CNRN Terms Exam 277 Questions with Verified Answers,100% CORRECT

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CNRN Terms Exam 277 Questions with Verified Answers Post-concussion syndrome - CORRECT ANSWER Short-term memory loss, emotional lability, and mental fatigue. Headache, dizziness, fatigue, irritabil... ity, anxiety, insomnia, loss of concentration, poor memory and light and noise sensitivity. Uncal herniation syndrome - CORRECT ANSWER form of herniation that involves downward displacement of the uncal portion of the temporal lobe, which is the most common type of herniation syndrome. Findings are indicative of Cushing's reflex, which are late findings of deterioration and indication of herniation. ipsilateral pupil dilation and contralateral motor deficits. Cushing's reflex - CORRECT ANSWER hypertension, bradycardia, and abnormal respiratory pattern CPP formula - CORRECT ANSWER MAP-ICP = CPP. [(DBP x2) + SBP)]/3 = MAP Normal CPP levels - CORRECT ANSWER 50-70 mmHg cortical visual impairment - CORRECT ANSWER complete or partial visual loss, with normal pupillary responses, and no other ocular abnormalities. Usually caused by hypoxia/ischemia (stroke, cardiac arrest), drugs/toxins (CO poisoning), and trauma (hemorrhage) Bitemporal hemianopsia - CORRECT ANSWER associated with optic chiasm compression (ex pituitary tumor), aka hemianopia, manifests as loss of view to both temporal fields or "tunnel vision." classic epidural hematoma - CORRECT ANSWER characterized by sudden, brief, loss of consciousness (concussion), followed by a lucid interval (resolving concussion). The patient then becomes progressively more confused, agitated, and unresponsive as the hematoma expands and ICP increases Sympathetic storm - CORRECT ANSWER - Stress response elicited by hypothalamic stimulation of the sympathetic nervous system and adrenal glands, causing an increase in the level of circulating corticosteroids and catecholamines. - Symptoms= agitation, increased posturing, hypertension, hyperthermia, tachycardia, tachypnea, and diaphoresis. Simple partial seizures - CORRECT ANSWER With preserved consciousness. Symptoms interfere with sensory and motor. Means only one hemisphere affected, usually small portion Complex partial seizure - CORRECT ANSWER - Begins with behavior arrest, consciousness is impaired. - Followed by staring, automatisms, posturing and postictal confusion. Automatisms - CORRECT ANSWER Lip smacking, chewing, mumbling, fumbling with hands. Involuntary repetitive motor activity Absence seizures - CORRECT ANSWER - Brief impairment of consciousness without unconsciousness, no aura, no postictal confusion. - Staring or blanking out spells. - May exhibit rapid blinking, chewing or aimless movements of head or limbs. - Lasts 2-15 seconds - Occurs more often in children. Generalized tonic-clonic seizures - CORRECT ANSWER - "Grand mal seizures" - entire cerebral cortex is involved - aura present - generalized tonic extension of extremities lasting a few seconds - followed by clonic rhythmic movements with hyperventilation and profuse salivation - prolonged postictal confusion doesn't feel, see, or remember anything during seizure - lasts 1-2 min, sleep for several hrs after. - Valproic acid first choice Generalized myoclonic seizures - CORRECT ANSWER - Generalized jerking of an extremity - Less than 5 seconds - Brief, easy to miss period of unconsciousness - Occurs in clusters Atonic Seizures - CORRECT ANSWER - Known as "drop attack" - Occurs in persons with clinically significant neurologic abnormalities, associated with falls and injuries Left vagus nerve stimulation (VNS) - CORRECT ANSWER - Implanted electrode that reduces seizure frequency in epileptic patients with medically refractory seizures. - It is automatically programmed to fire for 30 seconds every 5 minutes, but can be manually set as a patient needs change. - Alterations are made by a magnet, which is placed over the generator in order to temporarily stop stimulation. - Because of the proximity to the laryngeal nerve, voice changes are a major side effect of vagal nerve stimulation. Turning the VNS off while speaking prevents vocal changes Generalized Convulsive Status Epilepticus (SE) - CORRECT ANSWER - Condition of prolonged or frequent seizures - Incomplete recovery in between seizures, continuous overlapping recovery - Lasts greater than 5 minutes, medical emergency - 10% mortality rate - Benzodiazepines are the initial drug of choice. If the seizure continues, and for ongoing prophylaxis, either phenytoin (Dilantin) or fosphenytoin (Cerebyx) are administered next. Refractory SE - CORRECT ANSWER Seizures occurring >90 min after administration of anticonvulsant medications Nonepileptic event - CORRECT ANSWER - Resembles a seizure, no EEG changes when comparing to audio-video monitoring - Onset is dramatic, bizarre, gradual, in the presence of witness, after an emotional upset, screaming throughout with eyes closed. - Lasts longer than a real seizure Cluster Headache - CORRECT ANSWER - Age of onset= middle age - Gender= males at higher risk - Onset, evolution= rapid - Time course= clusters in time, daily for weeks, nocturnal - Quality= steady and sharp - Location= orbit, temple and cheek - Associated features- Ipsilateral lacrimation, rhinorrhea, Horner's syndrome. Tension headache - CORRECT ANSWER - Chronic lasts at least 15 days a month for at least 16 months - Age of onset= all ages - Gender= females - Onset/evolution= slow to rapid - Time course= episodic, may become constant - Quality= dull, aching - Location= bilateral temporal - Associated features= none Chronic daily headache - CORRECT ANSWER - Occurs >15 days a month or daily for 3 months - Age of onset= middle age, 30-40 years old - Gender= females - Time course= constant to near constant - Quality= variable - Location= variable - Associated features= none Cluster headaches - CORRECT ANSWER - Extremely severe for short duration, high frequency (up to 8 daily) for several months - treatments= prednisone, lithium, methysergide, Ca channel antagonists, valproate. - Acute attacks managed with oxygen, sumatriptan, ergotamin Tension Headaches - CORRECT ANSWER - Most common type of headache. - Mild to moderate bilateral headache - Tight band or pressure around head - Chronic= 15 days per month - Ice, ASA, NSAIDS, best managed with tricyclic antidepressants (amitriptyline, naproxen) - Avoid long-term use of antihistamines, tranquilizers, caffeine, ergot alkaloids. Communicating reabsorptive hydrocephalus - CORRECT ANSWER - CSF is absorbed through arachnoid villi into venous sinuses, decreasing reabsorption of CSF - Subarachnoid hemorrhage, meningitis - Treatment= ventricular drain, lumbar drain, ventriculoperitoneal shunt Non-communicating obstructive hydrocephalus - CORRECT ANSWER - Obstruction of CSF flow - Most common site is Aqueduct of Sylvius (between 3rd & 4th ventricles) - Tumor, edema, mass, infection - Treatment= remove obstruction if applicable. Ventricular drain, lumbar drain, VP shunt Normal Pressure hydrocephalus - CORRECT ANSWER - Symptoms= confusion, ataxia, incontinence. "Wet, whacky, wobbly" - Determine VP shunt placement. 72 hours of drainage with improved gait. Assess for infection 1 month after Pseudotumor Cerebri - CORRECT ANSWER - Known as idiopathic intracranial hypertension - Condition where pressure around brain increases, causing headaches and vision problems - Known as false brain tumor due to symptoms - Increased ICP may result from problems with CSF absorption process. - Treatment= weight loss, limiting fluids or salt, diuretics, spinal tap or shunt placement Neuropathic pain - CORRECT ANSWER - Tingling, shooting, burning, aching, throbbing, sharp - Sensitive to light touch - Neurontin is first line treatment - Tricyclic antidepressants is second-line treatment - Intrathecal/intraventricular opioid and local anesthetics Thalamic pain syndrome - CORRECT ANSWER - stroke of thalamus or parietal lobe. - Ischemic injury causing neurons to misfire, can be any time after stroke and increases in severity over time Peripheral Neuropathy - CORRECT ANSWER - Chronic numbness, pain, tingling - Caused by impact, chemical toxins (HIV), drugs, demyelination - DANG THE RAPIST- Drugs, Alcohol, Nutritional, Guillian-Barre, Traumatic, Hereditary, Endocrine, Renal, Amyloid, Porphyria, Psychiatric, Pseudoneuropathy, Infectious (Hansen's disease), Sarcoidosis, Toxins - Treatment= control diabetes, lidocaine patches, Pregablin, Amitriptyline, PT/OT Trigeminal neuralgia - CORRECT ANSWER - aka tic douloureux, prosopalagia - Sudden, recurrent, severe/intense burning pain, comes and goes. Sensitive to temperature stimuli. - Disruption of 1+ branches of CN V (MRI shows vessel compression) - Unilateral, not responsive to opioids - Occurs for few seconds over weeks, decreases. - Treatment= anticonvulsants (Carbamazepine. Monitor for liver toxicity), microvascular decompression, rhizotomy, nerve block, alcohol injections (relief for 8-16 mo) Alzheimer's - CORRECT ANSWER - Not disease, collection of symptoms. - Onset= 80 years old. - Genetic markers= ApoE e4 - MRI= Neural atrophy - Conclusive dx only done per autopsy (amyloid plaques and neurofibrillary tangles post-mortem) - Aspiration pneumonia is cause of death Alzheimer's Stage I Manifestations - CORRECT ANSWER - Short-term memory loss, loss of spontaneity. - Sporadic loss of words - Easy to anger - Less discrimination with choices Alzheimer's Stage II Manifestations - CORRECT ANSWER - Stage where patient is disoriented, difficulty in making decisions, impaired judgment - Rummaging/pillaging, avoid new situations. - Impaired communication - Loss of impulse control, decreased concentration - Wandering, sundown syndrome, personality changes Alzheimer's Stage III Manifestations - CORRECT ANSWER - Sundowning, catastrophic reactions. - Failure to recognize family an friends - Preservation, latency - Agnosia, apraxia Alzheimer's Stage IV Manifestations - CORRECT ANSWER - Inability to communicate - No recognition of others - Total dependence Alzheimer's treatment - CORRECT ANSWER - Anticholinesterase- promotes cholinergic activity. - Cognitive