Scott Gardner N211 Q4F05 Unit 4
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- What is a Craniotomy?
- An incision through the cranium.
- What is a Ventriculostomy.
- Plastic surgery to establish communication between the floor of the third ventricle of the brain and the cisterna interpeduncularis.
- What are the preoperative interventions for craniotomy?
- Ventriculostomy, Assess neurological status, remove hair at the surgical site.
- What are intraoperative craniotomy interventions?
- What are some potitions that a craniotomy can take place in?
- Sitting up in surgical chair, head down, depends on where problem is.
- What kind of problems can the supporting head frames cause with a craniotomy?
- Skin pressure on the head, edmea on the face, muscle soreness, especially in the neck.
- What happens to the eyes after craniotomy?
- Ecchymosis and periorbital edema may be present, but is temporary.
- Describe coughing /p a craniotomy.
- Coughing should not be encouraged simply for coughing sake such as in TCDB, but if the client needs to cough to clear the airway they should do so.
- Is ICP a problem after craniotomy?
- Yes, and stroke or trauma are a concern. Notify the neurosurgeon of any changes in the assessment.
- Name six complications of craniotomy.
- Increased ICP * Motor Sensory Deficits * Seizures * CSF Leak * Wound Infection * CNS Infection
- What is an example of a CNS Infection?
- Meningitis.
- Where might you see a CSF leak?
- From the wound or incision, but also from the nose or the ears.
- What is a hypophysectomy?
- Excision of the hypophysis cerebri.
- What are two approaches of Transphenoidal Hypophysectomy?
- Traditional and Endoscopic
- Describe the traditional approach of Transphenoidal Hypophysecotmy.
- Incision made behind the upper lip. Fat or muscle grafts might be implanted to help healing. Nasal packing may be used.
- Describe the new endoscopic incision transphenoidal hypophysectomy.
- The tumor tissue is removed with microsurgical instruments inside the nostril.
- What are some interventions postoperaively for a tradional approach hypophysectomy craniotomy?
- No Drinking straws. Provide frequent oral care. Use cool vaporizor to keep mucous membrains moist. Provide care to the donor site if tissue or muscle was used. Provide a Nasal drip pad or mustache dressing which should be assess for CSF and or Blood.
- When might you see Diabetes insipidus?
- After a craniotomy.
- What is Diabetes insipidus?
- Excessive urination caused either by inadequate amounts of antidiuretic hormone in the body (hypothalamic DI) or by failure of the kidney to respond to antidiuretic hormone (nephrogenic DI).
- Is DI permenant after a craniotomy?
- No, it is usually temporary.
- How much urine might one see per day with a post craniotomy patient?
- Between 2 and 15 liters of urine each day.
- When a client has DI, what are the properties of the urine?
- It has a very low specific gravity, very dilute (less than 1.005 SG).
- What lab tests might need to be tested after a craniotomy?
- Sodium and serum osmolality, due to DI complications.
- What is hypertonic encephalopathy?
- Generalized (i.e., not localized) brain dysfunction marked by varying degrees of impairment of speech, cognition, orientation, and arousal.
- What are two medications that might be given for DI?
- IV Vasopressin or Inhaled Desmopressin.
- What is what is polydipsia?
- Excessive Thirst.
- How do vasopressin and desmopressin help DI?
- They help replace the ADH.
- What is an SAH?
- Subarachnoid Hemorrhage
- What is an AVM?
- Atteriovenous Malformation
- Name six causes of SAH.
-
Brain Trauma (Most)
Intracranial aneurysms
AVM
Blood Dyscrasias
Anticoag Therapy
Tumors - What is a Blood Dyscrasia?
- An old term meaning abnormal mixture of the four humors.
- What is them most common type of aneurysm?
- Saccualr or Berry Aneurysm.
- Do men or women have more berry aneurysms?
- Women
- What is the pathology of berry aneurysm?
- Congenital, but weaken over time from HTN, Atherosclerosis, aging, and stress.
- Where are aneurysms most common?
- Anterior and middle cerebral areas, especially in circle of Willis, and at bifurcations.
- What happens with vasospasm in an aneurysm?
- It can cause additional bleeding, which might be worse than the original bleed, leading to death.
- What are some premonitory Sx of an aneurysm?
