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51 Cards in this Set

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MN45b ANZCA version [Jul07]

A 33-year-old chronically spinally injured patient becomes hypertensive and sweaty during general anaesthesia for urinary sphincterotomy. His level of spinal cord injury is T4 and it is complete. You consider the diagnosis of autonomic hyperreflexia.

Autonomic hyperreflexia

A. could have been prevented by performing subarachnoid anaesthesia

B. is unlikely with a T4 lesion

C. should be treated by administration of a beta-blocker

D. should be treated by administration of an opioid analgesia

E. will resolve once the surgical stimulus ceases
ANSWER A

A. TRUE : Spinal anaesthesia.can reliably prevent autonomic dysreflexia and spasm

B. FALSE : Increased sensitivity of sympathetic reflexes in patients with spinal cord injury above T5/6. Cutaneous or visceral stimuli below the level of the lsion may result in mass discharge of sympathetic nerves, causing sweating, vasoconstriction and hypertension, with high levels of circulating catecholamines. Baroreceptor stimulation results in compensatory bradycardia. Distension of hollow viscera, especially the bladder, is a potent stimulus. It may occur during abdominal surgery and labour. Onset of susceptibility is usually within a few weeks of injury.

C. FALSE : Where autonomic dysreflexia occurs during surgery, management should begin with removal of the precipitating stimulus, if possible. Most episodes appear to be brief and self-limiting and in 21 of our 43 cases no specific treatment was given. Dysreflexia occurring under general anaesthesia is best treated with increasing anaesthetic depth in the first instance. Where drug therapy is required, nifedipine and labetalol are used most commonly, though propranolol, midazolam, spinal anaesthesia and transdermal glyceryl trinitrate patches were all used on survey patients.

D. FALSE : Nifedipine (10mg SL) or GTN (SL or TD) or alpha-blockers are all used in first-line therapy"

E. FALSE

Window
-3 weeks to 12 years

Stop stimulation
Deepen Anaesthesia
Nifed/GTN/labetolol
consider phentalamine
MN44 ANZCA version [2005-Sep] Q99

Cerebral palsy is associated with each of the following EXCEPT

A. gastro-oesophageal reflux

B. increased sensitivity to non-depolarising muscle relaxants

C. malnutrition

D. recurrent aspiration

E. scoliosis
ANSWER B

Cerebral Palsy associated with increased sensitivity to depolarising NMBDs and resistance to non-depolarising NMBDs.
MN43 ANZCA version [2004-Aug] Q99, [Mar06] Q72

Common complications of spinal cord injury include each of the following EXCEPT

A. deep vein thrombosis

B. diarrhoea

C. heterotopic calcification

D. pressure sores

E. urinary tract infection
ANSWER B
MN42 ANZCA version [2005-Apr] Q111

The respiratory pattern of a patient sustaining an acute C5 spinal cord injury is characterised by

A. a rapid respiratory rate

B. arterial hypoxaemia

C. chest wall immobility

D. preservation of the cough

E. preservation of the inspiratory force
ANSWER A

* A. a rapid respiratory rate - probably most true: For those thinking the answer is B, B is controversial, and if you get B, you're definitely going to have A. Also if intercostal and abdominal muscles are affected, TV will decrease and so RR must increase.
* B. arterial hypoxaemia - false although some would disagree
* C. chest wall immobility - false: flaccid paralysis initially so chest will move passively; i.e. chest wall compliance decreases
* D. preservation of the cough - false: abdominal muscles required to cough
* E. preservation of the inspiratory force - false: inspiratory is active. Some muscles will be lost.
MN41 [2005-Apr] Q122, [2005-Sep] Q80, [Mar06] Q13 | Aug10

Von Hippel-Lindau disease is associated with

A. increased risk of malignant hyperthermia

B. meningiomas

C. peripheral neuropathy

D. pheochromocytomas

E. poor dentition
ANSWER D

Von Hippel-Lindau disease (VHL)?

von Hippel-Lindau disease (VHL) is a rare, genetic multi-system disorder characterized by the abnormal growth of tumors in certain parts of the body (angiomatosis).

The tumors of the central nervous system (CNS) are benign and are comprised of a nest of blood vessels and are called hemangioblastomas (or angiomas in the eye). Hemangioblastomas may develop in the brain, the retina of the eyes, and other areas of the nervous system.

Other types of tumors develop in the adrenal glands, the kidneys, or the pancreas.

Symptoms of VHL vary among patients and depend on the size and location of the tumors. Symptoms may include headaches, problems with balance and walking, dizziness, weakness of the limbs, vision problems, and high blood pressure. Cysts (fluid-filled sacs) and/or tumors (benign or cancerous) may develop around the hemangioblastomas and cause the symptoms listed above. Individuals with VHL are also at a higher risk than normal for certain types of cancer, especially kidney cancer.

Inheritance

* Familial
* Autosomal dominant

Features

* Retinal angiomas
* Haemangioblastomas
* Cerebellar and visceral tumours (usually benign but can cause pressure effects)

Associations An increased incidence of

* Phaeochromocytoma - apparently 20%
* Renal cysts
* Renal cell carcinoma

Anaesthesia

* Treat hypertension occurring with phaeochromocytoma
* Haemangioblastoma of spinal cord may limit use of spinal although epidural has been used for LSCS
* Exagerrated hypertension with surgical stimulation or laryngoscopy
o Treat with β blockers and/or SNP
MN40 ANZCA version [2002-Mar] Q91, [2005-Sep] Q83, [Jul07], [Mar10]

An INCORRECT statement regarding the autonomic nervous system is that

A. autonomic dysfunction is a predictor for worse long term survival after myocardial infarction

B. heart rate responses are primarily mediated through the sympathetic nervous system

C. inhalation anaesthetics all impair autonomic reflex responses

D. autonomic dysfunction is a predictor for haemodynamic instability following anaesthetic induction

E. low heart rate variability is associated with worse cardiac outcomes following non-cardiac surgery
ANSWER B
MN39 ANZCA version [2004-Aug] Q113