treatment= Donepezil (Aricept) Ropinirole (Requip), Rivastrigmin (Exelon), Reminyl (Galantamine), Memantine (Namenda)- NDMA-type glutamate receptor antagonist side effects= hallucinations, confusion, dizziness Vascular Dementia - CORRECT ANSWER - Dementia due to series of small lacunar strokes- focal neurological deficits, hemiparesis. - Frontal lobes infarcted, mainly white matter - Risk factors= High BP, high cholesterol, DM, increased age. - Symptoms= decline in executive function, trouble focusing, magnetic gait, pseudobulbar effect Diffuse white-matter dementia - CORRECT ANSWER - Binswanger's disease - Subcortical atherosclerotic encephalopathy - Confusion, apathy, forgetfulness. Behavioral changes, gait disorders, urinary incontinence, difficulty speaking Lewy bodies - CORRECT ANSWER deposits of proteins in nerve cells in area of brain associated with cognitive and motor function Lewy body dementia - CORRECT ANSWER - Second most common type of dementia, > age 60, males - generally retain short-term memories, but forget events in the distant past with a continuous, gradual, progressive decline in mental status. - Amyloid plaques in most cases with minimal neurofibrillary tangles - Symptoms fluctuate frequently, slow progression, dizziness, falls constipation - Visual hallucinations, rapid eye movement, sleep behavior disorder, Parkinsonism (muscle rigidity, tremors, slow movement) - Treat agitation with cholinesterase inhibitors (Rivastigmine, donepezil, galantamine, carbidopa/levodopa) Sundown syndrome - CORRECT ANSWER - Disruption in circadian rhythm - Symptoms are anger depression, anxiety, fear, delusions, emotional outbursts, paranoia. - treatment is benzodiazepines, low potency antipsychotics, hypnotics, managing agitation. Delirium - CORRECT ANSWER - Acute confusional state, fluctuates in level of consciousness. - Symptoms are hyperactive, hypoactive, and mixed. Decline in cognitive function. Prevention is early mobilization. - Antipsychotics haloperidol Parkinson's disease - CORRECT ANSWER - Motor disorder with degenerative loss of basal ganglia. -Decrease in dopaminergic cells in substantia nigra. - decreased thalamic excitation of motor cortex. - Symptoms tremor, rigidity, akinesia/bradykinesia (slow motor movement), posture. Drooling, orthostatic hypotension, sleep disturbance, decreased smell (anosmia) Parkinson's disease treatment - CORRECT ANSWER - Dopaminergics- converts into dopamine, increases dopamine. Levodopa (Sinemet). Side effect is dyskinesia, orthostatic hypotension, hallucinations. - dopamine agonist- improves effect of dopamine by acting directly on the postsynaptic dopamine receptors. Side effects are orthostatic hypotension and hallucinations. Addictive behavior. - COMT inhibitors- Comtan (Entacapone), Tasamer (Tolcapone) - Anticholinergics- Congentin (Benztropin), Artane (Trihexyphenidyl) Deep Brain Stimulation - CORRECT ANSWER - Parkinson's treatment to improve motor symptoms, tremors and rigidity. - Awake throughout procedure. Hold meds prior - Stimulator placed in sub-thalamic nucleus Pallidotomy - CORRECT ANSWER - Surgical removal of globus pallidus internus, regulates function of motor signal pathways for Parkinson's disease - Fewer complications but not adjustable Dystonia - CORRECT ANSWER - Nervous sustem dysfunction of cerebral cortex and basal ganglia involved - Persistant involuntary muscle contractions - Twisting, repetitive movement, abnormal posture affecting any part of body. - Tx: botox injections, anticholinergics, antispasmotics, dopaminergic. DBS or surgical denervation Oromandibular dystonia - CORRECT ANSWER - Jaw & tongue, leads to deformation of mouth Spasmodic dystonia - CORRECT ANSWER larynx affected, causes whispering Oculogyric crisis - CORRECT ANSWER eyes, neck and jaw dystonia causing eyes to look up and converge. Neck flexion, jaw open or clenching Focal dystonia - CORRECT ANSWER segmental dystonia affecting specific muscle groups such as neck, eyes, eyelids and jaw primary dystonia - CORRECT ANSWER idiopathic or genetic Secondary Dystonia - CORRECT ANSWER has attributed cause such as trauma or medication side effect cervical dystonia - CORRECT ANSWER Rotation and flexion of neck. Eyes blink uncontrollably or remain shut causing blindness or blepharospasm Restless leg syndrome - CORRECT ANSWER - Pain and paresthesia in legs while at rest, especially in evening, periodic jerking. - Movement relieves pain causing difficulty sleeping and daytime exhaustion - Genetic and related to iron deficiency anemia - Tx: Requip and Mirapex, carbidopa, tramadol, cyclobenzapine, gabapentin, iron replacement Benign essential tremor - CORRECT ANSWER - Most common tremor in adults - High frequency, oscillatory movements, bilateral - Posture is maintained. - Tx= Primidone, propanolol Degenerative Disc Disease - CORRECT ANSWER - Due to dehydration of intervertebral discs and loss of blood supply, causing deterioration of disc and increased risk of disc herniation & vertebral slippage. - Decreased height and volume of nucleus pulposus from aging and degeneration of annulus fibrosis (outer disc) - Treat with NSAIDs and spinal fusion Spondylolisthesis - CORRECT ANSWER - Anterior shifting of vertebral body from front to back - Usually between L5-S1 or L4-L5. - Causes= hyperthyroidism, osteoporosis, tumors, spinal cord injury - Tx: rest, surgery, back support Spinal stenosis - CORRECT ANSWER - Narrowing of spinal foramina causing pressure on spinal nerves, usually in lumbar region - Pain in back/buttocks, when leaning forward and standing - Develops from intervertebral disc degeration, osteoarthritis, spondylolisthesis - Tx: laminectomy or surgical decompression Lumbar level herniated disc - CORRECT ANSWER - L4-L5, L5-S1, sometimes L3-L4. - Pain on hip, groin, side of thigh and calf, top of foot (first 3 toes), foot drop, difficulty walking on heels - L5-S1= Pain on gluteus back of thigh, calf, lateral outer foot herniated nucleus pulposus (HNP) - CORRECT ANSWER - affects lumbar area, most common on L4-L5, C6-C7 - 50% of herniation due to trauma - Tx: bedrest, injection therapy Peripheral nerve injury - CORRECT ANSWER - Seddon or Sunderland classification. - Neuropraxia: no nerve/connective tissue injury - Axontmesis- nerve damage, connective tissue in tact - Wallerian degeneration- connective tissue allows regeneration of nerves, connective tissue in tact carpal tunnel syndrome (CTS) - CORRECT ANSWER - "Entrapment neuropathy" - Pain in hand, may extend to elbow. Difficulty gasping and pinching - Associated with occupational overuse and repetitive movement syndromes - Tx: Exercises that hyperextend fingers and hand, steroid injections, micro decompression. - Open carpal tunnel release= incision to decompress nerve Thrombotic stroke - CORRECT ANSWER - Large vessel disease (carotid or MCA) - Obstruction due to atherosclerosis Embolic stroke - CORRECT ANSWER - Small vessel disease. - Obstruction due to clot. - Occurs during activity or from atrial fibrillation or patent foramen oval. - MCA will affect arms and present with lower facial droop - ACA stroke will present with leg dysfunction - Cerebellar arteries will present with ataxia, dizziness, nystagmus - Give tPA if within window Lacunar stroke - CORRECT ANSWER - Affects small penetrating vessels, deep arteries (small vessels, large deficits) - Usually found in basal ganglia, thalamus, internal capsule and pons. - Leticulostriate arteries - Vascular dementia - Presents with cognitive decline - Control risk factors (HTN, diabetes, smoking) - Tx: thrombolytic therapy, carotid endarctectomy, aspirin within 48 hrs of onset Penumbra - CORRECT ANSWER - Area outside of ischemic area - Located around irreversible area of infarct - Amendable to reversal from ischemia - Tx: O2, blood pressure and glucose management Wernicke-Korsakoff (W-K) syndrome - CORRECT ANSWER - non-reversible encephalopathy associated with atrophy of specific brain regions. - Consists of two distinct syndromes: Wernicke encephalopathy is characterized by a confusional state that is often reversible, whereas Korsakoff dementia causes chronic memory loss. - Classic findings of syndrome include visual disturbances, gait abnormalities, balance problems, apathy, hallucination, agitation, and confabulation (the spontaneous production of false memories). - It can be prevented by administering thiamine (vitamin B1) prior to 50% dextrose infusion. rt-PA administration - CORRECT ANSWER - Within 3-4.5 hrs from onset of symptoms - perform NIHSS - Negative non-contrast CT scan - Contraindication= anticoagulation within 48 hrs, INR >1.7, platelet count <100,000, recent history of surgery, GI bleed, TBI, spinal surgery - Dose= 0.9 mg/kg, max 90 mg - Admin 10% of dose by bolus over 1 min - remainder of dose via IV pump over 1 hr - Complications= angioedema (2%), ICH (6%) Contraindications of TPA administration - CORRECT ANSWER - Anticoagulation within 48 hrs - INR >1.7, platelet count <100,000 - recent history of surgery - GI bleed - TBI - spinal surgery Large vessel occlusion - CORRECT ANSWER - MCA obstruction (affects upper body, face and arms) - Treat with endovascular thrombectomy and/or intra-arterial thrombolytic (thrombolytic first if possible) - Up to 24 hours from last known well time - Use stent retriever to grab and remove clot Assessment post-thrombolytic administration - CORRECT ANSWER - Monitor for 24 hours - Every 15 min for 2 hrs - Every 30 min for 6 hrs - Every hour for 16 hours Stroke blood pressure management - CORRECT ANSWER - Ischemic stroke NON-thrombolytic candidates: <220/120 - Ischemic stroke thrombolytic therapy candidates: <185/110 - Ischemic stroke post-thrombolytic : <180/105 - Treat with labetalol then Nicardipine Intracerebral hemorrhage (ICH) - CORRECT ANSWER - Common cause= hypertension, coagulopathies - Symptoms= HA, decreased LOC, HTN, vomiting, seizures - Location= Basal ganglia (most common), thalamus, lobarm pons, cerebellum - Rupture of cerebral artery with accumulation of blood in parenchyma - Steady worsening of initial symptoms as blood accumulates. - Increase in ICH volume up to 12 hrs post-bleed - Vasogenic edema