34. List nine potential complications of SAH.

G7 p.1040:95mm

Hint: veraNdsah

a. v_____

vasospasm

b. e_____

embolus—pulmonary

c. r_____

rebleed

d. a_____

arachnoid granulation blockage

e. N_____

Na metabolism

f. d_____

deep vein thrombosis

g. s_____

seizures

h. a_____

acute hydrocephalus

i. h_____

hyponatremia

35. Complete the orders for SAH patient.

G7 p.1041:135mm

a. intravenous (IV) fluids

normal saline (NS) and 20 milliequivalents (mEq) KCI

b. rate

2 cc/kg/hour

c. anticonvulsants?

yes—Dilantin-fosphenytoin

d. amount

17 mg/kg load and 100 mg three times a day (or Keppra 500 mg every 12 hours)

36. For the listed SAH conditions, give the frequency of seizure incidence.

G7 p.1041:145mm

a. during acute illness

3%

b. immediate postop

5%

c. during 5-year follow-up

10%

d. middle cerebral artery (MCA)

20%

e. posterior cerebral artery (PCA)

9%

f. anterior cerebral artery (ACA)

2.5%

37. The dosage of Keppra should be

G7 p.1041:182mm

a. _____mg IV

500

b. every_____ hours.

12

38. During the postsubarachnoid hemorrhage period, with the aneurysm unclipped, phenothiazines should be avoided because

G7 p.1042:35mm

a. True or False. They may be overly sedating and obscure neurological assessment.

false

b. True or False. They may lower seizure threshold.

true

c. True or False. They cause elevation of systolic blood pressure.

false

d. True or False. Their metabolites may hasten vasospasm.

false

e. Instead use_____.

Zofran (ondansetron)

39. Ideal systolic blood pressure should be in the range of_____ to_____.

120 to 150

G7 p.1042:145mm

40. True or False. The following is the most reliable parameter to differentiate syndrome of inappropriate diuretic hormone (SIADH) from cerebral salt wasting syndrome:

G7 p.1043:55mm

a. serum atrial natriuretic factor (ANF) and brain natriuretic factor (BNF)

false

b. urine Na⁺ and osmolarity

false

c. serum Na⁺ and osmolarity

false

d. extracellular fluid volume

true (Extracellular fluid volume is low in CSW and normal or elevated in SIADH.)

e. 24-hour urine output

false (ANF = atrial natriuretic factor, BNP = brain natriuretic peptide. If they rise after SAH, it is more likely that the patient will develop negative fluid balance.)

41. Complete the following:

G7 p.1043:56mm

a. True or False. Cerebral salt wasting (CSW) is best differentiated from SIADH by measuring the:

     i. serum sodium

false

     ii. intravascular volume

false

     iii. urine osmolarity

false

     iv. fluid restriction

false

     v. fluorocortisone trial

false

     vi. extracellular fluid volume

true (Measurement [i.e., clinical estimation] of extracellular fluid volume is decreased in CSW).

b. Keeping serum Na levels normal is important because hyponatremic patients have three times the rate of d_____ c_____ i_____ as do normal natremic patients.

delayed cerebral infarction

42. Cerebral salt wasting is

G7 p.1043:90mm

a. more common after SAH than_____.

SIADH

b. Treat with_____ _____.

normal saline

c. Use caution regarding the rate of treatment because you risk producing_____ _____ _____.

central pontine myelinolysis

43. True or False. Regarding SAH:

G7 p.1043:115mm

a. The maximum frequency of rebleeding from SAH is on day 7.

false (4% on day 1, maximum)

b. SAH is associated with stunned myocardium.

true

c. Approximately 50% of ruptured aneurysms will rebleed within 6 months.

true

d. Epsilon-aminocaproic acid may decrease the risk of rebleeding.

true

G7 p.1044:20mm

44. Complete the following:

G7 p.1043:116mm

a. Maximum frequency of rebleeding is on the_____ day

first

b. at a rate of _____%

4%

c. then at _____%

1.5%

d. for _____days.

13

e. Total of rebleed in 2 weeks = _____%

15 to 20%

f. _____% in 6 months

50%

g. Thereafter rebleed rate is _____% per year.

