neuro tx Flashcards
Tx for MND
No cure, tx symptoms
- MND specialist nurses
- tx comm. needs (speech therapy, voice banking)
- nutritional tx (dietitian, gastrostomy)
Bulbar dysfunction MND tx
Comm aids (AAC)
Nutritional saliva
Gastrostomy
Botulism tx
- antitoxin but only useful if given early before toxin has attacked nerves
- therefore mainly supportive: Ventilation (otherwise will die)
Myasthenia gravis tx
(Not emergency)
1st line: pyridistigmine (long acting anticholinesterase inhibitor)
Long term: high dose prednisolone then Steroid sparing agents- aza/mycophenolate
thymectomy
which antibiotic should be avoided in mysathenia gravis
Gentamicin
Guillian barre syndrome tx
1st line:Immunoglobulin infusion
2nd: plasma exchange
Ms relapse tx
(mild, moderate and severe)
Mild: symptomatic tx
Moderate relapse: high dose oral steroids
Severe relapse: admit for IV steroids (short period)
Ms spasticity tx
(first line and others)
baclofen and gabapentin first line
physio (important)
Botox for rare and severe cases
Ms sensory tx
(4)
Anti convulsant eg. Gabapentin
Anti depressant eg. Amitriptyline
Tens machine
Acupuncture
Relapsing-Remitting ms tx
1st line: tecfidera (oral)/interferon (injectable)
last line: stem cell transplant
1st line- natalizumab on passmed- monocolonal antibody
Acute pharmacological tx for migraines
NSAIDS (asp. Naproxen. Ibuprofen) and oral triptan +/- anti-emetic
or
oral triptan + paracetomol +/- anti- emetic
Take as early as poss.
If gastroparesis consider anti-emetic
When is prophylaxis for migraines given.
How long must they be tried fof
If >3 attacks a month/very severe
Must trial each for min. 3 months
Consider non pharmacological eg. Acupuncture, relaxation excersizes
prophylaxis for migraines
1st line:
- propanolol
Avoid in asthma, PVD, heart failure
or
topiramate (carbonic anhydrase inhibitor) (Na+ channel blocker)
AVOID in women of childbearing age as it may be teratogenic/reduce effectiveness of hormonal contraceptive
2nd:- Amitriptyline (blocks serotonin re-uptake) (causes vasoconstriction)
Se. Dry mouth, postural hypertension
if pharamocoligical prophylaxis migraine mx fails then consider…
10 weeks of acupunture
Tension headache tx
Relaxation physio
Antidepressant- dothiepin/Amitriptyline
- 3 months Rx
- reassure
Cluster headache tx
High flow o2 for 20 mins
Sub cut sumatriptan 6mg injectable
Acute tx^^^^
long term: verapamil / Steroids- reduce course over 2 weeks
Cluster headache prophylaxis
Verapamil
Hemicrania tx
Indomethacin (absolutely cured by this, if not then it is a diff diagnosis)
Idiopathic raised intracranial pressure tx
Weight loss
Acetozalmide
lumbar puncture used for short term management
Trigeminal neuralgia tx
1st line: Carbamazepine,
(other drugs: gabapentin, phenytoin, baclofen)
Surgical (rare): ablation compression , decomrpession
when to refer for tigeminal neuralgia
failure to respond to tx/ atypical features:
-sensory changes
- deafness/ear problems
-hx of skin/oral lesions
-pain only in opthalmic division or bilaterally
-fam hx ms
- <40 yrs old
Giant cell arteritis tx
High dose steroids
When is acute blood pressure mx indicated for stroke
- Lowering bp (if >185/110) for safe thrombolysis
- ICH (intracerebral haemorrhage) as to reduce haematoma expansion
Mx of intarcerebral harmorraghe
Correct clotting- vit k antagnoist, doac patients consider reversal
Control bp- sbp goal: 130-139 in <1hr & sustain for 7 days
surgical decompression for the well but deteriorating patient
Unless
Gcs<5…
(150-229 tx in <6hrs of symptom onset to achieve)
Primary generalised epilepsy
(same tx as tonic/atonic)
males
females
males
1st line: sodium valproate
Females: Lamotrigine
Focal onset epilepsy tx
1st line: Levetiracetm or Lamotrigine
2nd: carbamezapine
(same for men and women)
Partial seizures tx (uni)
1st: carbamazepine and lamotrigine (Lam takes a while to work)
Then can add on other drugs eg. Gabapentin
When to give epileptic drugs
Epilepsy
Seizure with high risk of recurrence
If they want it…
absence seizures tx
first: ethosuximide
2nd male: sodium valproate
2nd female: Lamotrigine or levetiracetm
LEMS (Lambert Eaton Myasthenic Syndrome) tx
3-4 diaminopyridine
(increases ach, this helps as lems is due to voltage gated calicum channels not working properly= reduced ach= reduced muscle contractions)
Emergency tx for myasthenia gravis
plasmapharesis and IV immunoglobulins
mx of raised ICP
sedation: propofol, benzos, barbiturates
maximise venous drainage; head of bed tilt (30 degrees), cervical collars et tube ties
CO2 control- HYPERVENTILATION ( dec CO2= cerebral artery vasoconstriction)
osmotic diuretics; mannitol, hypertonic saline
CSF release
If all the above fails then decompressive craniectomy
Myasthenia Gravis tx
first: pyridostigimine (long acting acetylcholinesterase inhibitors)
2nd: + prednisolone
3rd: aza etc
4th: thymectomy
chronic stroke managemen
HALTS
-Hypertension: anti-hypertensive therapy started 2 weeks post stroke
-Antiplatelets: 75mg clopidegrol once daily
-Lipids-lowering: atorvastatin 20mg-80mg once nightly
-Tobacco: stop
Sugar- screen for diabetes
what type of stroke patients are offered cardioendarterectomy
patients with ipsilateral carotid artery stenosis greater than 50%
suspected TIA management and when/what kind of referral
aspirin immediately (unless contraindicated) and referred for a specialist within 24 hours unless tia attack was over a week ago in which case refer for within 7 days.
