Neuro problems Flashcards
What is Idiopathic intracranial hypertension (IIH)
a disease of unknown aetiology, which is associated with increased intracranial pressure without hydrocephalus or mass lesion, with normal cerebrospinal fluid composition.
Idiopathic intracranial hypertension (IIH) predominantly affects which target group
Obese women of child bearing age
What is the common presenting symptom of IIH
Headache and transient visual obscuration.
The headache can occur daily and is typically a throbbing, retrobulbar headache that can worsen with eye movements & coughing
straining Diplopia in 38% +/- loss of vision (31%) with diplopia
IIH ratio in males to females
IIH has a female to male ratio of 8:1.
The incidence of IIH in women of childbearing age is
about 0.9/100 000
which increases to 19.3/100 000 in obese women.
Other symptoms of IIH
- nausea
- vomiting
- photophobia
- visual blurring
- visual loss
- double vision
- tinnitus
- vertigo
- rarely, spontaneous CSF otorrhoea or rhinorrhoea.
This condition may aggravate pre-existent migraine
What is the Lumbar pressure to diagnose IIH
Greater than 250 mmh2o
How we manage IIH
- MDT
- Growth scan are recommended for obs indications
- The frequency of visual field testing depends on the symptoms
- If the patient visual symptoms are stable: Visual field testing be done every 2 to 3 months
IIH
When we take anasthesia input?
in later half of pregnancy (36 weeks)
What mode of delivery is allowed in IIH
Vaginal delivery can be allowed (50%)
Which anasthesia is safest in IIH
Spinal
Avoid general and epidural
Why can’t we give epidural anastgesia to patients with IIH
it carries a potential risk of increasing ICP because of large volume of drugs in the epidural space .
IIH
Those patient who already have lumboperitoneal shunt ..What measures we can take for them
- Particular attention to be given to women with lumboperitoneal shunt who need regional anesthesia.
*There is potential risk of shunt damage - Prior imaging is recommended because there is a risk of shunt enlargement
Why we don’t prefer general anesthesia in IIH
Raises ICP when we use rapid sequence induction
How we manage patients of IIH medically
It is ideal for women with IIH to limit their weight gain to 20 lb during the pregnancy.
Analgesics:
- paracetamol is safe
- Opioid can be use but can cause physical dependence in neonate
- NSAID should be avoided in late pregnancy
Diuretics:
* Acetazolamide
* Loop diuretics (only for short time)
* Steroids only in acute condition
IIH
What is the mechanism of action of acetazolamide
Carbonic anhydrase inhibitor
Inhibits carbonic anhydrase enzyme in the CNS which delays abnormal and excessive discharge of CSF from choroid plexus .
Why thiazide diuretics are contraindicated in IIH
Fetal Growth Restriction
IIH
Treatment in case of acute deterioration of optic nerve function
optic nerve sheath fenestration use lesi stent and divert the CSF flow.
If there is worsening of visual function despite medical treatment then we will go towards lumboperitoneal shunting to divert the CSF FLOW
Lumbar puncture in treating of IIH
Another treatment which can be done everyday in acute cases is lumber puncture.
Can be done multiple times.
Give relief in symptoms but for a temporary period again when CSF pressure will high there will be headache and vision problems and again we have to repeat the procedure
IIH
For breast feeding women what treatment you will prescribe?
- Acetazolamide can be continued during breastfeeding
- Paracetamol and short-term use of NSAIDs are safe to use.
- Ibuprofen is the drug of choice if long-term use is contemplated.
Define epilepsy
Recurrent unprovoked seizures resulting from excessive neuronal discharge
Define SUDEP
Sudden unexpected witnessed or unwitnessed, non traumatic and non drowning death in a patient with epilepsy with or without evidence of a seizure and excluding documented status epilepticus in which postmortem doesn’t reveal a toxicology or anatomic cause of death.
What is the prevalence of epilepsy in.child bearing age?
0.5-1%
WHAT is the most common cause of SUDEP?
