Neuro Flashcards
Cluster headache acute attack (without CVD or uncontrolled htn)
- FL: sub. Cut. Sumatriptan 6mg single dose. Repeat after at least 1 hour if needed. Max 12mg/d. (CI in CAD, PVD or cerebrovascular Dx). Also give high-flow oxygen >12L/min for >15mins or until attack terminated (not CI in vascular Dx)
- 2L: zolmitriptan nasal 5mg as single dose can repeat >2hrs after initial dose if nec. Max 10mg/day. . (CI in CAD, PVD or cerebrovascular Dx)
- 3L: intranasal sumatriptan (5-20mg, repeat at 2hr if nec. Max 40mg/day) or PO zolmitriptan 2.5-5mg single dose, repeat at 2hrs if nec. Max 10mg/day)
3L: lidocaine 1mL of 10% solution placed with cotton swab intranasally for 5mins
translational therapy in acute cluster headache in ALL patients
For all acute attacks in this group as translational therapy: pred 60mg OD PO 5d then reduce by 10mg every 3 days.
adjunct to acute cluster attack in ALL patients
greater occipital nerve block: effective in 2/3. Should be considered before any surgical procedure when medical treatment has failed. Mixture of corticosteroid and LA or LA alone is injected into GON (situated 2/3 between mastoid and external occipital protuberance, leave 3 months between blocks)
Acute attack cluster headache with CVD/uncontrolled HTN
- FL: Oxygen >12L/min for at least 15mins or until attack terminted
- 2L: intranasal lidocaine: 1mL of 10% lidocaine placed with cotton swab
Episodic/ongoing cluster headache
- FL: verapamil 80mg PO immediate release TDS initally. Titrate up to max of 480mg/day.
a. Start therapy as soon as possible at the start of an episode. Perform ECG to rule out conduction delay and don’t use if patient has heart block or arrythmia.- 2L: Lithium consult spsecialist for guidance (max conc. = 1.2mEq/L)
- 2L: topiramate: 25mg OD 7d increase dose to 100-200mg/day in 2 doses over period of weeks
- Gabapentin: consult specialist on dose
- Melatonin: consult specialist on dose
Surgery is a 4th line treatment only in medically refractory headaches. (occiptal nerve stimulation, or deep brain stimulation of posterior hypothalamic region)
ALL ongoing/episodic cluster headache tapering
FOR ALL: If episodic taper off therapy after 2 wks no symptoms. If chronic continue indefinitely (trialling perioidic dose reduction if Sx free)
Complications of cluster headache:
A/w psychiatric conditions (depression, anxiety, aggressive behaviour) Autonomic dysregulation (brady/tachycardia, hypertension, arrythmias (AVN block and SA block) Blood pressure regulation abnormality increases end organ disease and CV disease.
Prognosis of cluster headache
Hard to predict - progression from episodic to chronic is possible ane vice versa.
Tends to remit with age, with longer periods of remission.
There is no underlying sinister disease so these patients are not at higher mortality resulting from the condition alone
May have large impact on life if severe and therefore mental health and quality of life.
encephalitis management initial (immunocompetent)
All cases of community acq. Viral encephalitis is treated with 10mg/kg IV every 8hrs for 10-21 days. Assumed to be HSV until proven otherwise.
encephalitis Mx inital (immunosupressed)
Ganciclovir 5mg/kg IV every 12hrs for 14-21 days AND foscarnet 60mg/kg IV every 8hrs for 14-21 days. AND aciclovir 10 mg/kg every 8hrs for 21d. In immunocompromised CMV is treated alongside the HSV cover.
Supportive care in encephalitis
IF cx (electrolyte abn., stroke, raised ICP, cerebral oedema, coma, seizure) manage in ICU
May require tubing, circulatory and electrolyte support.
