Neurological Problems Flashcards
1st line pharmacological treatment for muscle cramps in patient with motor neurone disease?
quinine
(2nd line is baclofen)
(other options-tizanidine, gabapentin, dantrolene)
Pharmacological treatments for muscle stiffness/spasticity/hypertonia associated with motor neurone disease?
baclofen, tizanidine, gabapentin, dantrolene
1st line pharmacological tx for excessive salivation in pt with motor neurone disease and cognitive impairment?
glycopyrrolate (glycopyrronium) (anticholinergic)
if pt did not have cognitive impairment then hyoscine hydrobromide patch + amitriptyline OR atropine drops 0.5% SL, would be 1st line
Which investigation would be most useful to differentiate between a benign essential tremor and a tremor associated with Parkinson’s disease if unable to differentiate clinically?
SPECT-single photon emission CT
Only licensed drug treatment in UK for MND?
Riluzole-started at 50mg BD
this is a disease modifying drug and acts to inhibit the release of glutamate
only licensed for ALS
Blood test monitoring for Riluzole?
Monthly FBC and LFTs in first 3 months, then every 3 months for further 9 months, then annually
Which are the only treatments to improve prognosis in MND?
Riluzole and NIV
DVLA guidance for drivers of cars who have had a first unprovoked epileptic seizure or a single isolated seizure?
Must not drive for 6 months, risk of recurrence must be less than 20% or can’t drive for 1 year
(group 2 drivers-5 years-must be seizure free for 5 years with normal investigations and seizure risk less than 2% per year)
Must notify DVLA
How long must patients with established epilepsy be seizure free for to continue driving a car?
1 year (can be on medication) (or pattern of seizures established for 1 year where no effect on level of consciousness or ability to act)
(group 2 drivers-10 years-must be fit free without medication)
Must notify DVLA
How long must patients who drive cars not drive for if had a seizure while asleep?
1 year
unless hx or pattern of seizures occurring only ever while asleep has been established over course of at least 1 year from date of 1st sleep seizure or pattern established over 3 years if pt previously had seizures whilst awake
DVLA guidance for drivers with epilepsy with regards to medication changes or withdrawal?
for group 1 drivers, must not drive during changes or withdrawal and for 6 months after their last dose
if a seizure occurs during changes or withdrawal then licence will be revoked for 1 year.
n/a to group 2 drivers-unable to drive if on medication, must be seizure free for 10 years not medicated
Lamotrigine is 2nd line tx for generalised tonic-clonic seizures, but what type of seizures might it exacerbate?
myoclonic
What type of seizures is ethosuximide a 1st line tx option for?
absence seizures (type of generalised)
Which drug has a specific role in treating epilepsy associated with menstruation?
Acetazolamide (carbonic anhydrase inhibitor)
Which is the most common atypical parkinsonian syndrome?
PSP-progressive supranuclear palsy
*vertical gaze palsy (downward), frequent falls especially backward, subtle personality changes
3 commonest presentations of multisystem atrophy (MSA)?
- urogenital dysfunction-ED, incontinence
- postural hypotension
- ataxia
Non-motor sx associated with essential tremor?
cognitive decline
mental health problems
Pharmacological tx of essential tremor?
if functional disability can treat with a beta blocker (propranolol, atenolol)
or primidone
Why should a throat swab be considered with abrupt onset tics in a child or adolescent patient?
to check for streptococcus-look for PANDAS-paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
Most helpful intervention for mild tics?
habit reversal training
What drugs can be offered as an adjunct to levodopa to patients with PD who have developed dyskinesia or motor fluctuations despite optimal dose of levodopa therapy?
dopamine agonists
MAO-B inhibitors
COMT inhibitors
Examples of non-ergot derived dopamine agonists?
ropinirole
rotigotine
pramipexole
Examples of ergot derived dopamine agonists?
bromocriptine
cabergoline
pergolide
*rarely used now due to risk of fibrotic reactions
Examples of MAO-B inhibtors?
Rasagiline
Selegiline
Examples of COMT inhibitors?
Entacapone
Opicapone
Tolcapone
Indications for antimuscarinic drugs in parkinsonism?
for drug-induced parkinsonism
example-procyclidine, can be given for side effects induced by anti-psychotics, BUT has no improvement on tardive dyskinesia
Antimuscarinics should NOT be used in PD
Management of impulse control disorders in patients with PD?
if on dopamine agonist then gradually reduce the dose
if modifying dopaminergic therapy is not effective offer specialist CBT targeted at impulse control
Pharmacological tx of excessive daytime sleepiness in PD?
consider modafinil if a detailed sleep hx has excluded reversible pharmacological and physical causes
note NOT to be given to pregnant women or those planning to become pregnant-risk of congenital malformations
1st line pharmacological tx of postural hypotension in patients with PD?
midodrine
Pharmacological tx of hallucinations and delusions in patients with PD?
consider quetiapine if no cognitive impairment
if standard tx not effective consider clozapine-note need to register with patient monitoring service
Treatment of mild-moderate PD dementia?
offer an acetylcholinesterase inhibitor e.g. donepezil, galantamine, rivastigmine-rivastgimine capsules only current option with UK marketing authorisation
consider memantine only if above not tolerated or CI
Acute tx of migraine?