Generalized tonic colonic seizures
Or Grand mal seizures
How much is the risk of death increases in pregnant women with epilepsy
10 folds
Who we consider as low risk women in pregnancy
10 years no seizure attack or 5 years is well controlled without AEDS
What are the important features of preconception counselling for WWE
- Compliance with AED
- Drug adjustment
- Folic acid 5 mg/day
What is the risk of congenital anomaly in WWE not taking AED
2 - 2.3%
What are the factors contributing to deterioration of epilepsy in pregnancy
- Poorly contolled epilepsy prior to pregnancy
- Seizure frequency of more than
1 per month - Multiple seizure type
- Drug resistant epilepsy
- High dose polytherapy
- Poor compliance
- Reduce drug concentrations due to increase clearance and pregnancy.
- Specific Nausea, vomiting, sleep deprivation, labour pain and hyperventilation
What are the risk of epileptic fits on fetus?
- Increase risk of IUGR
- Increase risk of hypoxia
- Developing childhood epilepsy
What are the medication you will prescribe pre conceptual and in early pregnancy for WWE
- Folic acid supplementation
- taking AED at lowest dose, usually monotherapy, avoid sodium valproate
What are thesuggested AED in pregnancy
Levoteracetam
Lamotrigine
Carbamazepine
Sodium valproate is associated with which congenital anomalies
Facial cleft
NTD
poor cognition & neurodevelopment
hypospadias
Phenobarbital and phenytoin are associated with?
Cardiac defects
Fascial cleft
Risk of malformation with sodium valproate
6-10%
Risk of malformation with lamotrigine 300 mg
2-5%
Risk of malformation with carbamazepine 400 mg
2-5%
Risk of malformation with levetiracetam
0.07
If 1 child has congenital anomalies what is the risk of recurrence in next child
0.168
Is there any risk of autism.with AED?
Yes
When to avoid or postpone pregnancy
Uncontrolled epilepsy
drug resistant epilepsy
Non compliance
Polytherapy
High dose AED
How we care this patient antenatally?
- 5mg folic acid pre conception and
12 weeks - Manage as low risk and high risk
In high risk MDT - Individualize the frequency of visits and at each visit ensure involving other specialities
- avoid triggers
- ensure AED compliance
- asses seizure frequency
-consider AED level - Serial growth scan from 28 weeks
What is preffered analgesia during labour?
TENS, Entonox, regional analgesia
Which analgesia is contraindicated
Pethidine
increase seizures potential
Intrapartum care of WWE
Avoid stress, hyper ventilation or sleep deprivation.
AED should be continue in labour
If high risk of seizure manage with benzodizapine
CEFM
What is the percentage of tonic clonic seizure in labour
3-5%
Define status epilepticus
Seizure lasting for more than 5 mins or having more than 1 seizure without any break in 5 mins
What is management of status epilepticus
- Left lateral
- Oxygen
- IVlorazepam 0.1mg/kg
- Diazepam 5-10 mg I/ v as alternative
If no IVaccess then p/r 10-20 mg diazepam
If seizure not control then phenytoin 10-15 mg/kg IV
if no IV access then give diazepam 10-20 mg rectally repeat after 15 minutes if needed.
- Prevention tongue bite protection
What period is most vulnerable for seizures
Postpartum
If AED dose increases in pregnancy what time duration in which we have to taper it off postpartum
10 days
Which aed excreted in breast milk
- Lamotrigen
- Levetiracetam
- Topiramate
transfer to larger extent through breast milk
What will be the contraception advice for WWE
- Cu IUD
- LNG- IUS
- DMPA
Emergency contraception for WWE
Cu-IUD
Which antiepileptic has the least risk of malformations in the fetus?
Lamotrigine
If there is no history of epilepsy and a fit of seizures presented in 2nd trimester treat it as:
Eclampsia
The effect of pregnancy on epilepsy
- Seizure free: 64%
- Increased seizure frequency: 17%
- Decreased seizure frequency: 16%
- Intrapartum seizures: 3.5%
- Status epilepticus: <2%
At which weeks to perform fetal anomaly scan?
18 - 20+6 weeks
Do we encourage wwe who are taking aeds to breastfeed?
Yes
Do we use levonorgestrel or ulipristal acetate as emergency contraceptives in wwe taking enzyme inducing aed?
No they are affected by them
Women taking lamotrigine monotherapy and estrogen containing contraception should be informed that
Potential increase in seizures due to fall in levels of lamotrigine
Babies born to wwe should be given
1 mg of IM VIT K
Do lamotrigine crosses in breast milk
Yes, so women must be encouraged to breastfeed before taking the medication
