about 6% of brain tumors and can vary widely in origin and symptoms.
What are some other less common types of brain tumors?
Other types include Schwannomas, Craniopharyngiomas, and Dermoid tumors.
Other types include Schwannomas, Craniopharyngiomas, and Dermoid tumors:
The mass effects of any brain tumor can cause increased intracranial pressure (ICP), papilledema, headaches, mental impairment, mobility impairment, vomiting, autonomic dysfunction, and seizures.
What should be reviewed during pre-anesthesia for a patient with a brain tumor?
Review the patient’s history, previous therapies, and presenting symptoms.
What effect can radiation have on patients with brain tumors?
Radiation damage may lead to lethargy and altered mental status (AMS).
What are potential neurological effects of chemotherapy in patients with brain tumors?
Chemotherapy may also have neurological effects.
Why are patients with brain tumors often on steroids before surgery?
Patients are often on steroids to minimize cerebral edema.
What is important to monitor when continuing steroids in brain tumor patients?
It is important to continue steroids and monitor glucose levels.
How may autonomic dysfunction manifest in brain tumor patients and what should be monitored?
Autonomic dysfunction may manifest on EKG, with labile heart rates and blood pressures.
Why are anticonvulsants commonly used in patients with brain tumors?
Anticonvulsants are common, especially for those with supratentorial lesions.
What routine tests should be performed preoperatively for brain tumor patients?
CBC, BMP (especially glucose), and EKG should be performed preoperatively.
What medications should be managed preoperatively for brain tumor patients according to the surgeon’s instructions?
Manage pre-operative steroids and anti-seizure medications per the surgeon’s instructions.
What is Mannitol’s role in the preoperative management of brain tumor patients?
Mannitol is often used to reduce intracranial volume and pressure preoperatively.
What should be reviewed pre-operatively in patients with cerebrovascular disease?
Review the patient’s history, deficits, imaging, treatments, and co-existing diseases carefully.
What physical assessments should be done for pre-op cerebrovascular disease patients?
Assess orientation, pupils, bilateral grip strength, and lower extremity (LE) strength.
What symptoms should be asked about in patients with cerebrovascular disease?
Ask about headaches, tinnitus, vision/memory loss, and bathroom issues.
Look at the root cause of CVA, including vascular disease, embolic causes (such as atrial fibrillation, prosthetic valve, right to left shunt/Patent Foramen Ovale).
What imaging is recommended for preoperative assessment in cerebrovascular disease?
Imaging should include Carotid Ultrasound, CT/MRI of head & neck, and echocardiogram.
What are the routine preoperative investigations for cerebrovascular disease?
Preoperative investigations should include an EKG and a CBC, BMP including glucose.
What is the guideline for elective cases in patients on new anticoagulants for cardiac thrombus?
No elective cases should be scheduled within 3 months for patients on new anticoagulants for cardiac thrombus.
What should be done pre-operatively for patients on anticoagulants for cerebrovascular accident (CVA) prophylaxis?
Consult the prescriber to establish a protocol for managing anticoagulants pre-operatively.
What is the management strategy for high-risk CVA patients who pause long-acting anticoagulants?
High rx pts for CVA that pause LA anticoags (Warfarin) will need SA anticoags (LMWH, IV unfractionated heparin) to bridge the gap
Close monitoring of coagulation status is required
What is required when managing cerebrovascular disease patients who are pausing anticoagulants for surgery?
Close monitoring of coagulation status is required for patients who are pausing anticoagulants for surgery.
What is the protocol for discontinuing anticoagulants in relation to regional anesthesia?
Regional Anesthesia requires discontinuing anticoagulants for a sufficient time to safely perform the block.
What are the clinical features of an anterior cerebral artery stroke?
Contralateral leg weakness.
What are the clinical features of a middle cerebral artery stroke?
Contralateral hemiparesis and hemisensory deficit (face and arm more than leg), aphasia if it affects the dominant hemisphere, and contralateral visual field defect.