- Premonitory symptoms might be mild H/A, Fainting/Vertigo, and is often found during a H/A workup.
- What might the client complaining of the most sudden, severe headach they have ever experienced be experiencing?
- The onset of a bleed in an aneurysm.
- What is nuchal rigidity?
- Inflexibility of the neck movement, esp. forward flexion of the neck.
- What is Kernig's Sign?
- A sign of meningeal irritation evidenced by reflex contraction and pain in the hamstring muscles, when attempting to extend the leg after flexing the hip.
- What is Brudzinski's Sign?
- Flexion of the hips when the neck is flexed from a supine position.
- Name three Dx methods for SAH, and which is the most definitive.
-
CT
Angiography
Transcranial Doppler.
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Angiography is the most definitive. - What are some interventions or medications that might be given to treat vasospasm?
-
Increase Volume
Maintain pressue
Hemodilute (HCT Low)
Might use CCB Nimodinine - When is clipping performed?
- Within 3 days if alert, later if not alert. If Vasospasm is still present might delay further.
- What is an AVM, according to John?
- Congenital lack of bapillaries causing a tangled array of veins and arteries to form. They can be small or large.
- Where are AVM found?
- Brain or spinal cord.
- What age are AVM usually found?
- Usually before 40.
- A Surgical frame to support the head during surgery can cause what kind of skin problems?
- Pressure
- What medication might be given for Dibeates insipidus?
- Vasopressin.
- What is the most common intervention used for aneurysms?
- Clipping.
- What is the main nursing intervention that should be focused upon in neurosurgery?
- Increased Intracranial Pressure.
- Is there a specific cause for epilepsy?
- It can be Genetic, Acquired, or Idopathic.
- What is the pathyphysiology of Epilepsy?
- The impulses are not controlled.
- What two elements are rapidly used up during an epilepsy seizure?
- Oxygen and Glucose, which cause Hypoxemia and Lactic Acidosis.
- Other than epilepsy, what are some other reasons for seizures?
-
Intracranial Tumor
Head Injury
CVA
AVM
Meningitis
ETOH or Barbituate ingestion/Withdrawl
Fever - What is a Pseudoseizure.
- A psychiatric problem in which the patient does not exhibit the same activity each time.
- What are four types of Seizures?
-
Partial /s Loss of Consiousness
Complex Partial which may incluse LOC
Generalized
Status Elipepticus. - Name the four subtypes of partial seizure, without LOC.
-
Motor
Sensory
Autonomic
Aura - What happens in a partial motor seizure?
- Starts in upper arm with involuntary movement spreads to same side face and lower extremety. AKA Jacksonian March.
- What is a Jacksonian March?
- A localized form of epilepsy with spasms confined to one part or one group of muscles
- What happens in a Partial Sensory Seizure?
- Numbness or tingling in affeected area, bright or flashing lights and problems with aphasia.
- What is aphasia?
- Absence or impairment of the ability to communicate through speech, writing, or signs because of brain dysfunction.
- If a client has numbness or tingling with a sensory partial seizure, where will that probably be originated from?
- Parietal Lobe
- If a client has bright or flashing lights with a sensory partial seizure, where will that probably be originated from?
- Occipital Lobe.
- If a client has aphasia with a sensory partial seizure, where will that probably be originated from?
- Temporal lobe.
- What is seen in an autonomic partial seizure?
- GI Sensations, pallor, sweating, flushing, piloerection, pupil dilation, tachycardia, tachypena
- What is seen in a Psychic Partial Seizure?
- The client will usually have an Aura.
- What is an Aura?
- A localization of a seizure which can be a smell, noise, sensation, feeling of rising up or welling up in the epigastric area. Visual or deja vu.
- Where do psychic seizures usually originate?
- Temporal.
- What is automatism?
- Lip smacking, chewing, patting part of the body, picking at clothing while in a dreamlike state.
- When is an automatism seen?
- Partial complex seizure.
- What is postictally?
- After a seizure.
- Is the client aware of the automatimic behaviour during a complex partial seizure?
- No, they will be unaware during, and may be drowsy or confused after.
- List four types of Genarlized Seizures.
-
Absense
Myoclonic
Tonic Clonic
Atonic - What is differentiates a Generalized Seizure from others?
- The client will lose consiousness.
- What is an Absense Seizure?