The incidence of an intra-cranial aneurysm is increased by each of the following EXCEPT

A. Ehlers-Danlos syndrome

B. hypertension

C. neurofibromatosis

D. positive family history of intra-cranial aneurysms

E. type 2 diabetes mellitus
ANSWER E

* A. Ehlers Danlos disease - true:
o " A number of inherited conditions are associated with increased risk of cerebral aneurysm and SAH. These include autosomal dominant polycystic kidney disease, glucocorticoid-remediable aldosteronism, and Ehler Danlos syndrome." (Uptodate)

* B. hypertension - true:
o "Hypertension is a major risk factor for SAH"

* C. neurofibromatosis - true:
o "Several retrospective series have noted abnormal cerebral vasculature (eg, moyamoya syndrome, intracranial aneurysm) in 2 to 6 percent of children with NF1 who underwent neuroimaging" (Uptodate)

* D. positive family history of intra-cranial aneurysms - true:
o "A family history of SAH also increases the risk of SAH in individuals without one of these conditions. As an example, one case-control study found that patients with a family history of SAH had an odds ratio of 4.0 (95% CI 2.0-8.0) for SAH compared with controls" (Uptodate)

* E. type 2 diabetes mellitus - false and answer to choose


Multiple conditions have been associated with cerebral aneurysms; they include the following:

* Autosomal dominant inherited polycystic kidney disease
* Fibromuscular dysplasia
* Arteriovenous malformations
* Osler-Weber-Rendu syndrome
* Coarctation of the aorta
* Other vascular anomalies
* Moyamoya syndrome
* Marfan syndrome
* Ehlers-Danlos syndrome, type IV
* Other collagen type III disorders
* Pseudoxanthoma elasticum
* Alpha1-antitrypsin deficiency
* Systemic lupus erythematosus
* Sickle cell anemia
* Bacterial endocarditis
* Fungal infections
* Neurofibromatosis type 1
* Tuberous sclerosis
MN38 ANZCA version [2004-Apr] Q124, [2005-Apr] Q100, [2005-Sep] Q94, [Jul07] [Apr08] [Aug08] [Aug09][Mar10] [Aug10]

Respiratory function in quadriplegics is improved by

A. abdominal distension

B. an increase in chest wall spasticity

C. interscalene nerve block

D. the upright position

E. unilateral compliance reduction
ANSWER B
MN37 ANZCA Version [2004-Apr] Q136

In hemiplegic patients

A. neuromuscular blockade should be monitored on the affected side

B. suxamethonium may cause a hyperkalaemic response 3 months to one year after the stroke

C. there is resistance to non-depolarizing muscle relaxants in the unaffected muscle groups

D. the response to non-depolarizing muscle relaxants is similar to that seen in paraplegic patients

E. ventricular fibrillation after suxamethonium has been documented
ANSWER D>E

A. FALSE : NMB monitoring on the non affected side. The effected side may have contractures and as such will probably be abnormal.

B. FALSE : 1wk to 6 months

C. FALSE : resistence on the affected side, furthermore when compared to controls the unaffected arm shows resistence.

D. TRUE : both are UMN diseases with reduction in peripheral ACh release leading to immature nAChR upregulation.

E. TRUE : Ventricular fibrillation in a normokalemic hemiplegic patient during induction of anesthesia.
MN36 ANZCA version [2003-Apr] Q122

In patients suffering from multiple sclerosis it is better to avoid the use of

A. epidural lignocaine

B. neostigmine

C. pancuronium

D. spinal anaesthesia

E. suxamethonium
ANSWER E

suxamethonium is associated with a large efflux of potassium in debilitated patients and should be avoided
MN35 ANZCA version [2001-Apr] Q119, [2001-Aug] Q125

The knee jerk is

1. mediated through spinal segments L2-3-4

2. mediated through receptors in the patellar tendon

3. a monosynaptic reflex

4. diminished in a patient with an upper motor neuron lesion
ANSWER 1 and 3

1. True - L2-4

2. False - Quadriceps femoris

3. True

4. False - Increased
MN34b ANZCA version [2005-Sep] Q149

Cauda equina syndrome

A. involves large sensory fibres
initially

B. is not associated with back pain

C. results from compression of nerve roots

D. results in loss of sensation confined to the foot

E. results predominantly in an upper motor neuron lesion
ANSWER C

A- False: Usually affects small nerve fibres first, ie autonomic nerves.

B False: Is characteristically associated with low back pain.

C True: Spinal cord finishes at L1-2

D False: Nerve root distribution, mostly saddle/perineal anaesthesia

E False: LMN Lesion, see below
MN33a ANZCA version [2002-Mar] Q17, [2002-Aug] Q23, [2005-Apr] Q3 (Similar reported question in [Jul98] [Apr99] [Aug99] [Mar00])

A patient with a head injury who has eye opening to speech, no verbal responses and withdrawal
motor responses would have a Glasgow Coma Scale score of

A. 4
B. 5
C. 6
D. 7
E. 8
ANSWER E

E=3/4 V=1/5 M=4/6
MN33b ANZCA version [2003-Aug] Q102, [2004-Apr] Q61, [2005-Sep] Q56, [Mar06]

A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to
voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is

A. 5
B. 6
C. 7
D. 8
E. 9
ANSWER D

E=2/4 V=2/5 M=4/6
MN32 ANZCA version [2004-Aug] Q49 (Similar reported question in [Apr98] [Jul98] [Jul00])

The percentage of diabetic patients with autonomic neuropathy is reported to be

A. <5%

B. 10 - 20%

C. 20 - 40%

D. 60 - 80%

E. >80%
ANSWER C

Estimated to be present in 20% to 40% of patients with long-standing diabetes .