3%

h. Time period of the highest risk of rebleeding is the_____.

first 6 hours

45. Complete the following about acute post-SAH hydrocephalus:

G7 p.1043:130mm

a. The proper treatment is placement of a_____ _____.

ventriculostomy drain

b. Drain fluid_____.

slowly

c. It is recommended to keep the ICP in the range of_____ mm Hg.

15 to 25

d. This reduces the tendency to_____.

rebleed

e. A similar concern is present in use of_____ _____ _____.

lumbar spinal drainage

f. Risk of aneurysmal rebleeding after lumbar drain is _____%.

0.3%

46. Complete the following:

G7 p.1044:75mm

a. Hydrocephalus is more frequently associated with aneurysms in what location?

posterior fossa

b. Frequency of hydrocephalus in SAH is_____%.

15 to 20%

c. What aneurysm has a low incidence of hydrocephalus?

middle cerebral artery aneurysms

d. Treat with_____,

ventriculostomy

e. which will be helpful in _____% of patients.

80%

f. Keep ICP in the range of_____.

15 to 25 mm Hg

g.

     i. Is rupture of aneurysm more likely in patients with ventriculostomy?

probably

     ii. If so probably because of an increase in_____ pressure

transmural

47. Vasospasm. List the components of the “Triple H” therapy.

G7 p. 1045:50mm

a. hypert_____

hypertension

b. hyperv_____

hypervolemia

c. hemo_____

hemodilution

48. Complete the following about vasospasm:

G7 p.1045:95mm

a. also known as_____

delayed ischemic neurologic deficit (DIND)

b. True or False. Higher incidence occurs in:

     i. ACA aneurysm

true

     ii. MCA aneurysm

false

49. Complete the following:

G7 p.1046:25mm

a. The incidence of radiographic cerebral vasospasm is_____%.

30 to 70%

b. The incidence of symptomatic cerebral vasospasm is_____%

20 to 30%

c. as measured on the_____day

seventh

d. Produces infarction in_____%

7%

e. Produces mortality in_____%

7%

f. Onset never before day_____

3

g. Resolved by day_____

12

h. Radiographically resolves over_____ weeks.

3

50. Complete the following:

G7 p.1046:80mm

a. Spasmogenic region on ACA and MCA is the_____.

proximal 9 cm

b. True or False. There is more vasospasm with

     i. cigarette smoking

true

     ii. lower Hunt and Hess grade

false

     iii. amount of bleed on CT

true

     iv. advancing age of patient

true

51. Complete the following about vasospasm:

G7 p. 1046:147mm

a. True or False. Angiography has been shown to exacerbate cerebral vasospasm.

true

b. Describe the Fisher grading system.

     i. grade 1

no blood

     ii. grade 2

slight—less than 1 mm

     iii. grade 3

localized clot—more than 1 mm

     iv. grade 4

intracerebral or

intraventricular clot

c. Clinical vasospasm is essentially limited to Fisher grade_____.

3

G7 p.1046:155mm

52. What chemical has been identified as a critical mediator and cause of vasospasm?

endothelin 1 (ET1)

G7 p.1047:90mm

53. What transcranial Doppler (TCD) values are consistent with vasospasm?

G7 p.1048:20mm

a. Velocity at MCA of more than_____.

120cc/s

b. Ratio of more than_____ between

3

c. the_____ and the_____ indicates vasospasm.

MCA and the ICA mean MCA velocity MCA: ICA ratio (Lindegaard ratio)

d. Velocity <than_____ and ratio <_____ is normal.

120 and ratio 3

e. Velocity between_____ and_____ is mild.

120and200cm/s

f. Velocity above_____ is severe.

200 cm/s

g. Ratio between_____ is mild vasospasm.

3 to 6

h. Ratio above_____ is severe vasospasm.

6

54. Complete the following:

G7 p.1048:135mm

a. Describe the treatment for vasospasm

     i. avoid h_____, a_____, and h_____

hypovolemia, anemia, and hypotension

     ii. surgery

do early

     iii. remove c_____

clots

     iv. drug

calcium channel blocker nimodipine

     v. catheter

dilatation

     vi. drain

bloody CSF

     vii. obtain Hct of_____%

30 to 35%

b. Angioplasty produces clinical improvement of_____%.

