Neuro Treatments Part 1 Flashcards
1st line Empirical Tx for bacterial meningitis
Ceftriaxone (IV) 2g bd
if PA: Chloramphenicol + vancomycin (IV)
Why is ceftriaxone used instead of penicillin for bacterial meningitis?
Ceftriaxone has longer half-life (T1/2)
Which drug is given before the 1st ABx dose as part of empirical Tx of bacterial meningitis?
Dexamethasone 10mg QDS
When do you stop giving dexamethasone in bacterial meningitis?
Once causative organism is proven to NOT be strep!
since dexamethasone only helps in Tx of strep
Treatment for TB meningitis
isoniazid + rifampicin
Treatment for neonatal meningitis (first 4 weeks of life)
Benzylpenicillin + Gentamicin
Treatment for viral meningitis
Mild –> supportive care.
Severe –> Aciclovir
Tx for encephalitis
IV aciclovir
Brain abscess
Neurosurgical drainage
ABx
What is used for prophylactic contact tracing in meningitis?
Ciprofloxacin (500mg - one time dose)
Contraindication for ciprofloxacin
children <12 yo
Acute migraine Tx
Triptans
+
NSAIDs, paracetamol, anti-emetics
Contraindications to Triptans
IHD, SSRIs, unstable HTN, COCP
Class & S/Es of Triptans
Class: 5-HT agonists
S/Es: “Triptan sensations”:
- tingling
- heat
- tightness in throat or chest, heaviness, pressure
Migraine Prophylaxis:
- 1st line
- 2nd line
- others
1st line –> propranolol, topiramate
2nd line –> amitriptyline
others –> gabapentin, pizotifen, valproate
Contraindications for BBlockers
CI: asthma, heart failure, peripheral vascular disease
Class and S/Es of Topiramate
Class = carbonic anhydrase inhibitor (anticonvulsant)
S/Es: wt loss, paraesthesia, impaired consciousness, TERATOGENIC!
Class & S/Es of Amitriptyline
Class = TCA
S/Es: dry mouth, postural hypoTN, sedation
How many migraine attacks are required before trialling prophylactic Tx?
over 3 attacks per month of extreme severity –> trial prophylaxis for 4 months
Tension Headache Tx
Acute –> reassurance + analgesia (paracetamol, NSAIDs (e.g. naproxen))
Chronic –> amitriptyline or dothiepin
Cluster Headaches Tx:
- Acute
Acute:
- high flow 02 via non-rebreathable mask (20mins)
- add SC Sumatripan
- steroids –> reducing course over 2 weeks
Cluster Headaches Prophylaxis
Verapamil
SUNCT Tx
Lamotrigine or Gabapentin
Paroxysmal Hemicrania Tx
Indomethacin
Idiopathic Intracranial HTN
1st line –> Wt loss
Other:
- Acetazolamide
- prednisolone
- ventricular shunts
Acetazolamide Contraindications
Hepatic or Renal failure (since its a diuretic)
Trigeminal Neuralgia Tx:
- 1st line
- 2nd line
- other
- 1st line –> Carbamazepine OR Baclofen
- 2nd line –> Gabapentin or phenytoin
- other –> surgical decompression or ablation
Nacrolepsy Mx
- sleep hygiene
- lifestyle changes
- may require Modafinil
DMD Mx
- Physio
- Steroids –> prednisolone
- Surgery –> to ease contractures
- Air stacking –> prevent contracture of lungs
- Cardioprotective drugs –> e.g. BBlockers + ACEis
Huntington’s Disease Mx
1st line –> COUNSELLING (since high suicide risk!!)
Tx mental health problems –> e.g. ADs for depression, anxiety
Chorea Tx –> Tetrabenzine, anti-psychotics
What is the anti-chorea mechanism of Tetrabenzine?
UNKNOWN
Parkinson’s disease general Mx aims
Aim = increase dopamine!
