Neuro Treatments Part 2 Flashcards
1st Line Tx for acute generalised seizures
Benzo’s & ABCDE
Prophylactic Tx of generalised seizures
(if >2 attacks)
1st line –> Na Valproate
What drug is given instead of Na Valproate if patient is a female of childbearing age?
Lamotrigine
Specific Tx for absent seizures
Na Valp,
Ethosuximab
Specific Tx for Myoclonic seizures
Na Valp,
Levetircepam,
Clonazepam
What drug do you NEVER give to patients with myoclonic seizures?
Carbamazepine
Specific Tx for Atonic, Tonic & tonic-clonic seizures
Na Valp
How long must a patient NOT drive for following 1st seizure?
6 months for Car
5yrs for HGV/PCV
How long must a patient be seizure-free for before they can drive again if they have a Dx of epilepsy?
12 months for car (or 3 months if seizures occur during sleep)
10yrs off medication for HGV
1st Line Tx for focal seizures
Carbamazepine or Lamotrigine
2nd Line Tx for focal seizures
Na Valp
Mx for Status Epilepticus
EMERGENCY!!!! –> ABCDE
Tx algorithm:
1) Lorazepam (IV) 0.1mg/kg
- if no response, give 2nd dose after 10 mins
2) Phenytoin (IV)
3) Diazepam infusion
4) Dexamethasone
5) General anaesthesia
S/Es of Na Valproate
Nausea –> so take with food
Wt gain, increased appetite, liver failure, pancreatitis, hair loss, oedema, ataxia
TERTATOGENIC
thrombocytopenia,
encephalopathy
Dose of Na Valproate
300mg/12h increase by 100mg every 3 days to max of 30mg/kg
S/Es of Lamotrigine
Rash –> SJS, TEN
Diplopia, blurred vision, tremor, agitation, N+V
APLASTIC ANAEMIA - bone marrow failure
Dose of Lamotrigine
Monotherapy = 25mg/day increase by 50mg every 2 weeks to max 100mg/12hr
1/2 dose if on Na Valp also
x2 dose if on carbamazepine
S/Es of Phenytoin
High toxicity –> Nystagmus, diplopia, tremor, ataxia
Depression, acne, gum hypertrophy
CIs of Phenytoin
Progesterone contraception
because it is a liver enzyme inducing drug
S/Es of Carbamazepine
Leucopenia
Blurred vision, diplopia, balance problems, rash,
CIs of Carbamazepine
Progesterone contraception
since liver enzyme inducting drug
Dose of Carbamazepine
100mg/12hr increase by 200mg every 2 weeks to max 1000mg/12hr
When/how should you stop AEDs?
Consider stopping if seizure free for >2yrs.
Taper off over 2-3 months
What kind of diet helps in epilepsy?
Ketogenic: high fat low carb & controlled protein
Tx for Peripheral neuropathies:
1) Motor
2) Vasculitic
3) Inflammatory
1) Tx cause & symptomatic relief
2) pulsed IV prednisolone & cyclophosphamide
3) IV IG, steroids, may need AZA or cyclo
Tx for Guillian-Barre Syndrome
- Plasma exchange, plasmapheresis = filters blood to strip out demyelinating substances
- IV Ig infusion
- Supportive care = 1/4 its need ventilation & ECG monitoring for arrhythmias
Tx for HSMN (Charcot-Marie-Tooth)
Goal = maintain movement, muscle strength, flexibility
Supportive - physio, OT, orthosurgery etc.
1st Line Tx for LEMS (Lambert-Eaton)
3,4-Diaminopyridine (DAP), IV IgG,
What is the mechanism of action for 3,4-DAP (used to Tx LEMS)?
LEMS is an autoimmune disease attacking Ca channels in pre-synaptic terminal & thus preventing release of ACh….
3,4-Diaminopyridine blocks K-channels -> AP lasts longer and more Ca has chance to enter pre-synaptic terminal => hopefully more ACh can be released into NMJ
What regular Ix do patients w/ LEMS need?
Regular CXR/CT due to risk of malignancy! (Small cell lung cancer paraneoplastic syndrome)
1st Line Tx for Myasthenia Gravis (MG)
Pyridostigmine
+ prednisolone for relapses
What is the mechanism of action for pyridostigmine?
Long-acting cholinesterase inhibitor
Other Tx for Myasthenia Gravis (other than pyridostigmine)
IV Ig or plasmapheresis
Thymectomy - consider if <50yo and NOT responding to pyridostigmine
What needs to be regularly monitored in patients w/ Myasthenia Gravis?
Vital capacity –> since usually die from aspiration pneumonia
What Antibiotic must be AVOIDED in patients w/ Myasthenia Gravis?
Gentamicin
–> can cause “Myasthenia Crisis” leading to resp fail.
Mx for Myasthenia Crisis
Intubate, high-dose steroids, plasmapheresis & IV Ig
1st Line Tx for MND e.g. ALS
Riluzone.
NB: can prolong life by ~3 months by delaying onset of ventilation. BUT not all pt’s want this
Symptomatic relief for NMD:
- Resp
- Muscle spasms/cramps
- Cant expel mucous
- Drooling
- Resp –> non-invasive ventilation (BiPAP at night)
- Muscle spasms/cramps –> Baclofen
- Can’t expel mucous –> Carbocistein (mucolytic)
- Drooling –> Anticholinergic
What is the mechanism of action of Riluzone?
Anti-glutamine action via blocking Na Channels to prevent release of glutamine.
Tx for hydrocephalus
Ventriculoperitoneal (VP) shunt.
OR
Endoscopic third ventriculostomy (ETV) - used more for non-communicating hydrocephalus
CI to VP shunts
AVOID if Dx tumour - since the tumour can disseminate into peritoneal cavity via VP shunt
Extra-dural haematoma Tx
Definitive Tx = Craniotomy + surgical clot evacuation
Tx of acute sub-dural haemorrhage
small or incidental finding –> conservation observation
OR
Decompressive craniectomy
Tx of Chronic sub-dural haemorrhage
small or incidental + no neuro deficit = conservative observation (hope it will dissolve itself)
Severe or neuro deficit = Burrhole decompression
Tx of SAH
Tx according to cause:
- intracranial aneurysms are at risk of re-bleed so need intervention within 24hrs
- -> majority = coil insertion- -> minority = craniotomy + surgical clipping
GIVE nimodipine (CCB) to decrease risk of vasospasm in cerebral arteries
Tx of Cx of SAH
- Re-bleeding = coils or clips
- Delayed ischaemic neuro defects = Fluids for triple “H” therapy (induced HTN, hypervolemia, haemodilution)
- Hydrocephalus = usually transient
- Seizures = give anti-convulsant
- HypoNa = can affect hypothalamus causing transient “cerebral salt wasting” so give fludrocortisone + Na supplements
NEVER fluid restrict!!