Autonomic dysfunction, which is of par-ticular importance to the anaesthetist, is detectable in up to 40% of type 1 and 17% of type 2 diabetic patients.
MN31 [Aug96] [Apr97] [Jul97] [Apr98] [Jul98] [Aug99] [Mar00] [Jul00] (type K MCQ)

A 25 year old man has a subarachnoid haemorrhage. Two hours later a CXR shows patchy
perihilar infiltrates.

Possible diagnoses include:

1. Early bronchopneumonia

2. Aspiration

3. ARDS

4. Pulmonary oedema
ANSWER 4
MN30 ANZCA version [2001-Apr] Q97 (Similar reported question in [Apr96] [Jul97])

Cerebellar hemisphere lesions are characterised by

1. cogwheel rigidity

2. intention tremor

3. absent deep tendon reflexes

4. dysarthria
ANSWER 2 and 4

CEREBELLAR FUNCTION

*Dysergia: Improper co-ordinated function of a muscle group.
*Dysmetria: Inability to properly gauge the distance between two points. Tested
with finger-to-nose movements.
*Dysdiadochokinesia: Inability to do rapid alternating movements.
*Scanning Speech: Prolonged separation of syllables, often seen with cerebellar
dysfunction.
*GAIT Disturbances:
:Cerebellar Lesions: Central cerebellar lesion shows unsteady gait, but
conventional cerebellar signs may be normal.
:Posterior Columns Lesions: Loss of proprioception results in unsteady gait when eyes
are closed, but relatively normal gait when eyes are open.
:Festinating Gait: Parkinsonian gait, shuffling walk.
*Romberg's Test: Patient can't maintain balance with legs tight together, with eyes closed.
*Titubation: Body tremor when standing or walking, sign of cerebellar disease.




Cog-wheel rigidity is the phrase used to describe the feeling of periodic resistance to passive movement felt by the examiner in a parkinsonian limb. The phenomenon may be unilateral initially. The cog-wheeling is in fact a tremor superimposed on lead pipe rigidity - the teeth of the cog are analogous to the tensed parts of the tremor.
MN28 [Mar92] [Aug96]

Autonomic hyperreflexia:

A. Can be seen any time after an acute spinal injury

B. Does not occur if lesion is below T10

C. Lesion is above T6

D. ?

E. ?
ANSWER C

Autonomic dysreflexia is a syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) above the splanchnic sympathetic outflow (T5-T6).
MN27d ANZCA version [2003-Aug] Q130, [2004-Apr] Q1

Clinical features of autonomic neuropathy include all of the following EXCEPT

A. increased risk of gastro-oesophageal reflux

B. postural hypotension

C. pronounced sinus arrhythmia

D. resting tachycardia

E. silent myocardial ischaemia
ANSWER C


-Hypertension
-Painless MI
-Orthostatic hypotension
-Lack of heart rate variability with breathing (normal heart rate variability during voluntary deep breathing is > 10 beats/min)
-Resting tachycardia
-Early satiety (due to delayed gastric emptying)
-neurogenic bladder
-lack of sweating and impotence.
-impaired thermoregulation
(intraoperative hypothermia)
-sudden death syndrome
-gastroparesis
-bladder atony
-asymptomatic hypoglycaemia
MN27c [Aug96]

Diabetics with cardiac denervation due to autonomic neuropathy develop:

A. Supine hypertension

B. Orthostatic hypotension

C. Resting tachycardia

D. Silent myocardial ischaemia

E. All of the above
ANSWER E

-Hypertension
-Painless MI
-Orthostatic hypotension
-Lack of heart rate variability with breathing (normal heart rate variability during voluntary deep breathing is > 10 beats/min)
-Resting tachycardia
-Early satiety (due to delayed gastric emptying)
-neurogenic bladder
-lack of sweating and impotence.
-impaired thermoregulation
(intraoperative hypothermia)
-sudden death syndrome
-gastroparesis
-bladder atony
-asymptomatic hypoglycaemia
MN27b [Aug93] [Aug94] [Aug95] [Apr96] [Aug96] [Jul98]

Diabetic autonomic neuropathy:
A. Resting tachycardia
B. Unrecognised hypoglycaemia may occur
C. Decreased respiratory response to hypoxia may occur
D. Faecal impaction and constipation
E. Postural hypotension
F. Supine hypertension
ANSWER ALL

-Hypertension
-Painless MI
-Orthostatic hypotension
-Lack of heart rate variability with breathing (normal heart rate variability during voluntary deep breathing is > 10 beats/min)
-Resting tachycardia
-Early satiety (due to delayed gastric emptying)
-neurogenic bladder
-lack of sweating and impotence.
-impaired thermoregulation
(intraoperative hypothermia)
-sudden death syndrome
-gastroparesis
-bladder atony
-asymptomatic hypoglycaemia
MN26 [Mar91] [Aug94] [Mar95] [Aug95] [Apr96]

Autonomic ?neuropathy/ ?dysfunction is associated with:

A. Spinal cord transection

B. Diabetes mellitus

C. Tetanus

D. Alcoholism
ANSWER ALL
MN24 [Apr96] [Apr98] [Aug99] [Mar00] (?type K)

Proprioception is involved in lesions of:

A. Posterior columns

B. Tabes dorsalis

C. Cerebellum

D. Anterior horn cells

E. Spinothalamic tract
ANSWER A B C

Position sensation travels in the DORSAL COLUMN-MEDIAL LEMNISCUS system Ganong 9th pg 597

Tabes dorsalis, a demyelination of DORSAL COLUMNS causes alterations in proprioception. - Neurological Skills Harrison.