- Usually seen in childhood. Brief LOC, may progress to tonic-clonic.
- What is a myoclonic seizure?
- Single or multiple muscle groups. Will cause client to fall.
- What is an atonic seizure?
- Loss of Muscle tone.
- What was the former name of a Tonic Clonic seizure?
- Tonic Clonic.
- Do Tonic Clonic seizures have an aura before they begin?
- They can have an aura.
- What is the Tonic Phase of Seizure?
-
Stiffening of all muscles.
Cry out and Fall. Respirations cease. May become cyanotic, pupils become fixed and dialated. A deep sigh or breath signals the end of the tonic phase. - What is the Clonic Phase of a Seizure?
- Rhythmic jerking. Contraction and relaxation of all body muscles. May beocome incontinent, biting the tongue and mouth.
- How long does an entire Tonic Clonic Seizure last?
- Two to Five Minutes.
- Will a client be tired after a Tonic Clonic?
- Yes, several minutes to several hours.
- Will the client remember the Tonic Clonic Seizure?
- No, will have amnesia.
- What are some other after care issues for a Tonic Clonic Seizure?
- Client may be stiff, nauseated, sore, with fatigure, depression, confusion, headache or other injuries from the fall or jerking.
- What tests might be used for diagnosing Epilepisy?
-
Often EEG.
Occassionally, CT, MRI, PET, SPECT - Why would an EEG be used in the OR?
- The client can not answer questions or participate in a Neuro Assessment, but the EEG will show what the brain is doing.
- What is the preparation for an EEG?
-
Wash Hair
Not Stimulints, sedatives, antidepressants, or anticonfulsants for 1-2 days before test.
May want client sleep deprived before test.
Anxiety might interfere with results. - What are post care issues with EEG?
- Resume normal diet, shampoo and acetone to remove gel from electrodes.
- What is the EEG used for?
- Finds the Focus and identifies the specific type of seizure.
- What are nursing interventions during a seizure?
-
Put in side lying.
Provide Oxygen
Pad the head and arms to prevent injury. - Is suctioning used during a seizure?
- Yes, but don't force in an airway.
- When should help be called for with a seizure?
- If lasts longer than ten minutes, or a second seizure rapidly follows, or if having respiratory trouble, or the client is pregnant.
- What are some observations that need to be made about a seizure?
-
Length of time.
Where it started, what body part.
Eye or head deviation
Respirations labored or frothy
Incontinence
Loss of Consciousness. - What is another name for Phenytoin?
- Dilantin
- What is the brand name for Carbamazepine?
- Tegretol.
- What is the brand name for valproic acid?
- Valproate.
- How does Anti-Seizure drugs work?
- They block the initiation or spread of sizures.
- What are the three first line anti-seizure drugs?
-
Phenytoin
Carbamazepine
Valproic Acid - Name three second line anti-seizure drugs.
- Valium, Phenobarbitol, Gabapentin.
- What are some side effects of anti-seizure medications?
- Fatigue, Weighloss, dizziness.
- What are some General Adverse Affects of Anti-Seizure medications?
-
Allergies, extreme fatigue, staggering, slurring of speach.
Depression, Psychosis - What two metabolic issues must be watched when taking anti-seizure medications?
- Serium levels of the drug, and liver functions.
- How long should someone be seizure free before discontiuing medications?
- Two Years.
- Phenytoin is only compatible with which colloid?
- NS Only.
- What happens when Phenytoin is mixed with D5 and Water?
- A precipitant forms.
- What are the tube issues when giving Phenytoin?
- A filter must be used, even with NS so that in case a precipitant forms, it will be filtereed out.
- What is the fastest period that Phenytoion can be given?
- No more than 50mg per minute, so a syringe pump should be used.
- How can enteral feedings interfere with Phenytoin absorbtion?
- Must be turned off two hours before and after administration.
- What oral care is necessary when receiving phenytoin?
- Can develop Gingival Hyperplasia (Swollen tender gums). Reduced with brusing bid/tid.
- What is the target serum level for phenytoin?
- 10-20
- What are the adverse effects of Tegratol?
-
Slowed Cardiac Conduction
Heart Failure
Hyponatremia. - What are some adverse effects of Valproic Acid?
- Increased Amonia Levels.