60 to 80%

G7 p.1049:55mm

c. Intra-arterial drugs

G7 p.1050:55mm

     i. P_____ is not effective

Papaverine

     ii. V_____-watch for hypotension

Verapamil

     iii. N_____ restores vessel diameter to at least_____%;_____% patients had no stroke

Nicardipine; 60%; 70%

55. Complete the following regarding papaverine:

G7 p.1050:36mm

a. What does it do?

relaxes smooth muscle

b. How does it work?

as a calcium channel blocker

c. It is used to_____.

reverse mechanical vasospasm

d. What is the amount to be used?

30 mg in 9 cc normal saline

56. Complete the following:

G7 p.1052:15mm

a. What is “triple H” therapy?

     i. h_____v_____

hypervolemia

     ii. h_____ t_____

hypertension

     iii. h_____ d_____

hemodilution

b. The fluid to use is_____.

normal saline, a crystalloid

c. Maximum blood pressure (BP) for a(n)

G7 p.1052:90mm

     i. clipped aneurysm is_____

240 mm Hg

     ii. unclipped aneurysm is_____

160 mm Hg

d. What do you do if triple H does not work?

endovascular techniques

e. Goals for hypervolemia

     i. clipped aneurysm: CVP_____

CVP 8 to 12 cm H₂O

     ii. unclipped aneurysm: CVP_____

CVP 6 to 10 cm H₂O

f. Hemodilution to_____Hct

30 to 35

G7 p.1051:170mm

57. Complete the following:

G7 p.1053:50mm

a. complications of hyperdynamic therapy

     i. pulmonary edema_____%

17%

     ii. dilutional hyponatremia_____%

3%

b. benefits

     i. improved permanently_____%

81%

     ii. improved temporarily_____%

7%

     iii. no benefit_____%

16%

     iv. worse_____%

10%

58. Complete the following about dose for calcium channel blocker:

G7 p.1053:150mm

a. name of antivasospasm medication/drug_____

nimodipine

b. dose_____ mg every_____ hours

60 mg every 4

c. route_____

by mouth or nasogastric tube

d. duration_____

21 days

e. unless_____

patient going home intact—if so may stop the calcium channel blocker

59. EKG changes that can occur after SAH are

G7 p.1054:120mm

a. T wakes may be i_____

inverted

b. QT may be p_____

prolonged

c.

     i. ST segments may be e_____

elevated

     ii. or d_____

depressed

d. Premature atrial or ventricular c_____

contraction

e. f_____

fib

f. b_____

bradycardia

60. The mechanism for the EKG changes are thought to be due to

G7 p.1054:135mm

a. h_____ i_____,

hypothalamic ischemic

b. which causes increased_____

tone, sympathetic

c. which releases a surge of c_____,

catecholamines

d. which produces s_____ ischemia,

subendocardial

e. or c_____ a_____ vasospasm.

coronary artery

61. Complete the following about cardiac problems and SAH:

G7 p.1054:120mm

a. Electrocardiographic (ECG) changes occur in_____%.

50%

b. The mechanism is (Hint: hics)

G7 p.1054:135mm

     i. h_____ i_____

hypothalamic ischemia

     ii. i_____ s_____ t_____

increased sympathetic tone

     iii. c_____ s_____

catecholamine surge

     iv. s_____ i_____

subendocardial ischemia

62. Matching. What are ideas regarding the etiology of aneurysms? Match the lettered term with the numbered description.

G7 p.1055:55mm

Description:

less elastica; less muscle; more prominent; less supportive connective tissue

Term:

a. tunica media

b. adventitia

c. internal elastic lamina

d. location—occur

63. Give the% incidence of cerebral aneurysm for each of the following:

G7 p.130:130mm

a. A-comm

30%

b. P-comm

25%

c. MCA

20%

d. posterior circulation

15%

e. basilar

10%

f. multiple

20 to 30%

64. Complete the following about intraventricular hemorrhage:

G7 p.1056:25mm

a. General

     i. True or False. It does not affect morbidity-mortality.

false

     ii. It has a mortality of_____%.