Sensory tracts to cerebellum include DORSAL and ventral cerebellar tracts including signals regarding joint position, Guyton 9th edition pg 717.
MN15

A patient with bitemporal hemianopia has a lesion in the:

A. Optic nerve

B. Optic tract

C. Optic chiasma

D. Optic radiation
ANSWER C
MN16 [1985] [Mar93]

The site of a lesion producing blindness with preservation of the pupillary reflexes is:

A. Optic chiasma

B. Optic tract

C. Frontal lobe

D. Occipital lobe

E. None of the above
ANSWER D
MN17 [Mar91]

Cerebrospinal fluid:

A. Lower sodium then plasma

B. Pressure ? 8-10 mmHg in normal supine person

C. Hypochloraemia in tuberculous meningitis

D. Glucose level rises with bacterial meningitis
ANSWER C

* Sodium is 144-152mmol/L

* ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally less than 10–15 mmHg.

* Low CSF chloride is classic of TB meningitis.

* glucose is normal in viral meningitis but decreased in all other causes.

CSF composition -Reference values for CSF are as follows:

* Protein 0.15-0.45 g/L

Electrolytes:

* Osmolality 280-300 mmol/L
* Sodium 135-150 mmol/L
* Potassium 2.6-3.0 mmol/L
* Chloride 115-1 30 mmol/L
* Carbon dioxide 20-25 mmol/L
* Calcium 1.00-1 .40
* Magnesium 1.2-1.5 mmol/L
* Lactate 1.1-2.4 mmol/L
* pH 7.28-7.32
* PCO2 44-50 mm Hg
* PO2 40-44 mm Hg

Other constituents:

* Creatinine 50-110 umol/L
* Glucose 2.8-4.4 mmol/L
* Iron 0.2-0.4 umol/L
* Phosphorus 0.4-0.6 umol/L
* Urea 3.0-6.5 mmol/L

A comparison of the composition of CSF and plasma reveals that:

1. CSF proteins are -1 % that of plasma;
2. CSF calcium levels are -50% that of plasma;
3. CSF glucose levels are -60% that of plasma;
4. CSF chloride and magnesium levels are higher than plasma;
5. CO2 diffuses rapidly, and HCO3 slowly, from the plasma into the CSF.
MN19 [1985] [Mar90] [Aug93] [Mar94]

Regarding CSF:

A. The pH of CSF is the same as arterial blood

B. The pH is lower than arterial blood

C. The HCO3 concentration of CSF is the same as arterial blood

D. The pCO2 of CSF is the same as arterial blood

E. In active hyperventilation, greater difference in pCO2 in CSF as compared to ABG
ANSWER B


CSF composition -Reference values for CSF are as follows:

* Protein 0.15-0.45 g/L

Electrolytes:

* Osmolality 280-300 mmol/L
* Sodium 135-150 mmol/L
* Potassium 2.6-3.0 mmol/L
* Chloride 115-1 30 mmol/L
* Carbon dioxide 20-25 mmol/L
* Calcium 1.00-1 .40
* Magnesium 1.2-1.5 mmol/L
* Lactate 1.1-2.4 mmol/L
* pH 7.28-7.32
* PCO2 44-50 mm Hg
* PO2 40-44 mm Hg

Other constituents:

* Creatinine 50-110 umol/L
* Glucose 2.8-4.4 mmol/L
* Iron 0.2-0.4 umol/L
* Phosphorus 0.4-0.6 umol/L
* Urea 3.0-6.5 mmol/L

A comparison of the composition of CSF and plasma reveals that:

1. CSF proteins are -1 % that of plasma;
2. CSF calcium levels are -50% that of plasma;
3. CSF glucose levels are -60% that of plasma;
4. CSF chloride and magnesium levels are higher than plasma;
5. CO2 diffuses rapidly, and HCO3 slowly, from the plasma into the CSF.
MN21 [1985] [1986] [1987] [1988] [Mar93] [Apr98] (type A)

Which of the following is NOT a feature of long-standing
paraplegia above T6?

A. Flaccidity of the leg muscles

B. Poikilothermia

C. Mass autonomic reflex

D. Hyperkalaemia after Suxamethonium administration

E. Labile blood pressure
ANSWER A
MN02b ANZCA version [2003-Apr] Q142, [2003-Aug] Q25, [2005-Sep] Q24,

A patient presents with headache, morning vomiting and double vision for three weeks. On examination
nystagmus is present when the eyes are turned to either side. The most likely diagnosis is

A. acoustic neuroma

B. craniopharyngioma

C. frontal glioma

D. pituitary adenoma

E. posterior fossa tumour
ANSWER E

Posterior fossa tumour

Symptoms and their association:

* early morning vomiting = raised ICP
* double and blurred vision, nystagmus = infratentorial lesion
* problems with equilibrium, gait, and coordination = infratentorial lesion
* focal problems (eg motor or sensory deficit, speech change, seizures) = supratentorial lesion
* strong hand preference = supratentorial lesion
* neuroendocrine problems (DI, hypothyroidism) = suprasellar lesion
* change in visual acuity, visual field defect, Marcus Gunn pupil (afferent papillary defect), nystagmus = visual pathway lesion
* long nerve tract motor and/or sensory deficits, bowel and bladder deficits, and back or radicular pain = spinal cord lesion
MN02 ANZCA version [2002-Mar] Q25

A five-year-old child presents with headache, morning vomiting and double vision for three weeks.
On examination nystagmus is present when the eyes are turned to either side. The most likely
diagnosis is

A. tuberculous meningitis

B. craniopharyngioma

C. aseptic meningitis

D. posterior fossa tumour

E. acoustic neuroma
ANSWER D

Posterior fossa tumour

Symptoms and their association:

* early morning vomiting = raised ICP
* double and blurred vision, nystagmus = infratentorial lesion
* problems with equilibrium, gait, and coordination = infratentorial lesion
* focal problems (eg motor or sensory deficit, speech change, seizures) = supratentorial lesion
* strong hand preference = supratentorial lesion
* neuroendocrine problems (DI, hypothyroidism) = suprasellar lesion
* change in visual acuity, visual field defect, Marcus Gunn pupil (afferent papillary defect), nystagmus = visual pathway lesion
* long nerve tract motor and/or sensory deficits, bowel and bladder deficits, and back or radicular pain = spinal cord lesion
SN14 ANZCA version [2003-Aug] Q79, [2004-Apr] Q68, [2005-Sep] Q61, [Mar06] Q77

Hyperventilation during neurosurgery

A. only vasoconstricts intracerebral vessels

B. protects the brain from retractor injury

C. is relatively contraindicated in severe coronary artery disease

D. can reduce cerebral blood flow by 15% of normal at its peak effect

E. may cause a "steal" phenomenon
ANSWER C

A. FALSE : vasoconstricts most vessels

B. FALSE : vasoconstriction may exacerbate retractor injury by limiting blood flow to compressed areas

C. TRUE

D. FALSE : can reduced CBF by 30%

E. FALSE : reverse steal occurs, vasoconstrict normal brain with normal CO2 responsiveness while the injured brain stays vasodilated due to "vasomotor paralysis".
PZ126 ANZCA Version [2006-Mar] Q133 [2006-Jul] Q6

Transient Neurological Syndrome

A. comprises pain localised to the back

B. diagnosis is confirmed by typical findings on neurological examination

C. is associated with consistent abnormalities on magnetic resonance imaging and electrophysiological studies (EPS)

D. is associated with long term deficits in 5% of cases

E. may occur with lignocaine, bupivacaine, prilocaine and procaine
ANSWER E

* A. comprises pain localised to the back - false: "Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities—transient neurologic symptoms (TNS)" (A & A June 2005 vol. 100 no. 6 1811-1816)

* B. diagnosis is confirmed by typical findings on neurological examination - false: "In contrast to the lower extremity weakness and bowel and bladder dysfunction observed with cauda equina syndrome (8), neurologic examination, magnetic resonance imaging, and electropathological testing show no abnormalities in patients with TNS"

* C. is associated with consistent abnormalities on magnetic resonance imaging and electrophysiological studies (EPS) - false: See B

* D. is associated with long term deficits in 5% of cases - false: "There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day."

* E. may occur with lignocaine, bupivacaine, prilocaine and procaine - true: "The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine)"
MM18 ANZCA Version [Jul06] Q130, [Apr07] Q19

Findings in a patient with serotonin syndrome include each of the following EXCEPT

A. clonus

B. diaphoresis

C. hyperreflexia

D. miosis

E. tachycardia
ANSWER D


Serotonin toxicity has now been more clearly characterized as a triad of neuro-excitatory features.

Neuromuscular hyperactivity; tremor, clonus, myoclonus, hyper-reflexia and (in the advanced stage) pyramidal rigidity.

Autonomic hyperactivity; diaphoresis, fever, tachycardia and tachypnoea.

Altered mental status; agitation, excitement and (in the advanced stage) confusion.
PZ113 ANZCA version [2004-Aug] Q110, [Mar06]

Following acute subarachnoid haemorrhage, the use of antifibrinolytic agents is associated with decreased

A. incidence of hydrocephalus

B. incidence of rebleeding

C. incidence of pulmonary embolus

D. mortality from all causes

E. mortality from ischaemic neurological events
ANSWER B

Antifibrinolytics : transiemic acid and aprotinon.

Antifibrinolytic drugs prevent rebleeding after aneurysmal rupture, but because they increase the
risk of cerebral ischaemia, they have no useful effect on overall outcome.
IHAST trial
Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST)

Multicentre blinded randomised control trial
-Multicentre : 30 centres
-assessor blinded
-prospective
-published in the NEJM

Inclusion criterea
1. >18yo
2. preoperative WFNS I, II and III
3. SAH <14days old
4. open aneurysm surgery via clipping

1001 patients recruited between 2000 and 2003
-randomised to
1. intra-operative hypothermia
were cooled to a target oesophageal temperature of 33°C using surface
cooling techniques (forced air cooling, IV cold saline, ice packs) and maintained until the last aneurysm clip was secured, after which rewarming began.
2. Those assigned to normothermia group were kept at 36.5°C.

Patients were examined 90 days post surgery.

No significant differences found in neurological, cardiovascular, coagulation or infective events.

?slight trend towards favorable outcomes with cooling.
Describe the vascular of the brain.
Blood supply to the brain
-two internal carotid arteries
-two vertebral ateries
-Cirle of Willis (only 20% have a complete Circle)

Venous drainage
-most blood in the brain is in the venous system
-superfical veins -> cortical sulci
-deep veins -> great vein of galen
-veins of he posterior fossa
-diploic veins
-emissary veins
*all veins -> meningeal sinuses -> IJ
-right IJ is dominant
-no valves in the veins therefore pressure in IJ is transmitted directly to intracranial veins.