Prevention of secondary Cx eg DVT, bacterial infection, gastric ulcer
Antiretroviral therapy if HIV
Raised ICP: corticosteroid and mannitol, bed at 30-45 deg. Hyperventilation at PaCO2 of 30
Shunting or decompression indicated if medical Mx fails to reduce ICP
Confirmed viral cause of encephalitis HSV
aciclovir 10mg/kg IV every 8 hours for 14-21d (immunosuppressed full 21d)
confirmed VZV encephalitis
aciclovir 10mg/kg IV every 8 hours 14d OR ganciclovir 5mg/kg every 12h 14-21d
Adjunctive methylprednisolone 1000mg IV OD 3-5d for possible cerebral vasculitis
Confirmed CMV encephalitis
ganciclovir 5mg/kg IV every 12h 14-21d FU w/5mg/kg/day for 7d AND foscarnet 60mg/kg IV every 8hrs 14-21d
Confirmed EBV encephalitis
aciclovir 10mg/kg IV every 8hrs 14d. PLUS 1000mg methylprednisolone IV 3-5d
confirmed HBV encephalitis
ganciclovir 5mg/kg every 12h 14-21d OR aciclovir 10mg/kg every 8hrs 14-21d
confirmed HH6 encephalitis
ganciclovir 5mg/kg every 12h 14-21d. OR foscarnet 60mg/kg IV every 8hrs
NON viral encephalitis Mx
Treat underlying cause: examine and culture CSF e.g. appropriate Abx, Afx, Avx
Auto-Immune: methylprednisolone 1000mg IV 3-5d
ADEM: methylprednisolone 1000mg IV 3-5d
Paraneoplastic: normal human IG 2g/kg IV given over 4-5 days
Syphilis: Benzylpenicillin 1.2-2.4g IV every 4hrs 10d
Listeria: ampicillin 1-2g IV every 4hrs 21d AND gentamicin 2mg/kg loading dose then 1.7mg/kg every 8hrs
Mycoplasma pneumonia: doxycycline 100mg IV every 12hrs 5-10d
ALL aetiologies of encephalitis aftercare
- Depends on functional deficits can include cognitive and behavioural rehab and motor rehab.
Complications of encephalitis
electrolyte abn - correct
Stroke - neuroimaging with appropriate Mx
Raised ICP - corticosteroid and mannitol, bed at 30-45 deg. Hyperventilation at PaCO2 of 30. Shunting or decompression indicated if medical Mx fails to reduce ICP
Cerebral oedema,
Coma
Seizure: manage in ICU
May require tubing, circulatory and electrolyte support.
Prevention of secondary Cx eg DVT, bacterial infection, gastric ulcer
Prognosis of encephalitis
Aetiological agent found in 50%
30% mortaility in HSV with treatment 70-80% without
If mild most can expect full recovery
Viral usually recover without sequele
May have residual difficulties in concentration, behaviour, speech, memory loss
Rarely can become in vegetative state
Depends on patient underlying health eg age, HIV status
Extradural haemorrhage Management
> 30cm3 should be managed surgically regardless of other factors
<30cm3 with low thickness, minimal midline shift and GCS >8 without any FNS are candidates for non surgical management.
non-surgical Mx of extradural haemorrhage
Non surgical mx: serial CT scans and close neuro obs
Surgical Management of extradural haemorrhage
NO specific procedure but craniotomy and burr holes are able to relieve raised intracranial pressure. Any bleeding sources can be identified and ligated/cauterised.
post-op extradural haemorrhage
neuro-critical care or HDU with close neuro-obs and routine post op CTs. Ongoing neurorehab often required.
Complications of extradural haemorrhage
Parenchymal compression/cerebral herniation: reducing ICP and controlling bleed with neurosurgery
Residual deficit - paralysis or loss of sensation
Coma
Normal pressure hydrocephalus leading to weakness, headache, incontinence, ataxia
Prognosis of extradural haemorrhage
Carries 30% mortality
Poor prognostic factors: age, herniation, raised ICP
Potential of residual symptoms
Guillain-Barre Management (without IgA def. or renal failure)
1L: plasma exchange and IVIG are equal in effectiveness.
Ambulatory patients: plasma exchange within 2 weeks of onset of neurology
Non-ambulatory: plasma exchange within 4 weeks of onset
Plasma exchange dose (through central line): 50mL/kg every other day for 7-14d. Monitor closely for coagulopathy and electrolyte abnormality
IVIG: 400mg/kg/day IV for 5 days
Guillain-Barre Mx (with IgA def. or renal failure)
Must use plasma exchange due to risk of anaphylaxis
Plasma exchange dose (through central line): 50mL/kg every other day for 7-14d. Monitor closely for coagulopathy and electrolyte abnormality
IVIG: 400mg/kg/day IV for 5 days
Severe Guillain-Barre supportive Mx
HR and BP until they are off ventilator support. With fluid bolus if needed. Consider intraarterial monitoring if labile. Hypertn. Use short acting agents (labetalol, nitroprusside) DVT proph (sc LMWH+TEDS). Pain: gabapentin or carbamazepine acute. TCAs, tramadol, gabapentin may be helpful long term
rehab in Guillain-barre
acute: gentle strengthening, focus on limb posture
Nutrition