64%

b. A-comm aneurysms rupture into the ventricle through the_____ _____.

lamina terminalis

c. Distal basilar artery aneurysms rupture through the_____ of the_____ _____.

floor of the third ventricle

d. PICA aneurysm may rupture through the

     i._____ of_____

foramen of Luschka

     ii. and into the_____ _____.

fourth ventricle

65. Third nerve palsy can occur with

G7 p.1056:95mm

a._____ or

aneurysm

b._____.

Diabetes

c. One can differentiate by examining the _____.

pupils

     i. Pupil dilated in_____.

aneurysm

     ii. Pupil not dilated in_____.

diabetic

d. The mnemonic is_____ from the third nerve palsy syndrome.

“diabetes deletes the pupil”

e. Aneurysms_____ the pupil.

include

f. NPSTN means_____ palsy.

non-pupil-sparing third nerve

66. True or False. All of the following conditions may be associated with SAH:

G7 p.1057:30mm

a. hypertension

true

b. Osler-Weber-Rendu syndrome

true

c. diabetes mellitus

false (Diabetes insipidus can be associated.)

d. renal fibromuscular dysplasia

true

e. Ehlers-Danlos type IV

true

67. The following conditions are associated with an increased incidence of aneurysm:

G7 p.1057:31mm

a. a_____ d_____ p_____ k_____ d_____

autosomal dominant polycystic kidney disease—15%

b. a_____ m_____

arteriorvenous malformation

c. a _____

atherosclerosis

d. b_____ e_____

bacterial endocarditis

e. c_____ of the a_____

coarctation of the aorta

f. c_____ t_____ d_____

connective tissue disorders

g. Eh_____-Da_____ Ehlers-Danlos type IV

h. fib_____ d_____ r_____ d_____

fibromuscular dysplasia renal disease—7%

i. f_____ o_____

familial occurrences

G7 p.1057:59mm

j. M_____ s_____

Marfan syndrome

k. m_____ d_____

moyamoya disease

l. O_____-W_____-R_____ s_____

Osler-Weber-Rendu syndrome

m. p_____ e_____

pseudoxanthoma elasticum

68. Complete the following about aneurysms and polycystic kidney:

G7 p.1057:87mm

a. ADPKD stands for _____ _____ _____ _____.

adult polycystic kidney disease

b. Incidence is 1 in _____ autopsies.

500

c. Prevalence of aneurysms in patients with ADPKD is _____%.

10 to 30% —15% a reasonable estimate

d. Risk of SAH in a person with ADPKD is _____ the general population.

10 to 20 times

e. Screening protocol in a patient with ADPKD with a prior aneurysm or a kindred with aneurysm is to perform _____ every _____ years.

MRA every 2 to 3

69. Complete the following:

G7 p.1058:100mm

a. In trapping an aneurysm is it better to tie off the common carotid artery or the internal carotid artery?

common carotid occlusion is better

b. It reduces the incidence of _____ _____.

thromboembolic phenomenon

70. True or False. Regarding treatment options for aneurysms:

G7 p.1058:115mm

a. The following procedure(s) offers protection if the aneurysm can’t be clipped or coiled:

     i. wrapping with muscle

false

     ii. wrapping with cotton

false

     iii. wrapping with muslin

false

     iv. coating with plastic resin

false

     v. coating with polymer

false

     vi. coating with Teflon

false

     vii. coating with fibrin glue

false

b. In such cases you could consider trapping or bypass or carotid ligation.

true

71. True or False. Coils are not ideal for

G7 p.158:173mm

a. very small aneurysms

true

b. very large aneurysms

true

c. aneurysms with wide necks

true

d. If after coiling residual filling is noted you should “recoil.”

false (Proceed with surgery.)

72. Data for Guglielmi detachable coils indicate

G7 p.1059:125mm

a. morbidity _____%

4%

b. mortality _____%

1%

c. complete obliteration of aneurysm _____%

40%

d. subsequently required open surgical repair _____%

20%

73. Complete the following about timing for aneurysm surgery:

G7 p.1060:105mm

a. The definition of early surgery is less than _____ to _____ hours.

48 to 96 hours

b. Late surgery is after _____.

10 to 14 days

c. Timing of basilar artery aneurysm is _____.

more likely to delay surgery

d. Avoid doing surgery between days _____ and _____ because that is considered a _____ _____.

4 and 10; vasospastic interval

74. Complete the following regarding vasospasm treatment:

G7 p.1061:85mm

a. It peaks in incidence between days _____ and _____.