Brain Blood Supply
• Brain has about 50-100 ml blood in it
• Brain has about 50ml/100gr/min blood flow
• Brain uses oxygen (CMRO2) about 3-3.5 ml/min
• About 40% directed to cellular integrity
• About 60% directed towards brain cell functioning
Notes on Intracranial Aneurysms
Definition & Epidemiology
• Aneurysms are abnormal dilations in the arterial wall.
• Mostly appear at the branching of cerebral vasculature
• From all SAH about 85% are from IA
• The incidence of SAH 5-10/100,000/year

Pathology
• Mostly in bifurcations
• Mostly at the ACA or MCA
• About 30% of patients who present with SAH have multiple aneurysms
• About 10% at ICA bifurcation or basilar tip

Patient Risk Factors
• Familial
• Genetic disorders of collagen
• PCKD
• Gender
• Age
• Cigarette
• ETOH
• Pregnancy (timing)

Aneurysm Risk Factors
• Size
• Location
• Previous Bleed
• Transmural Pressure

Presentation
• Incidental finding
• Screening
• Neurologic symptoms
• Sentinel Headache
• SAH

Different Classifications
• Hunt Hess Classification
• World Federation of Neurosurgeons
• Fisher Grading

Pre-Operative Considerations
• Similar to all other craniotomies
– History and physical with end organ involvement
– Family & social history
– Labs
– Radiology and Angiogram
– Meds

• Special considerations
– Presentation’
– Where is the patient?
– SAH (timing?)
– Vasospasm
– Seizure
– Transfusion (T&S or T&C)
– Electrolytes

Surgical Issues
• Positioning
• Surgical exposure
• Blood loss
• Temporary clipping
• Hemodynamic changes

Induction
• Smooth and controlled
• Monitoring plan & lines
• Premedication
– Anxiolytics
– Opioids
• Ventilation (hypo/hyper)
• Induction agents
– Intravenous agents
– Lidocaine
– Opioids
– Muscle relaxants

Maintenance
• Balanced Anesthetics
• Hemodynamic goals
• Ventilation goals
• Crucial moments

Balanced Anesthetics
• Volatile Agents
– Choice
– MAC
– N2O
• Narcotic
– Choice
– Bolus vs. infusion
– Post-operative pain
• Muscle relaxant
– Choice & importance
– Bolus vs. infusion
• TIVA

TIVA
• Benefit
– Rapid and predictable titration
– Swift wake up
– Fewer respiratory complication
– Less increase ICP following intracranial vasodilation
• Usually an intravenous anesthetic such as propofol and an opioid

Hemodynamic Goals
• Ultimately to keep more neurons alive
• Presentation dependant
– Non ruptured
– Ruptured
• Timing dependant
– Pre-clip
– Temporary Clip
– Post Clip
• Attention to baseline hemodynamics
• Attention to comorbid state
– CAD
– HTN
– Renal insufficiency

Ventilatory Goals
• Adequate oxygenation
• Avoidance of hyperventilation before the dura is opened
• Mild hyperventilation after dural opening

Emergence
• Decision for extubation
• Smooth
• Use of Lidocaine
• Short acting agents
• Neuro exam before extubation
• Differential diagnosis of prolonged wakeup

Post Operative Destination
• Depending on the clinical picture
• Monitoring
• Transport
• Post operative pain & nausea control
• Hemodynamic Goals
Therapeutic hypothermia
1. Hypothermia decreases metabolic rate of the whole body by 8% per °C.
2. Hypothermia is Neuroprotective:
• It decreases cerebral metabolic rate by 8% per °C.
• It decreases the production of glutamate.
• It decreases or reverses ischaemic depolarisation of CNS
causing membrane stabilisation.
• It maintains the integrity of the blood brain barrier.
3. Hypothermia is Cardioprotective:
• It decreases myocardial metabolic demand.
• It preserves intracellular high energy phosphate stores.
4. Inflammation and Hypothermia:
• It decreases the production of pro-inflammatory markers
(cytokines, interleukins, arachidonic acid cascade) and ROS.
• It increases the production of anti-inflammatory cytokine IL10.
All these effects may be beneficial in the setting of sepsis, but this has yet
to be translated into a benefit in the clinical setting as many studies show a worse outcome with induced hypothermia in the setting of sepsis.
The reason for this may be that hypothermia prolongs NF-ĸB action which augments the generation of pro-inflammatory cytokines.

ADVERSE EFFECTS:
1. Shivering which generates heat and also increases basal metabolic
rate and therefore O2 consumption. It is also uncomfortable for the
patient.
2. Sepsis. Mild hypothermia is associated with higher mortality in
patients with sepsis.
3. Electrolyte: hypokalaemia during cooling and hyperthermia during
warming and metabolic acidosis.
4. Cardiac arrhythmias
5. Coagulopathy
These adverse events are infrequent and their incidence seems to increase
with a greater drop in temperature.

TERMINOLOGY:
• 34-36°C : Mild Hypothermia
• 28-33°C : Moderate Hypothermia
• 17-27°C : Deep Hypothermia
• 4-16°C : Profound Hypothermia

CLINICAL CONSIDERATIONS WHEN COOLING:
1. Monitors:
• Continuous core temperature monitors should be used. Usually
oesophageal, rectal or bladder.
• Use a second temperature monitor.
• Insert the A-line before cooling as peripheral vasoconstriction from
hypothermia will increase the difficulty of placement after induction.
• Vital signs.
2. Shivering: which generates heat and also increases basal metabolic
rate and therefore O2 consumption. It is also uncomfortable for the
patient. Manage with the use of endovascular cooling devices or
Meperidine.
3. Sedation for patient comfort, agitation (Midazolam and Propofol for sedation) or pain (Morphine/Fentanyl for analgesia).

4. Cooling Methods:
4.1 Surface Cooling
• Ice Packs:
ISAT trial
International Subarachnoid Aneurysm Trial

Large multicentre, prospective randomised trial
-published in the lancet
-10 year followup
Inclusion Criterea
- >18 yo
-ruptured intrancranial aneurysms

2143 patients randomised
-clipping n=1070
-coiling n=1073

Results
-after 1 year
-23% dead with coiling vs 30% with clipping
-this early advantage was maintained for upto 7 years.
-risk of epilespy was lower with coiling
-risk of rebleeding was higher with coiling

Despite these initial early benefits
-the rate of aneurysm reoccurance and rebleeds are higher with coiling

Therefore it appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher recurrence rate after treatment.
IHAST trial
Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST)

Multicentre blinded randomised control trial
-Multicentre : 30 centres
-assessor blinded
-prospective
-published in the NEJM

Inclusion criterea
1. >18yo
2. preoperative WFNS I, II and III
3. SAH <14days old
4. open aneurysm surgery via clipping

1001 patients recruited between 2000 and 2003
-randomised to
1. intra-operative hypothermia
were cooled to a target oesophageal temperature of 33°C using surface
cooling techniques (forced air cooling, IV cold saline, ice packs) and maintained until the last aneurysm clip was secured, after which rewarming began.
2. Those assigned to normothermia group were kept at 36.5°C.