occurs hours to days, shift/herniation may occur - Poor prognosis with intraventricular extension - Tx: treat underlying cause, VTE once bleeding stops. ICH nursing care - CORRECT ANSWER - Airway and breathing - SBP <160 mmHg - Use prothrombin complex concentrate (PCC) for INR reversal - Fever management first 72 hrs - Glucose management - Swallow screen, seizure precautions Subarachnoid hemorrhage (SAH) - CORRECT ANSWER - Common cause is aneurysm or AVM - Located in subarachoid space between brain and membrane - CT scan then cerebral angiogram (CTA and digital subtraction angiography) - Symptoms= "worse headache of life", vomiting, focal neuro deficits, decreased LOC - Control SBP to 120-140 prior to securing aneurysm (coiling or clipping) - Administer nimodipine (neuroprotection) up to 21 days after admission, improves neuro outcomes - High-mortality rate, first 24-48 hrs, potential for re-bleeding Hunt and Hess Classification - CORRECT ANSWER Determines severity and outcome of SAH - Grade I: Asymptomatic, mild headache, nuchal rigidity - Grade II: Moderate/severe headache, nuchal rigidity, no focal deficits other than cranial nerve palsy - Grade III: Confusion, lethargy or mild focal deficits - Grade IV: Stupor, moderate/severe hemiparesis - Grade V: Coma, extensor posturing, moribound (at the point of death) appearance Communicating hydrocephalus - CORRECT ANSWER - SAH complication caused by disturbed reabsorption of blood in subarachnoid space (arachnoid villi blocked up) - Tx: Ventriculostomy drain, lumbar drain or VP shunt Vasospasms - CORRECT ANSWER - Also known as delayed cerebral ischemia (DCI) - 3-14 days post SAH, occurs in 30% of patients, presents with neuro deficit. - Distal artery spasm, no oxygen delivered. - Peak occurrence is 7-10 days post SAH, diagnosed with TCD, confirm with angiogram - Goal= euvolemia - Tx: Triple H therapy (hypertension, hypervolemia, and hemodilution) & use of vasopressors (norepinephrine, phenylephrine, epinephrine, and dopamine). Endovascular therapy, balloon angioplasty and intra-arterial vasodilator Syndrome of Inappropriate Antidiuretic Hormone (SIADH) - CORRECT ANSWER - Increased secretion of ADH, resulting in water retention. - Treat by replacing sodium and fluid restriction Cerebral Salt Wasting (CSW) - CORRECT ANSWER - Failure of the CNS to regulate sodium reabsorption, causing a true hyponatremia. - Increase in circulating atrial natriuretic peptide - Tx: replace sodium and volume Intraventricular Hemorrhage - CORRECT ANSWER - Blood entering deep fluid-filled spaces of ventricles - Blocks CSF circulation and potentially causes hydrocephalus (common in infants with LBW) - Usually complication of SAH and ICH - 50-70% mortality rate - No treatment at this time, but possible external ventricular drain placement and intraventricular TPA injection Hemorrhagic conversion/transformation - CORRECT ANSWER - Hemorrhage into infarcted area of brain - TPA/antiplatelets increase risk of hemorrhagic transformation - High pressure from embolic stroke causes fragile veins, more likely to rupture after TPA - Tx: supportive care, anti-convulsives, antihypertensives Hemorrhagic Infarct Types - CORRECT ANSWER - Type 1: Small petechial hemorrhage along margin of infarct - Type II: Within infarct, no space occupying lesion Parenchymal Hematoma Types - CORRECT ANSWER Type 1= < 30% of infarcted area, Type 2= >30% of infarcted area Transient Ischemic Attack (TIA) - CORRECT ANSWER - Brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms usually lasting < 1 hr, and without evidence of acute infarction - Most common cause is carotid stenosis - Symtoms= visual loss, visual blurring, diplopia, limb weakness or numbness, facial weakness, dysarthria, aphasia - Dx studies: carotid ultrasound, angiogram TIA management - CORRECT ANSWER - Anti-platelet agents: ASA, plavix, Aggrenox - Anticoagulants with atrial fibrillation= Coumadin - Treatment for carotid stenosis= carotid endarterectomy (risks= mobilization of emboli, BP instability, MI and seizures), carotid angioplasty and stenting Carotid endarterectomy - CORRECT ANSWER - Doesn't benefit patients with <50% stenosis. - Patients with >70% show significant reduction of stroke risk. - Risks include mobilization of emboli, BP instability, SBP maintained at 150 mmHg. - Complications= MI and seizures Cerebral Venous Sinus Thrombosis (CVT) - CORRECT ANSWER - Clot between endosteal and meningeal layer of dura covering brain - Causes venous congestion, cerebral ischemia, infarction (large may hemorrhage) - Symptoms= headache, papilledema, seizures, focal deficits, altered consciousness, loss of hearing, difficulty swallowing, incoordination - Etiology= infection, coagulopathy, hematologic disorder, inflammatory disorder, trauma, pregnancy, neoplasia - Treatment= decrease ICP, anticonvulsants, antibiotics, steroids, heparin. Fluid restriction, diuretics. Cerebral aneurysm - CORRECT ANSWER - Saccular (berry) most common type - Occurs at bifurcation (weak walls) of Circle of Wilis (anterior circulation) - Size ranges from 1 mm - 5 cm, giant > 2.5 cm. - Fusiform are outputting of vascular wall, no neck (tx= wrapping of aneurysm) - Mycotic is caused by septic emboli, bacterial endocarditis - Aneurysm rupture is due to sudden increase in blood pressure (exercise, stress, EtOH, etc) Unruptured aneurysms - CORRECT ANSWER - May not have signs or symptoms, may be detected through MRI or carotid angio. - CN palsy, pupil dilation, diplopia, eye pain behind eyes localized headache. Ruptured aneurysm - CORRECT ANSWER - localized headache, nausea/vomiting, stiff neck, diplopia, photophobia, loss of sensation. - Confirmed by CT scan, cerebral angio, or blood detected in CSF Cerebral aneurysm risk factors - CORRECT ANSWER - Age 50-70s - History of ruptured aneurysm - Connective tissue disorders: polycystic kidney disease, Ehlers-Danlos syndrome (collagen deficit) - Family history, female gender, African-American. - HTN, tobacco, drugs Detachable coils - CORRECT ANSWER - Endovascular intervention. Placed with micro catheter via femoral artery, occludes aneurysm from inside the vesel - low voltage apple to guide wire to detach the coil placed into the sac of aneurysm - ICU for at least 24 hours post-coiling - Monitor peripheral pulses post-angio - Follow-up angiography 6 mo-1 year after procedure to insure complete obliteration of aneurysm Stent placement - CORRECT ANSWER - Endovascular procedure that treats wide-neck or fusiform aneurysms got permanent obliteration - Provides a scaffolding effect for coiling with a small flexible cylindrical mesh tube Cerebral aneurysm surgical interventions - CORRECT ANSWER - Craniotomy - Clipping of aneurysm- 97% effective in obliterating the neck of the aneurysm. - Wrapping of fusiform - Trapping Aneurysm clipping - CORRECT ANSWER Isolation of aneurysm with clips to allow for deflation, angiography visualizes closure to ensure blood flow Arteriovenous Malformation (AVM) - CORRECT ANSWER - High-pressure arteries feed directly into low-pressure veins without capillaries causing vascular mass (arteries and veins interface directly) - Center called nidus- "nest" - Rupture of AVM bleeds into subarachnoid space, presenting like ruptured aneurysm AVM treatment - CORRECT ANSWER - Immobilization- injecting glue-like substance internally to shrink before radiosurgery - Embolization- permanent occlusion of nidus and feeding vessels. - Monitor catheter site for bleeding or hematoma, maintain heparin infusion. - Monitor for lower extremity ischemia (5 P's)- Pain, pallor, pulselessness, poikilothermia, paraesthesia - Maintain MAP <90 mmHg - Stereotactic radiosurgery- can only treat smaller lesions <3 cm - Deep AVMs are poor surgical candidates. Tx: deliver high dose of radiation to targeted area to thicken blood vessels and occlude for 18 months-2 years Arteriovenous fistula/Carotid-cavernous fistula - CORRECT ANSWER - Arterial blood to vein, diminishes flow of oxygen to targeted areas adding abnormal stress to the vein due to higher arterial pressure--may form aneurysm - Abnormal collections between internal carotid artery of external carotid artery and cavernous sinus. - Usually behind the eye. Spontaneous and idiopathic Type A carotid-cavernous fistula - CORRECT ANSWER High pressure, direct connection between carotid and cavernous sinus Type B carotid-cavernous fistula - CORRECT ANSWER Low pressure, dural shunt between carotid and cavernous fistula Type C carotid-cavernous fistula - CORRECT ANSWER Low pressure, dural shunt between meningeal branches of external carotid artery and cavernous sinus Type D carotid-cavernous fistula - CORRECT ANSWER Low pressure, combination of types B and C, with dual shunts between internal and external carotid artery branches and cavernous sinus Carotid Cavernous Fistula Signs and Symptoms - CORRECT ANSWER - Onset usually sudden - Ocular manifestations- ophthalmic venous hypertension, lid and orbital venous congestion, massive unilateral ptosis, corneal exposure, conjunctival chemosis, pulsating exopthalmous, diplopia, visual loss, central retinal vein occlusion, retinal hemorrhages - Epistaxis - Cranial nerve palsy III, IV, V, VII - Bruit and headache may be present Carotid-cavernous fistula treatment - CORRECT ANSWER - Surgery rarely done - Endovascular approach (balloon or coils)- obliteration of the fistulous connection with restoration of normal arterial and venous flow - External carotid self-compression: type B, C, and D fistulas (low pressure fistulas). 