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22 Cards in this Set

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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

BACKGROUND: Surgery for intracranial aneurysm often results in postoperative neurologic deficits. We conducted a randomized trial at 30 centers to determine whether intraoperative cooling during open craniotomy would improve the outcome among patients with acute aneurysmal subarachnoid hemorrhage.

METHODS: A total of 1001 patients with a preoperative World Federation of Neurological Surgeons score of I, II, or III ("good-grade patients"), who had had a subarachnoid hemorrhage no more than 14 days before planned surgical aneurysm clipping, were randomly assigned to intraoperative hypothermia (target temperature, 33 degrees C, with the use of surface cooling techniques) or normothermia (target temperature, 36.5 degrees C). Patients were followed closely postoperatively and examined approximately 90 days after surgery, at which time a Glasgow Outcome Score was assigned.

RESULTS: There were no significant differences between the group assigned to intraoperative hypothermia and the group assigned to normothermia in the duration of stay in the intensive care unit, the total length of hospitalization, the rates of death at follow-up (6 percent in both groups), or the destination at discharge (home or another hospital, among surviving patients). At the final follow-up, 329 of 499 patients in the hypothermia group had a Glasgow Outcome Score of 1 (good outcome), as compared with 314 of 501 patients in the normothermia group (66 percent vs. 63 percent; odds ratio, 1.14; 95 percent confidence interval, 0.88 to 1.48; P=0.32). Postoperative bacteremia was more common in the hypothermia group than in the normothermia group (5 percent vs. 3 percent, P=0.05).

CONCLUSIONS: Intraoperative hypothermia did not improve the neurologic outcome after craniotomy among good-grade patients with aneurysmal subarachnoid hemorrhage.
IC86 ANZCA Version [Apr07] [Jul07]

A 25-year-old man, involved in a motor vehicle crash, presented with a GCS (Glasgow Coma Score) of 5. He was intubated and ventilated, and CT scan of his head was consistent with diffuse axonal injury. An ICP (intra-cranial pressure) monitor has been placed. The patient's ICP has ranged between 15 and 25 mmHg over the
last 2 hours, despite intravenous mannitol and moderate hypocapnia. He has stable haemodynamics with a mean arterial pressure of 95-100 mmHg. He now requires general anaesthesia to manage his orthopaedic injuries. The most appropriate agents for maintenance of anaesthesia would be

A. isoflurane / remifentanil

B. propofol and fentanyl

C. propofol and nitrous oxide

D. sevoflurane and nitrous oxide

E. sevoflurane and remifentanil
ANSWER B
SN16 [Apr07] [Jul07]

Post grade II SAH in 50 year old woman who has just returned from successful endoluminal coiling. The best thing to include in subsequent management to prevent vasospasm would be:

A. at least 3 L of IV normal saline per day

B. IV or oral magnesium supplementation

C. maintain systolic blood pressure above 160mmHg

D. Keep intubated and ventilate for 24 hours before de-sedating

E. cool to 33 degrees
ANSWER C
ANZCA Version [Apr 07]

Each of the following statements regarding vasospasm occurring after SAH is true EXCEPT:

A. cerebral vessel narrowing, demonstrated angiographically, can be reversed 30-40% of the time by administering nimodipine

B. combination therapy resulting in HT, hypervolaemia and haemodilution is a mainstay for prevention and treatment

C. other cause of neurological deterioration (such as hydrocephalus) need to be excluded before making the diagnosis

D. sequential TC doppler measurement may detect those patients at risk

E. the peak incidence is 7-10 days after the SAH
ANSWER A

Oral Nimodipine reduces the risk from 30% to 20%
(prophylactic not treatment)

Barash, Clinical Anaesthesia (in chronological order in the chapter)

* says peak of vasospasm is 7-10days
* says TCD has been used, and changes over time may be more useful than absolute values for predicting risk of vasospasm (ie, serial measurements)
* oral nimodipine has level I evidence for improving neurological outcome, "although angiographic studies did not demonstrate a difference in the frequency of vasospasm comapred with placebo" ( - suggesting A may be wrong as the question specifically mentions "demonstrated angiographically")
* HHH therapy is one of the mainstays of treatment of cerebral ischaemia, despite the lack of evidence for tis effectiveness, especially for its prophylactic use
* hydrocephalus is another cause of neurological dysfunction after SAH
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 B
Black Bank August 2008

SN (Q114 Aug 2008) Patient with traumatic brain injury has the following readings. Global CSF flow measured at 15ml/100gm/min while the CMRO2 is measured at 3.5ml/100gm/min. There is

A appropriate coupling of cerebral perfusion and cerebral metabolism

B autoreguation of cerebral vasodilation

C cerebral hypoperfusion

D cerebral ischaemia

E reperfusion injury
ANSWER??? C/D

Normal CBF = 50 ml/100g/min
Therefore there is hypoperfusion.

However, the measured CRMO2 is normal which is inconsistent with hypoperfusion.
As CRMO2 is limited by the amount of perfusion.