Patients were examined 90 days post surgery.

No significant differences found in neurological, cardiovascular, coagulation or infective events.

?slight trend towards favorable outcomes with cooling.
Describe the vascular of the brain.
Blood supply to the brain
-two internal carotid arteries
-two vertebral ateries
-Cirle of Willis (only 20% have a complete Circle)

Venous drainage
-most blood in the brain is in the venous system
-superfical veins -> cortical sulci
-deep veins -> great vein of galen
-veins of he posterior fossa
-diploic veins
-emissary veins
*all veins -> meningeal sinuses -> IJ
-right IJ is dominant
-no valves in the veins therefore pressure in IJ is transmitted directly to intracranial veins.

Brain Blood Supply
• Brain has about 50-100 ml blood in it
• Brain has about 50ml/100gr/min blood flow
• Brain uses oxygen (CMRO2) about 3-3.5 ml/min
• About 40% directed to cellular integrity
• About 60% directed towards brain cell functioning
Notes on Intracranial Aneurysms
Definition & Epidemiology
• Aneurysms are abnormal dilations in the arterial wall.
• Mostly appear at the branching of cerebral vasculature
• From all SAH about 85% are from IA
• The incidence of SAH 5-10/100,000/year

Pathology
• Mostly in bifurcations
• Mostly at the ACA or MCA
• About 30% of patients who present with SAH have multiple aneurysms
• About 10% at ICA bifurcation or basilar tip

Patient Risk Factors
• Familial
• Genetic disorders of collagen
• PCKD
• Gender
• Age
• Cigarette
• ETOH
• Pregnancy (timing)

Aneurysm Risk Factors
• Size
• Location
• Previous Bleed
• Transmural Pressure

Presentation
• Incidental finding
• Screening
• Neurologic symptoms
• Sentinel Headache
• SAH

Different Classifications
• Hunt Hess Classification
• World Federation of Neurosurgeons
• Fisher Grading

Pre-Operative Considerations
• Similar to all other craniotomies
– History and physical with end organ involvement
– Family & social history
– Labs
– Radiology and Angiogram
– Meds

• Special considerations
– Presentation’
– Where is the patient?
– SAH (timing?)
– Vasospasm
– Seizure
– Transfusion (T&S or T&C)
– Electrolytes

Surgical Issues
• Positioning
• Surgical exposure
• Blood loss
• Temporary clipping
• Hemodynamic changes

Induction
• Smooth and controlled
• Monitoring plan & lines
• Premedication
– Anxiolytics
– Opioids
• Ventilation (hypo/hyper)
• Induction agents
– Intravenous agents
– Lidocaine
– Opioids
– Muscle relaxants

Maintenance
• Balanced Anesthetics
• Hemodynamic goals
• Ventilation goals
• Crucial moments

Balanced Anesthetics
• Volatile Agents
– Choice
– MAC
– N2O
• Narcotic
– Choice
– Bolus vs. infusion
– Post-operative pain
• Muscle relaxant
– Choice & importance
– Bolus vs. infusion
• TIVA

TIVA
• Benefit
– Rapid and predictable titration
– Swift wake up
– Fewer respiratory complication
– Less increase ICP following intracranial vasodilation
• Usually an intravenous anesthetic such as propofol and an opioid

Hemodynamic Goals
• Ultimately to keep more neurons alive
• Presentation dependant
– Non ruptured
– Ruptured
• Timing dependant
– Pre-clip
– Temporary Clip
– Post Clip
• Attention to baseline hemodynamics
• Attention to comorbid state
– CAD
– HTN
– Renal insufficiency

Ventilatory Goals
• Adequate oxygenation
• Avoidance of hyperventilation before the dura is opened
• Mild hyperventilation after dural opening

Emergence
• Decision for extubation
• Smooth
• Use of Lidocaine
• Short acting agents
• Neuro exam before extubation
• Differential diagnosis of prolonged wakeup

Post Operative Destination
• Depending on the clinical picture
• Monitoring
• Transport
• Post operative pain & nausea control
• Hemodynamic Goals
Therapeutic hypothermia
1. Hypothermia decreases metabolic rate of the whole body by 8% per °C.
2. Hypothermia is Neuroprotective:
• It decreases cerebral metabolic rate by 8% per °C.
• It decreases the production of glutamate.
• It decreases or reverses ischaemic depolarisation of CNS
causing membrane stabilisation.
• It maintains the integrity of the blood brain barrier.
3. Hypothermia is Cardioprotective:
• It decreases myocardial metabolic demand.
• It preserves intracellular high energy phosphate stores.
4. Inflammation and Hypothermia:
• It decreases the production of pro-inflammatory markers
(cytokines, interleukins, arachidonic acid cascade) and ROS.
• It increases the production of anti-inflammatory cytokine IL10.
All these effects may be beneficial in the setting of sepsis, but this has yet
to be translated into a benefit in the clinical setting as many studies show a worse outcome with induced hypothermia in the setting of sepsis.
The reason for this may be that hypothermia prolongs NF-ĸB action which augments the generation of pro-inflammatory cytokines.