- What do increased amonia levels cause?
-
Decreased Level of Consiousness
Hepatic dysfunction
Decreased platelets. - What is the Generic Name for Depakene?
- Valproic Acid
- What is the Generic name for Valproate?
- Valproic Acid
- What is the generic name for dilantin?
- Phenytoin.
- What is the generic name for Tegretol?
- Carbamazepine
- What is a getogenic diet?
- High fat, low carb diet which mimics fasting, probably through ketosis.
- Is a Ketagonic diet firstline intervention for seizures?
- No, only after medications fail.
- What surgical interventions are available for seizures?
- Removal of corpus collosum, Temporal Lobe, or Parietal Lobe. Or the cortex of a hemisphere.
- What is a vagal nerve stimulator?
- Pacemaker like device implanted in neck and attached to vagus nerve. Causes interference with the seizure electircal activity.
- How long does a driver have to be seizure free in Washington? Other states?
- WA is 6 months. Others up to two years.
- Why should ETOH be avoided when a client has seizures?
- ETOH reduces the threshold and might allow seiure to begin. Seizure medications are metabolized by liver, and might cause problems.
- What are some personal safety issues for those with seizure disorders?
- Avoid dangerous things like smiming, horeback riding.
- Other than ETOH, what can decrease the seizure threshold?
- Poor diet, and sleeping habits.
- What is Status Epilepticus?
- A medical emergency consisting of seizure that lasts 30 minutes, or seizures that come in rapid succession.
- What are firstline drugs for treatment of Satus Epilepticus?
-
IV Diazepam or Lorazepam q15m.
Might also use IV Phenytoin. - If seizure just will not stop, what intervention might be used?
- Might induce a barbituate coma, or put client under general anesthesia.
- What equipment should be ready when a client is in Status Epilepticus?
- Ambu Bag, ET, Ventialtor. An NG should be ready for respiratory depression.
- A seizure where there is a stiffening of all muscles followed by alternating flexion and extension is called what?
- Tonic Clonic
- A seizure which is localized to one part of the body is called what?
- Partial Seizure.
- What is the classification of a Tonic Clonic Seizure?
- It is Generalized.
- What are some stimulents that can interfere with an EEG?
- Coffee, Tea, ETOH, Cola, Cigarettes.
- What is the most common type of Stroke?
- Ischimic which is about 83% of all storkes.
- What are the two major types of strokes?
- Ischemic and Hemorrhagic.
- What causes an ischemic stroke?
- When the blood supply to a part of the brain is interrupted or tatoally occluded.
- What is the most common type of stroke in DM patients?
- Thrombotic.
- What is a Lacunar stroke?
- A pathological change in the brain caused by diminished or lack of blood flow through one of the brain's small penetrating arteries.
- What is one of the disease processes that is assoicated with a high incidence of embolic stroke?
- Atrial Fibriliation.
- When are most people affected by an Intracerrebral Hemorrhage?
- After age 50.
- What is the most important modifiable risk factor for both ischemia and hemorrhagic stroke?
- HTN.
- Other than HTN what are some other modifiable risk factors for stroke?
- Hyperlipidemia, smoking, heavy ETOH, cocaine, obesity.
- When can cell death from cerebral ischemia happen?
- Between 3-10 minutes.
- What is the area in the center of the stroke called?
- Primary neuronal injury.
- What is the zone around the infarcted zone (Primary Neuroal Injury) called?
- The Penumbra.
- What are some general findings in stroke?
- H/A, Vomiting, seizures, changes in mental status, fever and ECG changes with t waves. PVC, Sinus Brady, ventricular and superventricular techycardias.
- What is a TIA?
- A focal neurologic deficit lasting less than 24 hours.
- What is hemiparesis?
- Weakenss on one side of the body.
- What is hemiplegia?
- Paralysis on one side of the body.
- If someone has an infarction on the left side of the brain, how will this affect paralysis?
- The right side will be paralized.
- When do trhombosis usually occur?
- During sleep or within 1 hour of waking.
- When do embolism occur?
- Not related to time or activity.
- When do brain hemorrhages usually occur?
- During active, waking hours.
- What other Sx might be seen with stroke?
-
Hemisensory loss
hemianopia
Apraxia
Agnosia
aphasia. - What is hemianopia?