CBF at which ischaemia becomes apparent on EEG is 20ml/100g/min
Black Bank August 2008

SN (Q108 Aug 2008) 55 year old subarachnoid haemorrhage secondary to aneurysm. Patient is confused with a oculomotor (3rd cranial nerve) palsy, complains of a severe headache. This patient is in Hunt and Hess class:

A 0

B 1

C 2

D 3

E 4
ANSWER D

Hunt and Hess Classification (NB any neurological deficit other than CN palsy is 3 or more)

1. Asymptomatic, mild headache, slight nuchal rigidity
2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
3. Drowsiness / confusion, mild focal neurologic deficit
4. Stupor, moderate-severe hemiparesis
5. Coma, decerebrate posturing
Black Bank August 2008

SN (Q131 Aug 2008) Traumatic brain injury with central diabetes
insipidus. Can be managed with

A democlocydine

B desmopressin

C fludrocortisone

D fluid restriction

E frusemide
ANSWER B
Black Bank April 2009

Patient (?48h post) SAH following bloods:

Na 155
Plasma osmolality 350
urine osmolality 250

Management includes:

A)DDAVP (?nasally)

B)Water restriction
ANSWER A
Black Bank April 2009

6 hour post pituitary surgery, Serum Na 153, next step in management

a)Dext 5%

b)Normal saline

c)DDAVP
ANSWER C
TMP-101 Aneurysm sugery. Propofol / remifentanil / NMDR. DOA monitoring (Entropy). MAP 70 , HR 70/min, State entropy 50, Response entropy 70. What do you do?

A.

B. Metaraminol

C. Check TOF

D. Nothing

E. Increase TCI
ANSWER C
EM66 What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping? (repeat question)

A. TOFC

B. TOFratio

C. Post tetanic count
ANSWER C
TMP-Jul10-017 Male undergoing trans-sphenoidal surgery. Now Na+ 155mmol/l and thirsty with polydypsia. Treatment:

A. Desmopressin (DDAVP)

B. Fluid restrict

C. Aldosterone

D.

E.
ANSWER A
TMP-Jul10-018 The STRONGEST stimulus for ADH secretion:

A. High serum osmolality

B. Low serum osmolality

C. Hypovolaemia

D. High serum Na

E.
ANSWER C
Black Bank August 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
SN18 [Mar11]

Absolute contraindication to sitting position for posterior fossa craniotomy for meningioma

A: Prescence of patent ventriculo-atrial drain/shunt

B: PFO

C: Oesophageal stricture so transoesophageal echo placement is out

D: ?

E: ?
ANSWER A/B

ABSOLUTE CONTRAINDICATIONS

* Patent ventriculo-atrial shunt
* Severe cardiovascular disease
* Large patent foramen ovale or other pulmonary-systemic shunt
* Cerebral ischaemia when upright and awake
* Anaesthesia or surgical team not familiar with the position
Black Bank March 2011

13. NEW. Which have been shown to decrease vasospasm post aneurysm? All EXCEPT:

A: Antiplatelet drugs

B: Nimodipine

C: HHH therapy

D:

E:
ANSWER A
Black Bank March 2011

35. New. What percentage of patients with SAH are troponin positive?

A: <5%

B: 15-30%

C: 40-60%

D: 70-90%

E: 100%
ANSWER B
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, other vessels are vasoconstricted too.
# B: may exacerbate retractor injury by limiting blood flow to compressed areas.
# C: TRUE. Coronary spasm can be triggered by hyperventilation causing respiratory alkalosis. The extension of this is a relative C/I in coronary disease. I don't know that I'd consider this a C/I in a patient that is coning. http://www.journalarchive.jst.go.jp/english/jnlabstract_en.php?cdjournal=internalmedicine1992&cdvol=36&noissue=11&startpage=760
# D: see KB's book. 4% / mmHg is the number I remember but limited by hypoxic vasodilation.
# E: "An increased frequency of brain regions with very low CBF has been demonstrated in head-injured patients who were acutely hyperventilated." Miller. This doesn't mean it is steal. Reverse steal can occur: vasoconstrict normal brain with normal CO2 responsiveness while the injured brain stays vasodilated due to "vasomotor paralysis"
SN10 ANZCA version [2001-Aug] Q140

Adequate analgesia for awake craniotomy necessitates bilateral blocks of the

1. greater and lesser occipital nerves

2. zygomaticotemporal nerve

3. auriculotemporal nerve

4. great auricular nerve
ANSWER 1,2,3

Six nerves need to be blocked bilaterally to completely anaesthetise the scalp.

* Supratrochlear

* Supraorbital

* Zygomaticotemporal

* Auriculotemporal

* Lesser occipital

* Greater occipital
SN09 ANZCA version [Apr98] [2001-Apr] Q66, [2001-Aug] Q53, [2002-Aug] Q61

To rule out raised intracranial pressure in an awake patient, the most reliable finding is

A. absence of papilloedema

B. presence of retinal vein pulsation

C. absence of headache

D. absence of diplopia

E. absence of vomiting
ANSWER B
SN01 ANZCA version [2004-Aug] MCQ-134

A youth of 19 is brought to hospital after a boxing contest because of headache and vomiting. His initial computerized axial tomographic examination of the skull is normal. Two hours later he loses consciouness and is found to have dilatation of one pupil. He shows no response to painful stimuli. His blood pressure is 160/100 and his pulse rate 55 per minute. In consequence of his deteriorating condition the next step in his management should be:

A. Urgent craniotomy

B. Repeat CT scan of the skull

C. Bilateral carotid angiography.

D. Treatment of cerebral oedema

E. Transfer to an intensive therapy unit
ANSWER B