20-30 seconds 4 times per hour may lead to thrombosis of fistula, causing bradycardia Interventional treatment of carotid-cavernous fistula - CORRECT ANSWER - occlusion coils or glue-like substitute blocking to feeding vessels, resulting in blocking of abnormal vessel collection Stereotactic surgery of carotid-cavernous fistula - CORRECT ANSWER Radiation to abnormal vessels. Stent-graft that covers artery/vein communication Carotid stenosis - CORRECT ANSWER - Treatment is carotid endarteretomy. - Carotid angioplasty and stenting for severe disease and multiple comorbidities Cavernous angiomas - CORRECT ANSWER - vein-like arrangement restricting blood flow, resembles tumor - congenital, nodular, purple lesion usually in intraocular space - sinusoid type vessel not separated by neural tissue - low flow low pressure vascular lesion - age-range is 30-50 years old - two types include sporadic or familial - s/s= weakness, numbness, vision/speech problems. If in brain stem, alters gag reflex, respirations, temperature, cardiac regulation etc. - diagnosed with CT/MRI - symptoms based on location - treat for hemorrhage/seizures with surgery hemangioma extirpation - CORRECT ANSWER 1. an orbiototomy 2. vessels caudarized 3. blunt dissection of lesion Carotid dissection - CORRECT ANSWER - anterior circulation - TRAUMA common cause (weight lifting, chiropractor) - intima tear develops at intramural hematoma, narrowing lumen causing "false lumen" - Progression occurs days to weeks, tinnitus, pulse awareness. Stagnant blood= risk for clots, TIA, stroke - Manifestations= pain in face, headache, Horner's Syndrome (ipsilateral ptosis, miosis/small pupil, anhidrosis), cranial nerve palsies (3 & 6) - Treatment= anticoagulation, thrombolysis, endovascular, intervention, surgery with stents Vertebral dissection - CORRECT ANSWER - posterior circulation- feeds occipital lobe, medulla, cerebellum, brainstem - Cranial nerves 9-12 (breathing) - traumatic cause (martial arts, younger population) - s/s occipital HA, neck/facial pain, nystagmus, temperature changes - diagnosed with angiogram - treat with anticoagulation and anti platelets (ASA) - surgery= intracranial bypass Moya Moya - CORRECT ANSWER - rare, occlusive intracranial vasculopathy, progressive stenosis, affects circle of willis and terminal portions of internal carotid arteries - small, thin-walled torturous arteries, causing eventual occlusion - may be connected with thyroid disorder, Down's syndrome, Marfan's syndrome, parasellar tumors, atherosclerosis diagnosis - "cloudiness," "puff of smoke" - presents with stroke-like symptoms - medical treatment= anti platelets, calcium channel blocker. - surgery= STA-MCA bypass, encephaloduralarteriosynangiosis, encephalomyosyangiosis (creating channel) Anoxic injury - CORRECT ANSWER - without oxygenation for >4 min - caused by airway obstruction, arterial obstruction, cardiac arrest, embolic or thrombotic stroke, carbon monoxide inhalation - cytotoxic injury - assessment= decreased LOC, seizure, ataxia, headache - long-term effects= changes in personality, cognitive impairment, mood swings - Management= monitor lOC, treat underlying condition, supportive care GSC classifications of brain injury - CORRECT ANSWER - Mild: GSC >13, "concussion" - Moderate: GCS= 9-12 - Severe: GCS= 3-8 Primary brain injury - CORRECT ANSWER direct contact to head or brain, hematoma, fractures acceleration-deceleration injury - CORRECT ANSWER antero postero direction causing damage to frontal or temporal lobes (DAI) rotational acceleration-deceleration - CORRECT ANSWER may cause shearing between cerebral and connective tissues Blast TBI - CORRECT ANSWER - leading cause is active military in war zone. - primary = over-pressurization with air or fluid - secondary= fragments fly through air - tertiary= MVA, acceleration/deceleration - severe= toxic, gas inhalation, traumatic amputation Blunt TBI - CORRECT ANSWER - MVC, falls, sports, assaults - deceleration= head strike to immovable object - acceleration= moving object to someone's head - rotational= side to side twisting. Penetrating TBI - CORRECT ANSWER - firearms, stabbing - bullet can remain in cranium, no risk for infection. may create 2nd and 3rd tracks - hematoma & pseudo aneurysm that develop from lacerations near temporal and posterior fossa may herniate - treatment= craniectomy contusion - CORRECT ANSWER - bruising (parenchymal hemorrhage) of brain tissue (frontal/temporal lobe), arachnoid still in tact - 30% will increase in size within 24 hours - may not show up on CT scan until 24 hours later - vasogenic edema occurs up to 36 hours, treat with mannitol - coup injury= same side as injury - contrecoup injury= opposite side of injury - coup-contrecoup injury- injury to lateral side of skull, causes epidural and subdural hematoma Diffuse axonal injury - CORRECT ANSWER - acceleration/deceleration injury - rotational injury, ex= rollover injury - shearing of axons= axonal blood vessel tearing - diagnosis= poor clinical status (decreased LOC), relatively normal CT scan. Vegetative state/coma in 90% of patients. - S/S= cognitive impairment, fever, increased BP, muscle rigidity, coma, death Types of DAI - CORRECT ANSWER - Mild: usually from basilar skull fracture - Moderate: can evolve to comatose state for up to 24 hours. - Severe: involves primary brain stem injury; immediate coma. Treatment= decrease ICP (diuretics), coma inducing drugs, anti-seizure meds, cognitive rehabilitation Concussions/mild traumatic brain injury - CORRECT ANSWER - caused by violent shaking - s/s= confusion, severe HA, seizures, amnesia, pupil changes, diplopia, weakness, CSF drainage lasting days to year. - post-concussion syndrome= fatigue, irritability, HA, forgetfulness. - post-traumatic headache= rest and triptans - observe for at least 24 hours after discharged from ED Levels of concussions/TBI - CORRECT ANSWER - Mild: GSC= 13-15, none to temporary loss of consciousness, post traumatic amnesia <24 hours, transient neuro deficits, transient confusion, headache - Moderate: GSC = 9-12. - Severe: GSC= 3-8, poor prognosis, intubated. monitor ICP, poor outcomes. Can be treated with ventriculostomy to drain CSF. Sedation can decrease complications from agitation, ventilator asynchrony, and elevated O2 demand. Goal is euvolemia with hypertonic NS + stool softeners Simple skull fracture - CORRECT ANSWER Break in skull with no skin damage Thin line fracture/linear skull fracture - CORRECT ANSWER Doesn't involve bone, depression or splintering Depressed skull fracture - CORRECT ANSWER Crushed bone pressing on brain. May start seizure meds Bone splintering - CORRECT ANSWER Break in skin compound fracture Open skull fracture - CORRECT ANSWER Treat with antibiotics (sulfisoxazole) and tetanus toxoid Occipital condylar fracture - CORRECT ANSWER Neck stabilization with c-collar Basilar skull fracture - CORRECT ANSWER - Fracture through the base of the skull. - Anterior, middle or posterior fossa - Based on s/s: 1) cranial nerve injury, 2) CSF leak, 3) hemorrhage - High risk for CNS infection & complications due to CSF leak - Assess for halo sign- Yellow ring surrounding CSF drainage. Do not test for glucose - CT scan for diagnosis, monitor for pneumocephalus (treat with oxygen) Anterior basilar skull fracture s/s - CORRECT ANSWER Rhinorrhea, periorbital hemorrhage (raccoon eyes), CNI injury Middle basilar skull fracture s/s - CORRECT ANSWER Otorrhea (Battle's sign), mastoid, CN VII/VIII injury Acute subdural hematoma - CORRECT ANSWER - Venous blood between dura and arachnoid layers. - Symptoms within 24 hours of injury, clotted blood. - S/S= increased ICP, hemiparesis, ALOC, pupil changes - Treatment= burr hole trephination, craniotomy, craniotomy if > 1cm thick. Evac SDH > 10 mm or MLS > 5ml. Chronic subdural hematoma - CORRECT ANSWER - Venous blood between dura and arachnoid layers. - Symptoms >2 weeks - months after injury - Elderly, alcoholics and dementia patients at risk. - Slower to hemorrhage, made from fluid blood. - Symtoms develop slow: Headache, confusion, drowsiness. Elderly more at risk due to brain atrophy and fragile veins. Stroke like symptoms: paresis, paralysis, ALOC, confusion, aphasia. - Treatment: burr hole trephination (2 on either side), closed system drainage for 72 hours Epidural hematoma/extradural hemorrhage - CORRECT ANSWER - Arterial bleed- immediate symptoms between skull and dura. - laceration of middle meningeal artery- temporal bone (smallest) - trauma to the side of head, temporal skull bone causes seizure and respiratory arrest - expands rapidly from increased ICP - Unconscious presentation, waxes and wanes - Uncal herniation= ipsilateral pupil dilation, non-reactive from pressure on brain stem affecting cranial nerve 3 Treatment for epidural hematoma - CORRECT ANSWER - Mannitol, hypertonic saline, antipyretics, high dose of methylprednisone, protamine and vit K. - Surgery: 1) craniotomy, laminectomy, 2) evac, 3) coagulation of bleeding sites, 4) inspect dura, 5) tenting dural bone, 6) insert epidural drain for 24 hours, post-op CT. Secondary brain injury - CORRECT ANSWER - Hypotension (establish perfusion) - Hypoxia (maintain airway, improve oxygenation) - Anemia - Hypercapnia - Hypocapnia - Hyperthermia - Hyperglycemia - Electrolyte abnormalities - Acid-base abnormalities TBI nursing interventions - CORRECT ANSWER Includes: - Airway and breathing; intubate for GSC < 8. Goals: - PaO2 > 80 mmHg - MAP > 80 mmHg, SBP > 90 mmHG - Cerebral perfusion pressure > 60 mmHg - Head of bed 30° - Mannitol to lower edema and ICP (hold for osmolality >320 Osm/L) - Caution when administering hypertonic saline (Na <155) to prevent central pontine myelinolysis - Hyperventilate for short period to lower ICP - Assess bone flap after decompressive crainectomy - Maintain temp < 37° C - Seizure prophylaxis for 7 days following severe TBI Hyperflexion - CORRECT ANSWER - Forward movement with compression of the vertebral bodies - Disruption of the posterior ligaments and intravertebral discs, resulting in a wedge or compression fracture. - Seen in head on collision accidents and diving accidents. Hyperextension - CORRECT ANSWER - Backward-downward movement, such as rear-end collisions - less severe form is called whiplash. - May see contusion and ischemia to the cord. - Greatest stress at C4 and C5 Axial load - CORRECT ANSWER - Blow to the top of the head - Shattering of vertebrae, burst fractures. - Diving or fall Vertebral fractures - CORRECT ANSWER - Bilateral fracture of C1- Hangman's fracture due to falls and MVC's. - Burst fracture of C1= Jefferson's fracture - Odontoid (C2) fractures= Type I is a stable fracture, Type II is most common and unstable - Hangings fracture C2 - 7 cervical vertebrae, 8 paired cervical nerve nods Unilateral cord damage - CORRECT ANSWER - Causes ipsilateral paralysis and loss of touch sensation - Contralateral loss of pain and temperature - Affects bowel and bladder, may not be affected if injury below L4 - C1-C4 voluntary and involuntary respirations - Lumbar region= legs, feet, pelvis Intervertebral disc herniation - CORRECT ANSWER - Trauma from heavy lifting - Affects cervical & lumbar regions, radiates to buttocks and legs. - Severe and chronic back pain Complete spinal cord injury - CORRECT ANSWER - No motor or sensory function below level of injury - No return of function - Considered to be complete and permanent - Level of consciousness does not relate to spinal cord injuries - Sensory neurons= Posterior & ascending - Motor neurons= Anterior and descending incomplete spinal cord injury - CORRECT ANSWER - Some sensory or motor function may be present below the level of injury - Classified based on type of function preserved - Sacral/anal sparing indicates incomplete cord injury Anterior cord syndrome - CORRECT ANSWER - Caused by acute disc herniation, hyperflexion injury, or stroke of the anterior spinal artery. - Loss of pain and temperature sensation, spinothalamic and corticospinal tract lesion. - Preserved two-point discrimination, position sense, deep pressure sensation. (Posterior column function) Central Cord Syndrome - CORRECT ANSWER - most common incomplete SCI syndrome - commonly caused by a severe hyper extension - characterized by upper extremities weaker than the lower extremities, usually occurs in elderly Brown-Sequard Syndrome - CORRECT ANSWER - transverse hemisection of the cord from penetrating trauma - Ipsilateral loss of motor and sensory function below the level of the lesion, with contralateral loss of pain and temperature sensation Conus Medullaris injury - CORRECT ANSWER - compression of the conical termination of SC - Located around L1 to L2 - Signs and symptoms: sudden and bilateral presentation, ankle reflects affected, numbness localized to perianal area, frequency impotent, urinary retention, urinary and fecal incontinence. Cauda Equina Syndrome - CORRECT ANSWER - Artery of Adamkiewicz supplies blood to cauda equina. - Caused by compression from massive ruptured disc, usually L4 to L5. - Loss of motor and sensory function. - Sphincter disturbances: urinary retention, fecal/urinary incontinence, anal sphincter tone diminished (60% to 80%) - bilateral absence of Achilles reflex. Spinal shock - CORRECT ANSWER - Acute. Loss of neurological function below the level of injury in the acute phase (T6 and above). - Sympathetic nervous system. - Usually occurs within 30 to 60 minutes of injury, Can last up to 4 to 6 weeks. - Treat symptoms: hypotension (fluids) and bradycardia (atropine), bladder and bowel paralysis, Poikilothermia (inability to regulate core temp), priapism. - Ends with return of perianal reflex Autonomic hyperreflexia - CORRECT ANSWER - Chronic. Medical emergency, uninhibited sympathetic nervous system response to noxious stimuli in spinal cord injury at T6 or above. - Noxious stimuli below the level of injury (bladder/bowel distention, skin breakdown, positioning. - Hypertension, headache, flushing and diaphoresis, bradycardia, chills, nasal congestion, blurred vision, anxiety, and apprehension, bronchospasms. - Treatment is to find the cause and treat: Check for bladder distention, constipation, skin breakdown. Immediately elevate HOB to 90 degrees Treatment of SCI - CORRECT ANSWER - Maintain airway and breathing (C4 and above), assess forced vital capacity/negative inspiratory force. - Maintain perfusion/adequate fluid volume. - Spine stabilization via collars, braces, and cervical traction. - Surgical cord decompression, pain management, DVT prophylaxis, skin care, bowel and bladder training, sexual dysfunction assessment Glioblastoma - CORRECT ANSWER - Neuroepithelial tissue - malignant, rapidly growing usually in the frontal lobe. - Seizure, memory loss - Males at higher risk (40 to 60 years old) - Treatment= surgery, radiation, concurrent chemo temozolomide. - Survival is 14 to 16 months. Glioma - CORRECT ANSWER - derived from glial tissue. - Includes astrocytes, oligodendrocytes, ependymal cells - gliomas are most common type of brain tumor Ependyoma - CORRECT ANSWER - Glioma in the central nervous system tumor that arises from ependymal cells located in the lining of the ventricles and in the spinal cord's central canal. - More common in children - Complete resection is recommended in order to prevent recurrence, although it may not always be possible. - shunting can relieve pressure, removal is most effective if accessible, chemo less effective. - Most receive radiation. Astrocytoma - CORRECT ANSWER - Neuroepithelial tissue, most common. - Grade one or two, located in cerebrum, cerebellum, or hypothalamus, Optic nerves, pons, spinal cord. - Presents with focal deficit, seizure. - Treatment and surgery, radiation, chemotherapy is controversial. - 5 to 6 year average survival. Oligodendroglioma - CORRECT ANSWER - Neuroepithelial tissue - originates in cells that cover and protect the brain and spinal cord nerve cells. - Similar to astrocytoma. - found in cerebrum or frontal lobe. Low grade and anaplastic, slow growing tumor. - Calcification in about 50%. - Presents with seizure. - Treatment is surgery, chemo with loss of heterozygosity of 1P and 19P chromosomes. - Radiation for those with intact tumors. - Survival is 5 to 10 years. Embryonal tumor - CORRECT ANSWER - Most are malignant and rapid growing. - Medulloblastoma- malignant small cell tumor between brainstem and cerebellum, occurs up to 20 years old, cerebellar symptoms. - PNET (supratentorial primitive neuroectodermal tumor): Medulloblastoma with muscle, before age 7. Aggressive, obstructs CSF flow. Schwannoma (acoustic neuroma) - CORRECT ANSWER - Cranial and spinal nerve tumor - Sheath of schwann cells, surrounds peripheral nerves. - Benign, slow growing. - Vestibular branch of CNVII. Can affect facial, trigeminal, glossopharyngeal, and vagus nerve. Facial weakness, difficulty talking, swallowing. - Tinnitus, vertigo, hearing loss. - Treatment: radiation- stereotactic radiosurgery (SRS), can be resected without damaging underlying nerve. - May have regrowth Neurofibroma - CORRECT ANSWER - "Von Recklinghausen disease" - Lesions attach to peripheral nerves. - genetic origin, autosomal dominant trait. - Benign, multiple, skin pigmentation and Hyperpigmentation. "Cafe au lait" - Resistant to radiation, possible surgery. Cannot be resected without damage to underlying nerves. - Infiltrates surrounding tissue Neurofibromatosis type 1 - CORRECT ANSWER - Genetic neurofibroma, chromosome 17 - Develops on peripheral nerves and skin, hyper pigmentation (brown/tan) - Small tumors on iris - Affects bone, leading to scoliosis and learning disabilities Schwannomatosis - CORRECT ANSWER - Development of multiple schwannomas on cranial, peripheral and spinal nerves. - Forms neurofibromatosis; nerve irritation and displacement causes pain and paresthesia Meningioma - CORRECT ANSWER - Intracranial or spinal cord - Slow growing, arises from meninges in the arachnoid layer, attaches to dura, proximal to venous sinuses - Firm and encapsulated - Women, age 50 - Headache - Tx: Surgery and radiation. Cure with total removal, recurs when resection is subtotal Grade I meningioma - CORRECT ANSWER - This type is most common, prevalent in women. - Benign, slow growing. Forms in dura matter covering brain near skull Grade II & III meningioma - CORRECT ANSWER - Prevalent in men. - Rare, malignant, fast growing. - Spreads within brain and spinal cord Hematopoietic Lymphoma - CORRECT ANSWER - Malignant, cellular tumor (like GBM), can occur anywhere in the brain - Common in immunocompromised adults, 40-50 years old. - Personality changes, increased ICP - Tx: biopsy, decadron, chemo, radiation - Survival 1-4 years Hemangioblastoma - CORRECT ANSWER - Hematopoietic - Vascular tumor, slow growing - Occurs sporadically in cerebellum, brain stem, spinal cord. - Dizziness, unilateral ataxia - Tx: Endovascular embolization & Stereotactic radiosurgery. - radiation with recurrence - Curable Stereotactic radiosurgery - CORRECT ANSWER Procedure that uses linear acceleration or gamma knife for tumor resection Endovascular embolization - CORRECT ANSWER Procedure that decreases tumor vascularity and potential blood loss during resection. Capillary hemangioblastoma - CORRECT ANSWER - Associated with Hippel-Lindau (VHL) disease. - Life expectancy = 49 years - Familial tumor syndrome Craniopharyngioma - CORRECT ANSWER - Endocrine disorder, arises from Rathke's pouch - Can compress pituitary, 75% are calcified - Upward tumor growth- 3rd ventricle obstruction - Elevates optic chiasm (bitemporal hemianopsia/peripheral field cut) - Usually congenital (affects children), growth retardation and optic disturbances. - Treated by surgery and radiation - 80% cure rate pineal - CORRECT ANSWER - Produces melatonin, endocrine - Arises from pineocytes - Manifests as chronic headache - Obstruction of CSF flow, next to 3rd ventricle (hydrocephalus symptoms) - Common in adults - 3 types= pineocytoma, pineoblastoma, pineal parenchymal Pineocytoma - CORRECT ANSWER Grade II, Slow growing with variable prognosis, occurs in adults Pineoblastoma - CORRECT ANSWER - Grade IV, rare embryonal tumor - highly malignant, rapid growing - poor prognosis Pituitary adenoma - CORRECT ANSWER - Anterior lobe - Visual disorders (compression of optic chiasm), bitemporal hemianopsia, optic atrophy - Paresis of extra ocular muscles - Causes headache, endocrine disorder (DI) - Treated by surgery, radiation and drug therapy. - Curable with complete resection Leptomeningeal spread - CORRECT ANSWER - Metastatic brain tumor - 20-40% of cancer patients - Originates in lung, breast and lower GI, can occur anywhere in the brain - Can cause headache, paresis, and cognitive deficits - Treat by surgery, radiation, and chemo - Survival is 1-3 years Brain tumor diagnosis - CORRECT ANSWER Common tests: - CT scan with contrast (edema and hemorrhage) - MRI with and without contrast (Gold standard) - Functional MRI (brain function test) - MR spectrostomy (necrosis due to tumor) - Positive emission tomography (recurrence/residual) - CT scan of chest, abdomen pelvis (to assess metastasis) - Cerebral angiography (vascularity of tumor) - Endocrine workup (pituitary) - Visual tests (tumor location, increased ICP) - Audiometric studies (acoustic neuroma) Brain tumor surgery - CORRECT ANSWER - Biopsy only for brain stem, basal ganglia, motor and speech center, vascular tumor, CNS lymphoma - Maximal resection to improve survival - Cortical brain mapping Brain tumor post-op complications - CORRECT ANSWER Includes: - Hemorrhage, edema, obstructive hydrocephalus - Hypertension - Meningitis, seizures - Neurological deficits - CSF leak - Periorbital edema - Intracranial hypotension (skull base-- excessive CSF drainage), lay flat Brain tumor radiation therapy - CORRECT ANSWER Conventional RT for meningioma, high-grade and low-grade glioma and metastases Side effects of radiation therapy - CORRECT ANSWER - Acute (treatment onset up to 6 weeks)- fatigue, headache, N/V, anorexia, focal deficits, alpaca, otitis external, dry eyes, radiation dermatitis - Early (6 weeks-6 months)- HA, somnolence syndrome, fatigue, cranial neuropathies, neuro deficits, persistent alopecia, otitis external, dry eyes, radiation dermatitis, attention deficits, short-term memory loss - Late (> 6 months later)- Cognitive deficits, radiation necrosis, diffuse leukoencephalopathy (white matter deterioration), memory and spatial function deficits. Chemotherapy - CORRECT ANSWER - Used in addition to surgery and radiation - Given before and or during radiation - Given with tumor recurrence - MGMT promoter methylation benefit in GBM (more response to alkylating agents, temzolomide and carmustine) - Oligodendroglial tumors usually respond Temozolomide (Temodar) - CORRECT ANSWER - Standard of care for newly diagnosed high-grade gliomas - Initiated post-op and concurrently with radiation therapy - Continued as adjuvant after radiation is completed - Side effects= N/V, myelosuppression, constipation, headache, fatigue - MGMT promoter responds bettter Primary spinal cord tumor - CORRECT ANSWER - Slow-growing & soft tumors accommodate to spinal cord/nervous tissue. - Fast growing/hard tumors compress & cause spinal contusions and ischemia - 50% found in thoracic region of spine - Intradural, extra medullary most common - Astrocytoma, ependymoma, meningioma Extradural-extramedullary primary tumor - CORRECT ANSWER Examples include chordoma or sarcoma (metastatic) intradural-extramedullary primary tumor - CORRECT ANSWER Examples include meningiomas & neurofibromas (most common spinal tumor) can be treated by surgical excision alone Intramedullary tumor - CORRECT ANSWER - Located in spinal cord, difficult to remove, requires combo treatment, such as a glioma. - For infiltrating/malignant tumors, decompression can improve symptoms, radiation to help mets. Metastatic spinal cord tumor - CORRECT ANSWER - 95% tumors spread to vertebral body - 15% paravertebral - Treat with chemotherapy - Hormonal therapy if breast or prostate was primary Cervical level tumor - CORRECT ANSWER - 1/3 of spinal tumors, C4 and above - May experience respiratory problems and quadriparesis, headache, stiff neck and paresthesia, difficulty swallowing or speaking (impaired CN IX & X). - Below level of C4 is pain and paresthesia in shoulders and arms Thoracic level tumor - CORRECT ANSWER - 50% of all tumors, usually metastatic - S/S= pain in chest or back, motor & sensory deficits. Spastic paresis, hyperasthesia above level of tumor, bowel, bladder and sexual dysfunction. - Babinski sign= corticospinal damage (elicited by stimulating plantar surface from heels to toes, causing dorsiflexing & splaying of toes) Spinal cord tumor assessment - CORRECT ANSWER Increased pain in supine position, decreased pain with sitting position pain with vertebral palpation Spinal cord tumor treatment - CORRECT ANSWER - Surgery then radiation - Biopsy, complete or partial resection, decompression - Radiation therapy- Spinal cord 4-5000 cGy over 5 weeks. 1-2 levels above and below lesion. Side effects= radiation-induced myelopathy, sensory impairment, spastic paraplegia, loss of bowel/bladder control Spinal cord tumor treatment - CORRECT ANSWER - Medical management: high-dose steroids. - Bracing increases stability of spine - Interventional radiology- vertebroplasty or kyphoplasty Abscess - CORRECT ANSWER - Caused by cyanitis, tooth decay, ear infection, IV drug use, disrupted meninges. - Liquified tissue, white blood cells, remains of bacteria and viruses, surrounded by fibroblasts then connective tissue. - Seen as hyper dense ring on CT scan or MRI. - Manifestations- Headaches, confusion, drowsiness, seizures, increased ICP causing herniation, hemiparesis, visual deficits, ipsilateral hemiparesis - Treatment- Antibiotics, surgical aspiration, mannitol for edema Meningitis - CORRECT ANSWER - Affects arachnoid and pia layers, subarachnoid space and CSF. - Headache, stiff neck, ALOC, light sensitivity, seizures. Viral meningitis - CORRECT ANSWER - Aseptic meningitis - Most common. Transmission is direct contamination, respiratory droplets, or fecal-oral contamination - Causative agents- Enteroviruses (coxasackieviruses, echoviruses, polioviruses). Arboviruses transmitted by arthropod vectors or ticks. Complications of mumps, measles, rubella, herpes viruses, varicella, Epstein-Barr virus - Symptoms= mild, flu-like symptoms, elevated lymphocytes, headache, fever, photophobia, nuchal rigidity. - Management= empiric antibiotic therapy until cultures negative, acyclovir, bedrest, usually recover in 2 weeks at home. Bacterial meningitis - CORRECT ANSWER - Insidious versus rapid fulminating - Signs= headache, high fever, nuchal ridigity, altered LOC, photophobia, Kenig's sign Brudzinski's sign, elevated neutrophils, decreased glucose in CSF. - Risk factors= Immunosuppression, disrupted meninges, environmental factors - Common causative agents= streptococcus pneumonia, neisseria meningitdis, haemophilus influenzae, steptococcus aureus, escherichia coli, listeria monocytogene, mycobacterium tuberculosis - Management= Empiric antibiotic therapy within 30 min after arriving to ED, corticosteroids (controversial) - Prevention- Isolation, Rifampin, rocephin, vaccines for high risk Meningococcal meningitis - CORRECT ANSWER - Risk for adrenal hemorrhage, presence of petechiae/small hemorrhages on skin or conjunctiva Fungal meningitis - CORRECT ANSWER - Highest risk group is immunocompromised - Causative agents= cryptococcus neoformans, candida albicans, blastomyces dermatitdis, aspergillus fumigatus - Management= antifungals, antiemetics, steroids, acetaminophen, Amphotericin B IV, oral 5-flucytosine, shunt placement for recurrent hydrocephalus Encephalitis - CORRECT ANSWER - Inflammation of the brain parenchyma caused by virus (most common), bacteria, fungus or parasite - Causative agents- enterovirus, poliovirus, arbovirus infections, mumps, measles, rubella, varicella, herpes, cytomegalovirus, HIV - Primary signs= headache, fever, malaise, ALOC. - MRI shows hyperintensities and enhancements - Management= antibiotics, manage seizures and increased ICP. - May sustain mental deficits, epilepsy, dementia, paresis, deaf/blindness. Herpes simplex encephalitis - CORRECT ANSWER - Most common and severe form of viral encephalitis - Caused by HSV-1, most commonly affects temporal lobe - Symptoms= fever, headache, confusion, hallucinations, ALOC, personality changes, behavioral abnormalities, aphasia, hemiparesis, temporal lobe seizures. - Management= acyclovir, supportive care Viral encephalitis - CORRECT ANSWER - Arbovirus= mosquito-borne viruses, transmitted by blood-feeding arthropods - West nile virus- Asymptomatic (80%) - West nile fever- Mild flu-like symptoms (20%) - West nile encephalitis- Sever symptoms (<1%), meningitis, meningoencephalitis, encephalitis Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig's Disease) - CORRECT ANSWER - Motor neuron disease, progressive weakness of focal nature. - Anterior horn cell and corticospinal tract degeneration, resulting in uncoordinated muscle fiber recruitment, spasticity, weakness. - Lower motor (spinal motor neurons & cranial nerves) leads to muscle fascinations, atrophy and paralysis. - Respiratory paralysis, death usually 3-5 years after onset. - Does not affect senses or mental ability - S/S- diagnosed based on symptoms, 40% weakness of upper extremity muscles, 20% weakness of bulbar muscles. Clumsiness -> muscle weakness, atrophy in hands -> dysarthria/dysphagia, -> fatigue/cramping lower limbs -> bowel/bladder dysfunction - Treatment: None, treat symptoms. Riluzole 100 mg daily, anticholinergic drugs for drooling, PEG tube, CPAP, BiPAP, palliative care. Bell's Palsy - CORRECT ANSWER - Inflammation of facial (VII) cranial nerve due to viral infection causing sudden unilateral facial paralysis - Peaks in 48 hours, resolves over 1-2 months - Clinical manifestations: Ipsilateral facial paralysis- loss of motor, sensory and parasympathetic function. Affected eye causes tearing, decreased lacrimination, absent corneal reflex. Post auricular pain (50%). - Patient cannot raise eyebrow (stroke patient can). - Management: acyclovir, solu-medrol, NSAIDS for ear pain - Interventions: lubrication & patching of affected eye, massage, warm/moist heat and electrostimulation to affected muscles, oral hygiene Guillain-Barre Syndrome (GBS) - CORRECT ANSWER - Acute idiopathic polyradiculoneuritis - Acute inflammatory polyneuropathy (affects bilateral lower motor neurons). Macrophages attack myelin sheath surrounding nerves throughout peripheral nervous system (peripheral nerve demyelination) - Viral infection within past 2 weeks, rapidly progressive. - S/S: Ascending weakness (symmetrical), paresthesia, loss of DTRs, weakness in diaphragm, facial and ocular muscles, abnormal BP and arrhythmias. Some may have chronic weakness, recover in 1-2 years. - Treatment= high-dose intravenous immunoglobulin (IVIG) for 3-5 days to boost immune system, plasmapheresis (watch for fluid overload), respiratory support (monitor vital capacity), steroids not effective Miller Fisher's Variant GBS - CORRECT ANSWER - Rare form - Triad: opthalmoplegia (no exraocular movements CN III, IV, V), areflexia (no reflexes), ataxia - Extremely fatigued even after treatment Acute Disseminating Encephalomyelitis (ADEM) - CORRECT ANSWER - Acute, monophonic, inflammatory, demyelinating disease of CNS. - Post-infectious (usually viral) autoimmune disorder; usually 1-2 weeks after infection, 90 days after vaccine. - Acute onset S/S- similar to MS (weakness, numbness, vision impairment, impaired coordination), ataxia, hemiparesis, optic neuritis, CN palsy, speech impairment, spinal cord involvement, fever, coma, seizure. - Treatment: methylprednisone (IV) 20-30 mg/kg per day for 3-5 days with oral taper of prednisone. - Most people recover but may have neuro deficits Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) - CORRECT ANSWER - Slow, progressive weakness (60%), symmetric, relapsing (33%), sensory changes over weeks or months. - Associated with viral infection - Treat with plasmapheresis, IVIG, prednisone. - Supportive care Multiple Sclerosis (MS) - CORRECT ANSWER - Creates lesions & plaques on myelin sheath, leading to delayed or blocked conduction. - Affects optic nerve, brain stem, cerebellum or spinal cords (optic neuritis, diplopia, ataxia, paresis, paresthesia) - Destruction of myelin, affects upper motor neurons - Onset at 10-50 years, average age 30, more common in women - Relapsing/remitting & primary progressive are most common forms. - S/S= fatigue, numbness/tingling, Lhermitte's sign (electric/shock-like), tremor, spasticity (treated with botox), pain, depression, bowel/bladder dysfunction, lower-extremity paralysis. - Diagnosed w/ MRI w/ contrast (identifies demyelination), LP (CSF contains oligodendroglial bands), EMG, NCV. - Treat symptoms: nerve pain/antispasmodics, PT, solu-medrol for optic neuritis, rest Multiple sclerosis medications - CORRECT ANSWER Disease modifying agents (A-B-C-R-N) - Avonex (interferon beta 1a) - Betaseron (Interferon beta 1b) - Copaxone (Glatirameterm-219r) - Rebif (interferon beta 1a) - Navantrone (Mitoxantherone) - Relapse therapy (IVIG, Solu-medrol IV) - Immunosuppressive therapy- Imuran, methotrexate Myasthenia Gravis (MG) - CORRECT ANSWER - Antibody-mediated autoimmune attack of the neuromuscular junction at the acetylcholine receptors, causing destruction of receptors at the polysynaptic muscle membrane. - Affects striated muscles - Voluntary muscle weakness and rapid fatigue. - Extra-ocular muscles affected first (ptosis and diplopia) and facial muscles (expression and masticator fatigue) - Weakness increased with repetitive activity, flat smile, droopy eyelids, nasal speech edrophonium test - CORRECT ANSWER - aka "Tensilon challenge", one way to diagnose MG - Entails IV administration of this medication, blocking acetylcholine degradation and temporarily keeping acetylcholine available at the neuromuscular junction for a longer time. - In patients whose MG involves eye muscles, the medication will briefly relieve weakness, thus confirming diagnosis. Relapsing-remitting MS - CORRECT ANSWER - Intermittent exacerbations in which new symptoms can appear and old ones resurface or worsen. - During remissions the patient fully or mostly recovers from deficits acquired during the relapse. - Lasts days/weeks, remission, then lasts weeks to years Primary-progressive MS - CORRECT ANSWER - Continuous deterioration from symptom onset, without remission or attacks. - Although near status may plateau, relapses are triggered by infection, physical/emotional stress, temperature changes, fatigue or menstruation. progressive-relapsing MS - CORRECT ANSWER - Downward course from onset, punctuated by relapses. - There is a significant recovery immediately following a relapse, but between relapses there is a gradual symptom worsening. Acetylcholine - CORRECT ANSWER Neurotransmitter released from motor neurons that stimulate muscle contraction (receptor failure diminishes voluntary muscle control) Myasthenia Gravis Treatment - CORRECT ANSWER - Anticholinesterase drugs: inhibits cholinesterase, the enzyme that degrades acetylcholine and prolongs activity. Pyridostigmine (Mestinon)-Overdose can lead to excessive drooling, diarrhea. Atopine is antidote. - Steroids-prednisone - IVIG, plasmapheresis - Tymectomy (slows progression of disease) Cholinergic crisis - CORRECT ANSWER Due to overmedication of anticholinergic drugs, resulting in profound weakness, increased pulmonary secretions, abdominal cramping and diarrhea. Stop drugs Myasthenic Crisis - CORRECT ANSWER - An exacerbation of symptoms of the disorder due to infectious process (UTI, pneumonia) - Treat the cause Medications that block transmission of nerve impulses - CORRECT ANSWER - Aminoglycosides, tetracycline - Phenytoin, mephytoin - Quinidine, procainamide, beta blockers - Lithium, phenothiazines - Succinylcholine, curare - Magnesium Toxic Encephalopathy - CORRECT ANSWER - Exposure to toxic substances such as drugs, carbon monoxide, cyanide resulting in tissue anoxia - S/S may mimic psychiatric, metabolic, inflammatory, neoplastic and degenerative diseases of the nervous system, - Manage by treating cause Metabolic encephalopathy - CORRECT ANSWER - Due to lack of glucose, oxygen (causes hypoxic-ischemic) or metabolic cofactors - hypoglycemia, ischemia, hypoxia, hypercapnia, vitamin deficiencies (Wernicke's) vit B12, alcoholism, peripheral organ dysfunction: hepatic, uremic and renal. - S/S= ALOC, restlessness, tremors, rigidity with normal eye reflexes or movement. Some experience seizures or coma Posterior reversible encephalopathy syndrome (PRES) - CORRECT ANSWER - Presents with headache, nausea, vomiting, confusion, lethargy, seizures, visual disturbances (blurriness, homonymous hemianopsia) - most commonly caused by malignant hypertension, eclampsia, or immunosuppression - Hypertension (occurs in 50-70%) - Parieto-occipital MRI shows lesions in subcortical areas - Presence of vasogenic edema - Treatment: Control HTN. 25% of lesions are irreversible Suture lines of skull - CORRECT ANSWER - Saggital - Coronal - Metopic - Lamboid Craniosynostosis - CORRECT ANSWER - premature closure of 1 or more cranial sutures - Nonsyndromodic occurs in 1 out of 2100 children - Occurs in 90 syndromes, but less common than syndromic - Treatment: Calvanial vault remodeling- large craniotomy and blood transfusion, monitor for bleeding and hemorrhage. Endoscopic strip craniotomy- less invasive, minimal blood loss. Sagittal Synostosis (Scaphocephaly) - CORRECT ANSWER - Oval shaped head - 40-60% of all craniosynostosis - Fusion of sagittal suture (midline) Coronal Synostosis (Anterior Plagiocephaly) - CORRECT ANSWER - Fusion of coronal suture of lateral head from anterior fontanelle to above the ear. - 20-30% of all craniosynostosis. Metopic Synostosis (Trigonocephaly) - CORRECT ANSWER - Fusion of metopic suture (midline suture from anterior fontanelle to the root of nose) - Triangle shaped pointy skull - 10% of all craniosynostosis Lambdoid Synostosis (Occipital Plagiocephaly) - CORRECT ANSWER - Fusion of lambdoid suture; Involves flattening of back of skull. - Often confused with positional plagiocephaly - Rare- 1-2% of all craniosynostosis Positional Plagiocephaly - CORRECT ANSWER - Pre-term infants at risk - Deformational forces caused by gravity of baby's head against the mattress - Torticolis (wry neck) - Reposition infant to back lying, correct torticollis - Helmet in severe cases if repositioning not successful Microcephaly - CORRECT ANSWER - Circumference below normal (34-35 cm), resulting in genetic abnormality, exposure to fetal toxins, maternal substance abuse and Zika virus. - Short stature, cognitive impairment, ADHD, facial abnormalities, seizures Anencephaly - CORRECT ANSWER - Most serious neural tube defect, part of both cerebral hemispheres of brain are absent, not covered by skull, intact brainstem which allows for vital functions to continue after short period. - Often stillborn, will die within days after birth Chiari I Malformation - CORRECT ANSWER - Descent of cerebellar tonsils 5mm or more below the foramen magnum, appears deformed. - Symptoms include headache, choking or dysphasia, upper extremity weakness or numbness, gait unsteadiness. - Bending downward and looking up worstens symptoms. Vision problems, blurred vision, diplopia - MRI to vascularize. - Surgery= posterior fossa craniectomy, cervical laminectomy and duraplasty Chari II Malformation - CORRECT ANSWER - Descent of cerebellum and brainstem below foramen magnum - Cervical meningocele present at birth. May have cervical or occipital encephalocele herniation of 4th and lateral ventricles, and hydrocephalus - Rare with poor prognosis Syringomyelia - CORRECT ANSWER - Cyst or CSF-filled cavity within spinal cord, usually occurs with Chiari malformation - Symptoms may include scoliosis, spasticity, leg or foot asymmetry, abnormal sensory exam, weakness - Posterior fossa decompression, if associated with Chiari malformation - If asymptomatic, may observe with serial MRIs and near exams - Syringopleural shunt diverts CSF into pleural spaces - Important to monitor post-operative respiratory status Hydrocephalus in children - CORRECT ANSWER Signs and symptoms: - Preemies: bradycardia, apnea, seizures, hypotonia, ophthalmoplegia, sunset eyes, macrocephaly - Infants with open sutures- bulging, nonpulsatile fontanels, splayed sutures, sunset eyes, increasing head circumference (usually 33-36 cm at birth in full term infants is normal) - Children- vomiting, lethargy, paralysis of upward gaze, (Parinaud's sign), frontal bossing, delayed development, poor school performance, headache Hydrocephalus treatment in children - CORRECT ANSWER - Ultrasound, CT scan, MRI - LP - Ventricular reservoir - VP shunt, 3rd ventriculostomy (aqueductal stenosis) Spina bifida - CORRECT ANSWER - Neural tube defect, failure of neural tube to close during first 3 weeks after conception. Usually related to latex sensitivity. - Can be anywhere along spinal axis, can be "open (aperta)" or "closed (occulta)" defect. - Inability