- Blindness in one-half of the visual field.
- What is apraxia?
- Inability to perform purposive movements although there is no sensory or motor impairment. 2. Inability to use objects properly.
- What is Wernicke's Aphasia?
-
Sensory
An injury to the Wernicke's area in the temporal lobe of the dominant hemisphere of the brain, resulting in an inability to comprehend the spoken or written word. - What is Brocas Aphasia?
-
Expressive or Motor
Aphasia in which patients know what they want to say but cannot say it; inability to coordinate the muscles controlling speech. - What is Global Aphasia?
-
Affects both speech comprehension and speech production.
Total aphasia involving failure of all forms of communication. - What is unilateral neglect?
- The state in which an individual is perceptually unaware of and inattentive to one side of the body and the immediate unilateral area that the patient visualizes.
- What is homonymous hemianopia?
- Blindness of nasal half of the visual field of one eye and temporal half of the other, or right-sided or left-sided hemianopsia of corresponding sides in both eyes. (X )(X )
- What is horners syndrome?
- A syndrome characterized by contraction of the pupil, partial ptosis of the eyelid, enophthalmos, and sometimes loss of sweating over one side of the face.
- What is agnosia?
-
Inability to recognize or comprehend sights, sounds, words, or other sensory information.
A person sees the fork, shirt, or toilet tissue and does not know what they are used for. Dangerous becuase client can not distinguis dangerous things. - If someone had a stroke in the left cerebral hemisphere, how might their attitude be?
- Slow, cautions, disorganized.
- If someone has stroke damage in the Right side how will their personality change?
- Impulsive, overestimate ability, short attention span.
- When the stroke affects the frontal lobe, what might be seen in personality.
- flat affect, lack of spontaneity, distractability and forgetfullness.
- Does stoke cause incontinence?
- Yes, Bowell and Bladder.
- What do stroke patients have contractures?
- The stronger flexors overbalance the extensors when volunary muscle control is lost.
- Name three manifistations of increased ICP.
- Change in LOC, refelx HTN, worsening neurologic status.
- What are HOB issues for clients with Increased ICP?
- Not below 30 degrees
- How is mannitol used to treat Increased ICP?
- An osmotic diuretic helps lower increased ICP.
- What is an effective aPTT for a stroke client?
- 1.5 - 2.5
- What is an appropritae INR for a stroke patient?
- 2.3 - 3.0
- When does death from stroke usually happen?
- Can happen in 3-12 hours, but usually in 1-14 days.
- What member of the interdisclipinary team would assess clients swallow ability?
- Speech Therapy
- By defination, how does a TIA differ from a stroke?
- TIA is less than 24 hours, and the client has complete recovery.
- How long does a TIA usually last?
- Most are 5-20 minutes.
- What is a carotid endarterectomy?
- A surgical technique for removing intra-arterial obstructions of the proximal cervical portion of the internal carotid artery.
- List six manifistations of stroke that should be warning signs to get help fast.
-
=Sudden Numbness or weakness of the face, arm or leg, especially on one side of the body.
=Sudden confusion, trouble speaking or understanding
=Sudden trouble seeing in one or both eyes
=Sudden trouble walking, diziness, loss of balance or coordination.
=Suddden, severe headache with no known cause. - Why would a physician order a non-contrast CT scan of the head prior to beginning thrombolytic therapy?
- To rule out hemorragic stroke as the reason of the stroke. This would contra-indicate the use of thrombolitics.
- What is the cause of an Ischemic Stroke?
- Thrombotic or Embolic blockage of blood to the brain.
- What is the cause of an Hemorrhagic Stroke?
- Bleeding into the brain tissue, may be due to an aneurysm.
- Which type of stroke has a higher incidence?
- Ischemic.
- Clients with this metabolic disorder are at a higher risk of developing hemorrhagic stroke.
- DM.
- The brain requires a MAP of how many mm Hg to maintain adequare blood flow?
- 50
- Why is it important to keep a client with stroke afebrile?
- Elevated temperatures require increased metabolic need, which in turn will cause cerebral edema and increased risk of ischema.
- How long after an infusion of thrombolytic should a nurse wait before beginning administration of anticoagulant and antiplatlet medications?
- Twenty Four
- If the client has hemiparesis, Hemisensory loss, loss of speech and slow onset, what type of stroke?