6 and 8

b. It never occurs before day _____.

3

c. Vasospastic interval during which surgery should be avoided is days _____ to _____.

4 to 10

75. Complete the following:

G7 p.1061:160mm

a. What is an aneurysmal rest?

residual unclipped part of aneurysm

b. Why are they dangerous?

they may bleed

c. What is the incidence of rebleeding?

3.7%

d. There is a risk per year of _____%.

0.4 to 0.8%

e. How should they be handled?

serial angiography

f. If they increase in size treat with _____ or _____ _____.

surgery or endovascular coiling

76. Answer the following about CSF drainage during craniotomy:

G7 p.1062:90mm

a. True or False. CSF should be drained before opening the dura.

false (This is associated with an increased incidence of rebleeding.)

b. True or False. CSF should be drained after opening the dura

true

c. What is the rate of rebleeding with CSF drainage?

0.3%

77. Complete the following:

G7 p.1062:135mm

a. O₂ consumption by the neuron is for two functions:

     i. to maintain _____ _____

cell integrity

     ii. for conduction of _____ _____

electrical impulse

b. If there is occlusion of a vessel it produces _____

ischemia

c. due to _____ _____.

oxygen deficiency

d. This precludes

     i. a_____ g_____ and

aerobic glycolysis

     ii. o_____ p_____

oxidative phosphorylation

e. What happens to adenosine triphosphate (ATP) production?

it declines

f. What happens to the cell?

cell death occurs

78. What can be done to protect against ischemia?

G7 p.1062:165mm

a. Tactics to reduce injury by ischemia include

     i. n_____

nimodipine—calcium channel blockers

     ii. b_____

barbiturates—free radical scavengers

     iii. m_____

mannitol

b. Tactics to reduce the cerebral metabolic rate of oxygen consumption (CMRO₂) required include

     i. reducing electrical activity of the neuron with _____

barbiturates-etomidate

     ii. reducing maintenance energy of the neuron with _____

hypothermia

79. Answer the following about temporary clipping during aneurysm surgery:

G7 p.1064:23mm

a. True or False. Under 5 minutes occlusion is well tolerated.

true

b. If occluded 10 to 15 minutes must add _____.

5 mg/kg thiopental loading dose and drip titrated to burst suppression

c. If occluded more than 20 minutes _____.

not tolerated

80. Answer the following about postop angiography after aneurysm or AVM surgery:

G7 p.1064:65mm

a. True or False. It is not needed.

false

b. Because _____% showed unexpected findings.

19%

c. True or False. It is the standard of care.

false

d. True or False. It is recommended.

true

81. Complete the following:

G7 p.1064:90mm

a. What special medications should be used during temporary clipping of an aneurysm?

etomidate or propofol

b. What do they do?

suppress neuronal activity by reducing neuronal metabolism

c. By how much?

50%

d. What is the side effect of etomidate?

lowers seizure threshold

e. Guard against this side effect by _____.

using preoperative antiepileptic drugs

82. Complete the following about intraoperative aneurysm rupture (IAR):

G7 p.1064:138mm

a. True or False. Intraoperative aneurysm rupture increases the morbidity and mortality of surgery threefold.

true

b. True or False. Techniques to decrease the probability of intraoperative rupture include

     i. preventing hypertension

true

     ii. minimizing brain retraction

true

     iii. sharp vs blunt dissection

true

     iv. radical removal of sphenoid wing

true

c. List the three general stages of aneurysm surgery during which intraoperative rupture is most likely to occur.

stage 1 = initial exposure, stage 2 = dissection of the aneurysm, and stage 3 = clip application

d. Of these, during which stage is intraoperative rupture most likely to occur?

dissection of aneurysm (stage 2)

83. True or False. During intraoperative rupture by clip application bleeding reduces as clip blades approximate.

false

G7 p.1065:130mm

84. Complete the following about aneurysm recurrence after treatment:

G7 p.1065:177mm

a. Can an incompletely clipped aneurysm bleed?

yes—0.4 to 0.8% per year

b. Can an incompletely coiled aneurysm bleed?

yes—0.16% per year

c. Can an aneurysm that has been completely obliterated recur and bleed?

yes—0.37% per year