to move legs in-utero may lead to club feet. - S/S= weakness, paralysis, lack of sensation lower body, bowel and bladder dysfunction - Prevention- Promote folic acid supplementation one month prior to conception and first trimester Spina Bifida Aperta - CORRECT ANSWER - Most common form - Myelomeningocele- Herniated sacs of neural tissue (spinal cord and meninges) are visible - 80-90% develop hydrocephalus - Decline in incidence due to improved maternal care and folic acid supplementation - Cover sac with sterile gauze dressing soaked in saline (24 hours) to keep sac moist, intact and to prevent infection. - "mudflap" to keep stool off myelomeningocele Meningocele - CORRECT ANSWER Name of sac composed of dura & arachnoid that protrudes through spinal cord defect but does not contain the spinal cord itself Spina Bifida Occulta - CORRECT ANSWER - Without visible exposure of neural tissue; enclosed sac on lower back. - Major cause of neurological compromise is due to traction or tension on spinal cord (tethered cord)- Leg paralysis, bowel and bladder dysfunction - Neuro deficits are usually irreversible. If untreated, deficits are usually progress. - 50-80% have cutaneous abnormality (dimple), hairy patch, lipoma. Scoliosis, foot deformity, leg paralysis, blader and bowel retention and constipation Vasogenic edema - CORRECT ANSWER - Extracellular edema of white matter, associated with brain tumors - Generalized with cerebral trauma and meningitis - Treatment= dexamethasone (if associated with brain tumor), osmotic diuretics & hypertonic solutions when in the acute phase Tethered cord - CORRECT ANSWER - Spinal cord becomes attached to the surrounding tissue, usually in the lumbar region. - Common in spina bifida (occulta) patients, but can be caused by spinal lipoma, tumor, or by a congenitally tight filum (a tissue filament extending from the lower spinal cord). - As a child grows, the cord is stretched, leading to neurological impairment such as lower extremity weakness, paresthesia, back pain and impaired bowel and bladder control. Diastematomyelia - CORRECT ANSWER "split cord", spinal cord divided lengthwise. Type of spina bifida occulta Lipomyelomeningocele - CORRECT ANSWER Fatty benign tumor that can form along lumber spine. Type of spina bifida occulta Dermal sinus - CORRECT ANSWER Openings or tracks in back that extends through dura to spinal cord. Type of spina bifida occulta Cytotoxic edema - CORRECT ANSWER - Intracellular edema of neurons and other cells in white and gray matter from accumulation of fluid and sodium from failure of ATP-dependent Na-K+ pump. - Caused by hypoxia from cardiac arrest & asphyxia. - Treatment: osmotic diuretics in acute stage to restore perfusion. - Occurs concurrently with vasogenic edema Interstitial Edema - CORRECT ANSWER - Associated with hydrocephalus and pseudo tumor cerebri when intravascular pressure forces CSF into white matter around ventricles. - Treatment= acetazolamide, drainage of CSF Lumbar drain - CORRECT ANSWER - Catheter inserted per Tuohy spinal needle into spinal canal between L3-L4 or L4-L5. - Complications= pneumocephalus from over drainage and infection Endoscopic Third Ventriculostomy - CORRECT ANSWER - Used for obstructive hydrocephalus, creates a bypass through the base of the 3rd ventricle, avoiding the need for a shunt. - Endoscope is inserted through a burr hole to the 3rd ventricle, opening/bypass is created in the floor of the 3rd ventricle and dilated to create a stoma. - Bypass allows CSF to flow from third ventricle to fluid chambers below and then into normal CSF circulation. - Patient may have continuous ICP monitoring for 48 hours - Complications= bleeding, infection, stroke, ALOC, DI Autonomic Dysreflexia - CORRECT ANSWER - Complication of central cord lesions at or above T6, precipitated by urinary infection, bladder distention, kidney stones, fecal impaction. - Other less common causes= ingrown toenail, pressure ulcers, sunburns, sexual intercourse, tight clothing. -S/S= hypertension with an increase of 20-40 mmHg SBP, vasoconstriction, pallor, piloerection below lesion, severe pounding HA, restlessness, nasal congestion. - Treatment: Elevate HOB, loosen clothing, urinary catheter, assess fecal impaction. Cardiogenic shock - CORRECT ANSWER - Usually secondary to myocardial infarct; damage reduces contractibility of ventricles, interfering with pumping mechanism of the heart, decreasing oxygen perfusion. - 3 characteristics: increased preload, increased after load, decreased contractibility (causing decreased cardiac output and increased SVR to compensate and protect vital organs) - As cardiac output decreases, tissue perfusion and coronary artery perfusion decreases, fluid backs up and left ventricle fails to adequately pump blood, resulting in pulmonary edema and right ventricular failure. - Symptoms: SBP <90 mmHg, tachycardia >100 bpm, weak thready pulse, dysrhythmia, chest pain, tachypnea, basilar rales, cool moist skin. - Treatment: IV fluids, inotropic agents, anti-dysrhythmics, IAB pump or left ventricular assist device Epidural hematoma (EDH) - CORRECT ANSWER - Sudden, brief, loss of consciousness (concussion), followed by a lucid interval (resolving concussion). - Patient then becomes progressively more confused, agitated, and unresponsive as the hematoma expands and ICP increases. - Bleeding (most commonly from the middle meningeal artery) typically produces signs of uncal herniation: ipsilateral pupil dilation and contralateral motor deficits. Periorbital ecchymosis "raccoon eyes" - CORRECT ANSWER Bleeding from an anterior fracture Post articular hematoma - CORRECT ANSWER - Fracture of the middle fossa, also known as battle's sign. - The patient can have otorrhea if the dura is disrupted. Central cord syndrome - CORRECT ANSWER Characterized by sensory and motor deficits in the upper extremities that exceed those in the lower extremities Anterior cord syndrome - CORRECT ANSWER Presents with sensory and motor loss (pain, pressure, temperature) below the level of the lesion, but proprioception and vibration are preserved Posterior cord syndrome - CORRECT ANSWER Proprioception and vibration deficits, while sensory and motor functions remain intact. Aneurysm recanalization - CORRECT ANSWER - Potential complication, refers to the opening of a previously occluded passageway due to coil remodeling or compaction of coils, allowing blood flow into the aneurysm where coils are present. - Ruptured aneurysms, larger aneurysms and younger patient age are all significantly associated. - Periodic follow up with cerebral angiography is necessary to identify this complication. Dural arteriovenous fistula - CORRECT ANSWER - Abnormal connection between a meningeal artery and meningeal vein or dural venous sinus, and can occur in either the cranium or the spine. - Frequently the sequela of a dural sinus thrombosis. - Depending on the location, patients may present with pulsatile proptosis (bulging of the eye), persistent or progressive headaches, and pulsatile tinnitus (described as a rhythmic pulsating ear noise, often beating in time with the heart, and occurs in 25% of patients with carotid dissection) Pontine hemorrhage - CORRECT ANSWER Catastrophic event caused by hypertensive bleeding; presents with coma, tetraplegia/quadriplegia, pinpoint pupils, but will maintain vertical eye movement (locked-in syndrome) Digital subtraction angiography (DCA) - CORRECT ANSWER The standard for imaging a cerebral aneurysm because it clearly images both the arterial and venous systems of the brain. Posterior fossa tumors - CORRECT ANSWER - Most common primary CNS tumors in children; age of onset peaks at 3-8 years. Typically located in the 4th ventricle or cerebellum. Findings include poor coordination, lethargy, headache, nausea and vomiting and ataxia, facial muscle weakness, partial loss of facial sensation, eye deviation, pupil dilation, visual field deficits, hearing loss, dysphagia, and taste disturbances - Examples= Medullablastoma, pineoblastoma, ependymomas, primitive neuroectodermal tumors (PINET) and astrocytomas. Anterior or middle fossa disorders - CORRECT ANSWER Manifestations include memory deficits, personality changes, unilateral paresis and weakness, short term memory loss and hearing deficits. Forced vital - CORRECT ANSWER - Volume of air that an individual can forcefully expel after maximal inspiration. - Equivalent to the inspiratory reserve volume, plus the tidal volume, plus the expiratory reserve volume. - Good indicator of respiratory muscle strength. Chronic inflammatory demyelinating polyneuropathy (CIDP) - CORRECT ANSWER - rare, autoimmune disorder of the peripheral nerves, characterized by gradual increasing sensory and motor dysfunction, associated with loss of reflexes. - It progresses slowly over months or years. - If untreated, 30% of patients will become wheelchair dependent. - Treatment involves IVIG, steroids and plasmapheresis. prion - CORRECT ANSWER - Infectious agent much smaller than a virus. - These proteins are hypothesized to infect and propagate by refolding abnormally into a structure capable of converting normal protein molecules into an abnormally structured form. - The structure is extremely stable and accumulates in infected tissue, causing tissue damage and cell death. - These proteins have been implicated in a number of conditions including bovine spongiform encephalopathy (aka BSE and "mad cow disease") in cattle and Creutzfeldt-Jakob disease (CJD) in humans. - All known infections affect the structure of the brain or other neural tissue and are currently untreatable and invariably fatal. - Human dural tissue transplants have been associated with CJD transmission to the graft recipient, and symptoms include anorexia, weight loss, insomnia, malaise, and cognitive slowing. Cortical mapping - CORRECT ANSWER - Done prior to epilepsy surgery to identify seizure foci and establish the location of eloquent brain tissue. - "Eloquent" tissues are those that involve critical language, motor or sensory areas of the cerebral cortex. [Show More]

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