Rules:
- if motor s/s affecting QOL = give Levodopa
- if not affecting QOL yet = give dopamine agonists, MAO-B inhibitors or levodopa
Examples of Dopamine Agonists used in PD Tx
Ropinirole
Pramipexole
Cabergoline & Bromocriptine
Baseline tests before starting Dopamine agonists
CXR, ESR, creatine, echo
Because prolonged use causes pulmonary fibrosis
Contraindications of carbergoline & bromocriptine
avoid if Hx of OCD/addiction since they increase dopamine –> can cause increased reward response e.g. gambling, hyper sexuality, risk-taking behaviour
S/Es of dopamine agonists
Nausea
More likely to cause hallucinations in older pts (than L-dopa)
Tx for Nausea caused by dopamine agonists
Domperidone
NEVER USE METOCLOPRAMIDE (since it is a dopamine antagonist!!!)
Mechanism of action of MAO-B inhibitors
Prevent breakdown of circulating dopamine.
However, only moderately effective, so used as add-on to dopamine agonist or L-dopa in sever PD s/s
Examples of MAO-B inhibitors
Rasagiline
Selegiline
Why is L-Dopa given w/ carbidopa?
Carbidopa is a peripheral decarboxylase inhibitor that prevents Levodopa being broken down in the body BEFORE it gets to the brain.
S/Es of Levodopa
N+V, somnolence, headache, cardiac arrhythmias, psychosis, postural hypoTN,
Dyskinaesia –> due to TOO MUCH dopaminergic effect
What is the “ON-OFF effect” of levodopa?
Levodopa becomes less effective over time so try to use symptomatic control first.
Mechanism of COMT inhibitors (Entacapone)
Given w/ L-dopa and Carbidopa to slow the breakdown of L-dopa IN the brain by inhibiting COMT enzymes.
Symptomatic Tx of tremor in PD (drug-induced PD)
Trihexyphenidyl or procyclidine
What must you carry out first to assess type of stroke?
Head CT to differentiate between ischaemic and haemorrhage strokes.
- ischaemic shows dark areas of brain
1st Line anti-platelet therapy for ischaemic stroke?
Aspirin 300mg given as soon as haemorrhage stroke is ruled out with CT.
1st line ischaemic stroke drug Tx (after anti-platelet)
Thrombolysis –> Alteplase
When is thrombolysis used to Tx ischaemic stroke?
Within 4.5 hours after ONSET of neurological symptoms
CI of thrombolysis
- Patient w/ previous intracranial haemorrhage
- uncontrolled HTN
- preg
When would you use mechanical thrombectomy for ischaemic stroke Mx?
Pt’s w/ acute ischaemic stroke confirmed as occlusion in proximal anterior circulation (by CT-A or MR-A)
& if potentially salvageable brain tissue
Must be carried out within 6 hours.
2’ Prevention of ischaemic stroke
if high cholesterol (>3.5) then start statin
–> most Dr’s delay starting until 48hrs after due to risk of haemorrhagic transformation of stroke.
Anti-platelet therapy:
- -> First 2 weeks = Aspirin (acute)
- -> After 2 weeks = Life-long clopidogrel
What life-long therapy is given as 2’ prevention of ischaemic stroke in pt’s who CANNOT tolerate clopidogrel?
Life-long aspirin AND dipyridamole
Mx for Haemorrhagic Stroke
- Supportive –> stabilise ABCDE
- STOP anticoag/antiplatelet therapy
- Acutely lower BP
Mx of TIA
GIVE ASPIRIN 300mg IMMEDIATELY!!
- if pt has bleeding disorder or is taking anticoagulants, they need CT to rule out haemorrhagic stroke
+ atherosclerotic factors Mx e.g. lifestyle, statin, HTN control
How long is specialist review for TIA in:
- High risk pt
- lower risk pt
- High risk (i.e. older pt, HTN, duration of symptoms, crescendo TIAs or had previous TIA within last 7 days) get review within 24 hours
- Lower risk (i.e. if suspected previous TIA over 7 days ago) then review within 7 days
How long must pt with TIA avoid driving?
ONE MONTH
First line Ix for Alzheimer’s disease (AD)
MMSE, bedside cognitive testing (ACE III)
- MMSE score < 24 needs further investigation