What are the clinical features of a posterior cerebral artery stroke?
Contralateral visual field defect and contralateral hemiparesis.
What are the clinical features when penetrating arteries are occluded?
Contralateral hemiparesis and contralateral hemisensory deficits.
What are the clinical features of a basilar artery stroke?
Oculomotor deficits and/or ataxia with crossed sensory and motor deficits.
What are the clinical features of a vertebral artery stroke?
Lower cranial nerve deficits and/or ataxia with crossed sensory deficits.
What percentage of aneurysm patients experience symptoms before rupture?
Only about 1/3
of aneurysm patients have symptoms before rupture.
How often are cerebral aneurysms diagnosed before rupture?
The majority of aneurysms are not diagnosed before rupture.
What are the common symptoms of cerebral aneurysms before rupture?
Symptoms include headache, photophobia, confusion, hemiparesis, and coma.
What are the risk factors associated with cerebral aneurysms?
Risk factors include hypertension, smoking, being female, oral contraceptive use, and cocaine use.
How are cerebral aneurysms diagnosed?
Diagnosis is via CT angiography, MRI, or lumbar puncture with CSF analysis if rupture is suspected.
When should intervention for a ruptured cerebral aneurysm be performed?
Intervention should be performed within 72 hours of rupture for the best outcomes.
Why is glucose monitoring important for patients with cerebral aneurysms?
Patients may be on steroids, making glucose monitoring important.
What are the pre-anesthesia considerations for a patient with a cerebral aneurysm?
Pre-anesthesia considerations include CT/MRI, EKG, echocardiogram, CBC, BMP, type and crossmatch with blood available.
What is important in the pre-anesthesia management of blood pressure in cerebral aneurysm patients?
BP control, mannitol? c*aim is to avoid rupture
What prophylactic measures should be considered pre-anesthesia in cerebral aneurysm patients?
Seizure prophylaxis and possibly the placement of a central venous catheter (CvC).
What are the surgical treatment options for cerebral aneurysms?
Surgical treatment options include coiling, stenting, and trapping/bypass for very large aneurysms.
A neurosurgeon may be on standby in case of intraoperative rupture or subarachnoid hemorrhage (SAH).
The risk for vasospasm is highest 3-15 days post-SAH.
What is triple H therapy in the context of post-SAH management?
Triple H therapy refers to Hypertension, Hypervolemia, and Hemodilution.
Which component of triple H therapy is initially the main treatment to avoid complications of hypervolemia?
Hypertension is the initial main treatment to avoid complications of hypervolemia.
What interventional treatments are used to relieve vasospasm?
Interventional treatments such as balloon dilation and direct injection of vasodilators are used to relieve the spasm.
What pre-anesthesia interventions are similar between managing cerebral aneurysms and post-SAH?
Pre-anesthesia interventions for post-SAH vasospasm are the same as with aneurysm, although normally they are less-invasive.
What does a score of 0 on the Hunt and Hess classification indicate?
An unruptured aneurysm with a mortality rate of 0%-2%.
What are the findings and mortality rate for a score of 1 on the Hunt and Hess classification?
A ruptured aneurysm with minimal headache and no neurologic deficits, with a mortality rate of 2%-5%.
What does a score of 2 on the Hunt and Hess classification signify?
A ruptured aneurysm with moderate to severe headache, no deficit other than cranial nerve palsy, and a mortality rate of 5%-10%.
Drowsiness, confusion, or mild focal motor deficit, with a mortality rate of 5%-10%.
What does a Hunt and Hess score of 4 represent?
Stupor, significant hemiparesis, early decerebration, with a mortality rate of 25%-30%.
What does a score of 5 on the Hunt and Hess classification indicate in terms of patient condition and mortality rate?
Deep coma, decerebrate rigidity, with a mortality rate of 40%-50%.
In the World Federation of Neurologic Surgeons grading system, what does a score of 1 represent?
A Glasgow Coma Scale score of 15 with no presence of major focal deficit and an intact, unruptured aneurysm.