- Ischemic.
- If a client has severe occipital and nuchal headache, what type of stroke?
- Hemorrhagic.
- Vertigo, Syncopye show what kind of stroke
- Hemorrhagic.
- What is a RIND?
- Reversable Ischemic Neurologic Deficit? It is like a TIA, but lasts up to a week.
- Define Dysarthria.
- Articulation and enunciation problems from paralysis of muscles in the face, mouth, and neck. Speech and writing are understood. Able to construct the sentence, just difficult getting it out.
- What is paresthesia?
- An abnormal or unpleasant sensation that results from injury to one or more nerves, often described by patients as numbness or as a prickly, stinging, or burning feeling.
- What is proprioception?
- The awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body.
- What is emotional lability?
- Bursts into tears or laugh without cause. Distracting them will usually stop this. Not sadness.
- What is the newer name for a Storke?
- Brain Attack.
- What is the window for brain thrombolitics?
- Three Hours
- What is a level that HTN needs to be treated?
- BP 185/105
- Talk about Hyperthermia.
- May use a hypothermia blanket. Oil or lotion the client to keep skin moist. May use muscle relaxant to prevent shivvering, which will only bring temperature back up.
- Who leads the team of people that work to rehab a client after a stroke?
- Case Manager facilitates the rehabilitation.
- What is nimodipine?
- Given for vasospasm in cerebral hemorrhage.
- Can you turn a stroke client to their affected side?
- Yes
- Other than skin integrity issues, why is it important to turn a client (even onto their affected side)?
- Helps increase ventillation and perfusion.
- What is the consistancy of food for someone with a swallowing disorder?
- It should be thickened.
- What are some issues about feeding for a stroke client?
-
Food should be softenend, but thick.
Watch for pocketing
Put food on unaffected side. - What is visual filed scanning?
- Moving head position to scan areas when eyes don't do it for them.
- This type of stroke with a rapid onset and may proceed rapidly to coma is called...
- Hemorrhagic.
- An abnormal sensation that may occur in a stroke patient is called ....
- Paresthesia.
- How soon must a thrombolitic be given in a stroke?
- Three HOurs
- What is a lack of awareness on one side of the body?
- Unilateral Neglect
- What can happen to the shoulder and hip if they are not supported properly in a stroke client?
- They can become dislocated.
- Paralysis of one side of the body is...
- Facial Palsy.
- To stimulate mouth closing, apply what to the lips?
- Ice
- What is done to prevent cornial abrasian in stroke patient?
- Apply eye drop/moisturizer and then cover with a patch.
- This is the inability to carry out a skilled act.
- Apraxia
- This type of aphasia is sensory or receptive.
- Wernickes.
- The client bursts into tears or laughter without provocation with....
- Emotional Lability
- What is the inability to recognize familiar objects through the senses?
- Agnosia
- How often should passive ROM be performed for a stroke client?
- BID
- Understanding Language, but has difficulty speaking clearly.
- Dysarthria.
- This test is performed to assess the nutritional status for a CVA.
- Prealbumin
- In helping a Right-sided hemiplegic client to transfer to a wheelchair, the chair should be placed on the ....
- Left side of the bed.
- What is the leading cause of SAH?
- Trauma.
- What does SAH stand for?
- Sub Arachnoid Hemorrhage.
- What is the Munroe-Kellie Hypothesis?
- Because the skull is fixed, when one of the three components of brain (blood, CSF, Brain Tissue) expand, one of the other two must compensate, or an outlet will form.
- What is normal brain ICP?
- 5-15 mm
- What is CPP?
- Cerebral Profusion Pressure and is the MAP-ICP.
- How is MAP calculated?
- (2D+S)/3=MAP
- What is the CPP Calculation?
- CPP=MAP-ICP
- Define Compliance
- Compensation by the brain to adapt to increasing pressure, using the Munroe-Kellie Mechanaism.
- What are the steps of compliance?
-
First: CSF Moves out of the brain.
Second:Blood flow reduction to brain.
Last:Herniation or Displacement across the tentorium or through the foramen magnum. - What is autoregulation?
- Blood vessels change diamater to maintain comstant blood flow. This is lost with ICP.
- What are some causes of ICP?
-
Brain swelling.
Cerbtral Edema.