Neuro Treatments Part 2 Flashcards by Michelle Callison

1st Line Tx for acute generalised seizures

Benzo’s & ABCDE

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Prophylactic Tx of generalised seizures

(if >2 attacks)

1st line –> Na Valproate

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What drug is given instead of Na Valproate if patient is a female of childbearing age?

Lamotrigine

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Specific Tx for absent seizures

Na Valp,

Ethosuximab

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Specific Tx for Myoclonic seizures

Na Valp,
Levetircepam,
Clonazepam

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What drug do you NEVER give to patients with myoclonic seizures?

Carbamazepine

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Specific Tx for Atonic, Tonic & tonic-clonic seizures

Na Valp

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How long must a patient NOT drive for following 1st seizure?

6 months for Car

5yrs for HGV/PCV

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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

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1st Line Tx for focal seizures

Carbamazepine or Lamotrigine

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2nd Line Tx for focal seizures

Na Valp

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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

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S/Es of Na Valproate

Nausea –> so take with food

Wt gain, increased appetite, liver failure, pancreatitis, hair loss, oedema, ataxia

TERTATOGENIC
thrombocytopenia,
encephalopathy

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Dose of Na Valproate

300mg/12h increase by 100mg every 3 days to max of 30mg/kg

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S/Es of Lamotrigine

Rash –> SJS, TEN

Diplopia, blurred vision, tremor, agitation, N+V

APLASTIC ANAEMIA - bone marrow failure

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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

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S/Es of Phenytoin

High toxicity –> Nystagmus, diplopia, tremor, ataxia

Depression, acne, gum hypertrophy

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CIs of Phenytoin

Progesterone contraception

because it is a liver enzyme inducing drug

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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!!