What does a score of 2 or 3 on the World Federation of Neurologic Surgeons grading system indicate?
A Glasgow Coma Scale score of 13 or 14 with no presence of major focal deficit for a score of 2, and possible presence for a score of 3.
How is a score of 4 on the World Federation of Neurologic Surgeons grading system defined?
A Glasgow Coma Scale score of 7-12, with the presence of a major focal deficit being possible or not.
What does a score of 5 on the World Federation of Neurologic Surgeons grading system imply?
A Glasgow Coma Scale score of 3-6 with the presence of a major focal deficit being possible or not.
What characterizes an arteriovenous malformation (AVM)?
An AVM is an arterial to venous connection without intervening capillaries, resulting in high flow, low resistance shunting.
What is the commonly believed origin of arteriovenous malformations?
AVMs are believed to be congenital.
What is the range of symptoms for arteriovenous malformations?
Symptoms can range from mass-effects to hemorrhage.
Where are the majority of arteriovenous malformations located?
The majority of AVMs are supratentorial.
How are arteriovenous malformations diagnosed?
AVMs are diagnosed via angiography and MRI.
What pre-anesthesia assessments are important for patients with arteriovenous malformations?
Pre-anesthesia assessments include history and physical, review of medications, imaging, CBC, BMP, type and crossmatch, EKG, and echocardiogram.
What are the treatment options for arteriovenous malformations?
Treatment options include radiation, angio-guided embolization, and surgical resection, which carries a higher mortality risk.
What are key considerations in the pre-anesthesia management of arteriovenous malformations?
Pre-anesthesia management should focus on BP control, potential use of mannitol, seizure prophylaxis, ensuring large bore IV access x2, and arterial line placement.
How is the nidus size of an AVM graded in the Spetzler-Martin system?
Nidus size is graded as small (<3 cm) for 1 point, medium (3-6 cm) for 2 points, and large (>6 cm) for 3 points.
What does eloquence of adjacent brain mean in the Spetzler-Martin AVM grading system?
Eloquent brain areas are those that, if affected, would result in a significant neurological deficit. Eloquent areas score 1 point, while noneloquent areas score 0 points.
The pattern of venous drainage is graded as superficial only for 0 points and deep only or deep and superficial for 1 point.
What is the likelihood of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1?
There is a 100% chance of no postoperative neurological deficit with a Spetzler-Martin AVM grade of 1.
How does the Spetzler-Martin AVM grade correlate with the percentage of patients with no postoperative neurological deficit?
Grade 1 correlates with 100% of patients having no deficits,
- Ggade 2 with 95%
- Grade 3 with 84%
- Grade 4 with 73%
- Grade 5 with 69% having no postoperative neurological deficits.
How are traumatic brain injuries categorized?
Traumatic brain injuries are categorized as either “penetrating” or “non-penetrating,” depending on the breach of the dura.
How is the severity of a traumatic brain injury categorized?
The severity is categorized by the Glasgow Coma Scale.
What is considered a primary injury in the context of traumatic brain injury?
Primary injury occurs at the time of the initial insult.
What are secondary injuries in the context of traumatic brain injury?
Secondary injuries include neuroinflammation, cerebral edema, hypoxia, anemia, electrolyte imbalances, and neurogenic shock.
When is intubation required for traumatic brain injury patients?
Intubation is required in severe TBI (GCS < 9, airway trauma, respiratory distress).
What role does mild hyperventilation play in the management of TBI?
Mild hyperventilation is used to control intracranial pressure (ICP).
What imaging is required as soon as possible in cases of traumatic brain injury?
A CT scan of the head and neck should be done ASAP.
Review co-morbidities, degree of injury, imaging, labs, and perform a gross neurologic exam. Emergent surgery should not be delayed.
C-spine stabilization, adequate IV access, central venous catheter (CVC), arterial line (Aline), and possibly uncrossmatched blood if there is no time for type and crossmatch.
Why should nasogastric or orogastric tubes be avoided in TBI patients?