when is aspirin contraindicated as TIA management
if patient has a bleeding disorder
patient is already taking low dose aspirin
following a first seizure when should anti-epileptic drug treatment be commenced
following first suspected seizure, must be refferred for specialist review.
anti-epileptic drug tx should not be started before review unless;
-seizure activity on eeg
- presence of a neurological defect
- presence of structural brain abnormality
- pt, parent or carer considers risk of further seizure to be unacceptable
what epilepsy patients can be prescribed midazolam
pts. with previous episode of prolonged/sewuential generalised seizures
(so they can use midazolam in event of status epilepticus)
viral encephalitis tx
IV aciclovir
essential tremor tx 1st line tx
propanolol 1st line
ischaemic stroke secondary prevention management
clopidogrel 1st line
2nd: aspirin + mr dipyridamole
3rd: dipyridamole
management after TIA diagnosed
1st line: clopidogrel
-aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
- high intensity statin
brain abscess tx
craniotomy abscess cavity debrided
IV 3rd-generation cephalosporin + metronidazole
intracranial pressure management: e.g. dexamethasone
symptomatic and defintive tx for normal pressure hydrocephalus
symptomatic- lumbar puncture
defintive: ventirculo-peritoneal shunt
intracranial venous thrombosis tx
acutely- low molecular weight heparin
long term- warfarin
subdural haemorraghe tx
small and asymtomatic- conservative
otherwise-
surgery:
- acute- decompressive craniectomy
-chronic- burr holes to relieve pressure
neurpathic pain tx
first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
juvenile myoclonic epilepsy tx
sodium valproate
bladder dysfunction Multiple Sclerosis management
ultrasound first to assess bladder emptying
if significant residual volume → intermittent self-catheterisation
if no significant residual volume → anticholinergics eg. oxybutnin
acute stroke management: who is offered thrombectomy
anterior circulation
offer thrombectomy within <24 hours of symptom onset if confirmed occlusion of proximal anterior circulation (CTa/MRA)
AND
if potential to salvage brain tissue (ct showing limited infarct core volume)
offer thrombectomy WITHIN 6 HOURS of symptom onset if confirmed occlusion of proximal anterior circulation on CTA/MRA
for all scenarios do with thrombolysis if within 4./5hours symptom onset
posterior circulation and thromebctomy: who should get it?
(4)
acute ischaemic stroke <12 hours of onset. confirmed intracranial vertebral/basilar artery occlusion.
NIHSS score is 10 or more,
favourable PC-ASPECTS score and Pons-Midbrain Index
acute stoke management: thrombolysis
it is administered within 4.5 hours of onset of stroke symptoms and
haemorrhage has been definitively excluded (i.e. Imaging has been performed)
how is vasospasm avoided in SAH
nimidopine
(vasospasm occurs in SAH patients and causes subsequent ischaemic damage)
supportive management of SAG
rest etc.
venous thromboembolism prophylaxis
discontinuation of antithrombotics.
surgical management of subarachnoid haemorrhage
most intracranial anyuersms are treated with a coil, preferably within 24 hours
1st line tx for spinal cord compression from malignancy
dexamethasone + PPI
how does metocolpramide work
dopamine antagonist- anti emetic
give examples of anti-emetics which are dopamine antagonists
metoclopramide, domideperone (does not cross brain barrier), prochlorperazine
initial empirical antbiotic tx for bacterial meningitis ages 3 months - 50 years
IV cefotaxime
initial empirical therapy for bacterial meningitis >50 yrs
IV cefotaxime + amoxicillin
initial empirical antbiotic tx for bacterial meningitits <3 months old
IV cefotaxime + amoxicillin (or ampicillin)
meningococcal meninigits antibiotic tx
IV benzylpenicillin or cefotaxime (or ceftriaxone)
Meningitis caused by Listeria abx tx
IV amoxicillin (or ampicillin) + gentamicin
mangement of patients for bacterial meningits without indication for delayed lp
IV access → take bloods and blood cultures
Lumbar puncture
IV antibiotics- empirical until known cause.
IV dexamethasone
immedieate management for GCS less than 8
intubate
wernickes encephalopathy tx
IV pabrinex (thiamine)
parkinsons: 1st line tx for improving daily activities
levodopa
eg. co-careldopa
degenerative cervical myelopathy tx
decompressive surgery
Ms fatigue tx
Amantadine or modanifil
Ramsay hunt syndrome tx
Prednisolone + aciclovir
chronic primary pain tx
avoid all analgesia apart from anti-depressants.
peritumoural vasogenic oedema tx
glucocorticoids eg. dexamthasone
this is given as the oedema can affect neuron transmission. glucorticoids reduce the oedema
narcolepsy tx
daytime stimulants eg. modanifil and nightime sodium oxybate