ADVERSE EFFECTS:
1. Shivering which generates heat and also increases basal metabolic
rate and therefore O2 consumption. It is also uncomfortable for the
patient.
2. Sepsis. Mild hypothermia is associated with higher mortality in
patients with sepsis.
3. Electrolyte: hypokalaemia during cooling and hyperthermia during
warming and metabolic acidosis.
4. Cardiac arrhythmias
5. Coagulopathy
These adverse events are infrequent and their incidence seems to increase
with a greater drop in temperature.

TERMINOLOGY:
• 34-36°C : Mild Hypothermia
• 28-33°C : Moderate Hypothermia
• 17-27°C : Deep Hypothermia
• 4-16°C : Profound Hypothermia

CLINICAL CONSIDERATIONS WHEN COOLING:
1. Monitors:
• Continuous core temperature monitors should be used. Usually
oesophageal, rectal or bladder.
• Use a second temperature monitor.
• Insert the A-line before cooling as peripheral vasoconstriction from
hypothermia will increase the difficulty of placement after induction.
• Vital signs.
2. Shivering: which generates heat and also increases basal metabolic
rate and therefore O2 consumption. It is also uncomfortable for the
patient. Manage with the use of endovascular cooling devices or
Meperidine.
3. Sedation for patient comfort, agitation (Midazolam and Propofol for sedation) or pain (Morphine/Fentanyl for analgesia).

4. Cooling Methods:
4.1 Surface Cooling
• Ice Packs:
ISAT trial
International Subarachnoid Aneurysm Trial

Large multicentre, prospective randomised trial
-published in the lancet
-10 year followup
Inclusion Criterea
- >18 yo
-ruptured intrancranial aneurysms

2143 patients randomised
-clipping n=1070
-coiling n=1073

Results
-after 1 year
-23% dead with coiling vs 30% with clipping
-this early advantage was maintained for upto 7 years.
-risk of epilespy was lower with coiling
-risk of rebleeding was higher with coiling

Despite these initial early benefits
-the rate of aneurysm reoccurance and rebleeds are higher with coiling

Therefore it appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher recurrence rate after treatment.
SN13 ANZCA Version [Jul06] Q135, [Apr07], [Mar10]

The intraoperative hypothermia for aneurysm surgery trial (IHAST) showed that cooling to a target
temperature of 33°C

A. did NOT improve neurological outcome in WFNS (World Federation of Neurosurgical Surgeons) grade I-III patients

B. did NOT improve neurological outcome in WFNS grade IV-V patients

C. improved neurological outcome in WFNS grade I-III

D. improved neurological outcome in WFNS grade III

E. improved neurological outcome in WFNS grade IV-V
ANSWER A
Black Bank April 2008

MN Central anticholinergic syndrome, which is NOT true:

A. Will improve with neostigmine

B. Peripheral anticholinergic symptoms

C. Caused by Anti-Parkinson drugs

D. CNS depression

E. Associated with agitation, delirium, and ???
ANSWER A

A. FALSE : neostigmine does not cross the BBB.

Use physostigmine

B. TRUE: tachycardia, blurred vision, dry mouth, urinary retention

C. TRUE : also antidepressant, anti histamines
MM21 Serotonin syndrome:

A. difficult to distinguish from NMS but it is not essential to differentiate as treatment is similar

B. Has direct antidote promethazine

C. May be contributed to by pethidine

D. familial linkage (can't remember exact wording) - no, this option belonged in NMS question with options "Fever does not Always occur/ is related to MH/ major feature raised creatinINE kinase)

E.
ANSWER C

Serotonin Syndrome
-excessive intra synaptic seretonin

Toxidrome
1. Clonus/Hyperreflexia
2. Hyperthermia
3. Agitation

Most common with MAOI givne with an SRI.

Treatment
1. Chlorpromazine
2. supportive

Triggers
-tramadol
-methadone
-pethidine

NOT morphine, codiene, oxycodone, buprenorphine
Blank Bank March 2010

Acetylcholine receptors are down
regulated in

A. Guillain-Barre syndrome

B. Organophosphate poisoning

C. Spinal cord injury

D. Stroke

E. Prolonged NMBD use
ANSWER B

AChR upregulated
1. CVA
2. Burns
3. Muscle damage
4. Disuse
5. Severe infection

Decreased AChR
1. organophosphate
2. Myasthenia
3. Atheletes
Black Bank March 2010


123. Head Trauma patient with unilateral dialated pupil, whats the diagnosis ?

A.Global injury

B.Optic nerve injury

C.Horners syndrome

D.Transtentorial herniation

E.
ANSWER C
Black Bank March 2011

10. NEW. Petit mal epilepsy - Which is true? (or words to that effect)

A: Most common in child <2 years old

B: Can precipitate seizures by hyperventilating (+/- deliberately???)

C: Often seizures last for more than 30 seconds

D: Rarely familial

E: Isoelectric EEG during seizure (burst suppression)
ANSWER A

Petit mal epilepsy : Absence seziures

Brief seizures
-less than 20 sec
-generalised epileptic seiures
-two essential components
1. clinically impairment of consciousness
2. EEG generalised spike and low wave discharges

Precipitating factors
-hyperventilation in 90%
-intermittant photic stimulation

Etiology of idiopathic epilepsies with age-related onset is genetic. About 15-40% of patients with these epilepsies have a family history of epilepsy; overall concordance in monozygotic twins is 74%, with 100% concordance during the peak age phenotypic ex. more common in females than in males. Onset of absence seizures in children varies but peaks around 4-8 (childhood), 8-14 (juvenile).
Black Bank March 2011

17. NEW. Autonomic dysreflexia. Which ONE is true?

A: 50% of patients with a level below T6

B: Unlikely if below T10

C: Can be prevented??

D: Can be precipitated by light touch

E. ?
ANSWER B