Refrain from nasogastric (NGT) or orogastric (OGT) tube placement due to the potential for basal skull fractures.
Intraoperative management includes ISTAT labs, pressors, hypertonic saline or mannitol, and calcium.
How is traumatic brain injury categorized?
Traumatic brain injury is categorized as “penetrating” or “non-penetrating,” depending on the breach of the dura.
How is the severity of a TBI categorized?
Severity of a TBI is categorized by the Glasgow Coma Scale.
What is a primary injury in TBI?
Primary injury occurs at the time of the initial insult.
What constitutes secondary injuries in TBI?
Secondary injuries include neuroinflammation, cerebral edema, hypoxia, anemia, electrolyte imbalances, and neurogenic shock.
When is intubation required in TBI?
Intubation is required in severe TBI, which is defined as a Glasgow Coma Scale (GCS) score of less than 9, airway trauma, or respiratory distress.
How is intracranial pressure (ICP) controlled in a patient with TBI?
Mild hyperventilation may be used to control ICP.
What imaging is essential in TBI cases?
A CT of the head and neck should be done as soon as possible.
What are the pre-anesthesia considerations for a patient with TBI?
: Review comorbidities, degree of injury, imaging, labs, and conduct a gross neurologic exam. Do not delay emergent surgery.
What is important regarding IV access and potential blood transfusion in the context of emergent TBI surgery?
Ensure C-spine stabilization, adequate IV access, central venous catheter, arterial line placement, and possibly use uncrossmatched blood if there is no time for type and crossmatch.
Refrain from using nasogastric or orogastric tubes due to the potential for basal skull fractures.
Intraoperative considerations include iSTAT labs, pressors, bicarbonate, and calcium administration.
Downward displacement of medulla and cerebellar tonsils and syringomyelia.
Herniation of the cerebellar tonsils, hydrocephalus, kink in the medulla, (Myelo)meningocele, and syringomyelia.
What is seen in a Chiari 3 malformation?
Further herniation of the cerebellum below the foramen magnum forming an encephalocele in addition to spina bifida.
How is Chiari 4 malformation defined?
Hypoplasia/Aplasia of the cerebellum with spina bifida.
What are common complaints in patients with congenital displacement of the cerebellum?
Complaints include headache extending to shoulders/arms, visual disturbances, and ataxia.
What is the treatment for Chiari malformations?
Treatment typically involves surgical decompression.
What are the pre-anesthesia considerations for patients with Chiari malformations?
Review the patient’s history and physical, deficits, imaging, CBC, BMP, type and crossmatch. You may hyperventilate to decrease ICP, and ensure large bore IV x 2 or central venous catheter, and arterial line are in place.
A seizure is a transient, paroxysmal, and synchronous discharge of neurons in the brain.
A seizure is a transient, paroxysmal, and synchronous discharge of neurons in the brain.
Seizures can be caused by transient abnormalities such as hypoglycemia, hyponatremia, hyperthermia, or intoxication
How can seizures caused by transient abnormalities be treated?
Treating the underlying cause is curative for seizures caused by transient abnormalities.
What distinguishes epilepsy from a single seizure event?
Epilepsy is characterized by recurrent seizures due to congenital or acquired factors.
What is the action of antiepileptic drugs?
Antiepileptic drugs decrease neuronal excitability and enhance inhibition.
What should be determined pre-anesthesia in patients with seizure disorders?
Determine the source of the seizures (if known) and how well they are controlled. It is important to have anti-seizure drugs on board before incision.
Why is it important to review drugs and their pharmacokinetic/pharmacodynamic actions in patients with seizure disorders?
Understanding the drugs and their actions is important for managing anesthesia in patients with seizure disorders.
Which antiepileptic drugs are enzyme inducers?
Phenytoin, Tegretol, and Barbiturates are enzyme-inducers.
What may an anesthesiologist be called to do post-seizure?
An anesthesiologist may be called to intubate post-seizure, typically employing Rapid Sequence Intubation (RSI) with cricoid pressure.