PO triptan and PO NSAID OR
PO triptan and PO paracetamol
if aged 12-17, consider nasal triptan in preference to PO
if cannot tolerate PO or nasal preps
offer non-oral metoclopramide or prochlorperazine AND
consider adding a non-oral NSAID or triptan
Prophylactic tx of migraine?
Offer topiramate or propranolol-should consider preventative tx if 2 or more migraines/month
Note teratogenecity of topiramate and can reduce effectiveness of contraceptives
If both of the above ineffective (sx not relieved after 2 months)/not tolerated consider a course of acupuncture
Can also consider amitriptyline
R/v the need for continuing prophylaxis after 6 months of treatment
Riboflavin may be effective in some people
for menstrual migraine prophylaxis note can use frovatriptan although not licensed for this use, frovatriptan or zolmitriptan can be given on days the migraine is expected if standard acute tx not effective
Acute tx of cluster headache?
off O2-100% flow rate at least 12L/min NRM+reservoir bag, and/or SC or nasal triptan
arrange provision for home and ambulatory oxygen
Minimum duration recommended for keeping a headache diary in evaluation of a primary headache?
8 weeks
Prophylactic treatment for chronic tension type headache (headache on 15 or more days/month for more than 3 months)?
acupuncture-consider a course of up to 10 sessions of acupuncture over 5-8 weeks
Prophylactic tx of cluster headaches?
consider verapamil during a bout of cluster headache
(consider if frequent attacks, last over 3 weeks or cannot be treated effectively)
very common side effect=constipation
Which Abx can lower seizure threshold in epilepsy?
quinolones-ciprofloxacin, levofloxacin
Driving advice if single episode of syncope, explained and treated e.g. cardiovascular?
1 month off driving for group 1, 3 months for group 2
if unexplained, then 6 months off if group 1, 12 months off if group 2
2 or more epsiodes-12 months off
Time off driving a car if multiple TIAs over short time period?
3 months
must inform the DVLA
Time frame of referral for patient with syncope and suspected underlying CVS cause?
urgent referral for CVS assessment to be reviewed and prioritised within 24 hours
If suspected epilepsy as cause of blackout how should pt be referred by primary care?
person should be referred for neurological assessment by an epilepsy specialist within 2 weeks
What referral might be considered if patient experiencing recurrent blackouts with suspected vasovagal syncope affecting their QOL or representing high risk of injury?
referral for tilt table test
Most common type of cerebral palsy?
spastic diplegia
Most severe form of cerebral palsy, often associated with generalised tonic-clonic seziures?
spastic quadriplegia
When can AEDs be considered to start to be withdrawn?
if seizure free for at least 2 years
Most common cause of epilepsy related death in young adults with uncontrolled epilepsy?
SUDEP-sudden unexpected death in epilepsy
significant RF=nocturnal seizures
Definition of remission in epilepsy?
5 years seizure free either on or off drug treatment (approx 70% of children and adults with epilepsy)
resolved if seizure free for the past 10 years and at least the past 5 years without AED treatment
Baseline tests arranged by GP for adults with suspected epilepsy?
- ECG
- Bloods-FBC, U+Es, LFTs, glucose and calcium
1st line tx in the community for a patient having a tonic-clonic seizure lasting for more than 5 mins or who have had more than 3 seizure in 1 hour?
buccal midazolam
if not available or preferred can use rectal diazepam
IV lorazepam if IV access already established and resuscitation facilities available
Anti epileptic drugs which increase risk of osteoporosis?
sodium valproate carbamazepine phenobarbitol phenytoin primidone
DVLA guidance for patients with dissociative seziures?
group 1-must inform DVLA and not drive, licensing may be reconsidered after 3 months seizure free
group 2-must inform the DVLA and not drive, licensing may be reconsidered once controlled for 3 months and no significant mental health issues
Contraceptive advice for women taking lamotrigine for epilepsy?
oestrogen containing contraceptives e.g. COCP can reduce effectiveness of lamotrigine and therefore increase risk of seizures, progestogen only contraceptives can be used without restriction
For which drugs used in epilepsy should patient be kept on a specific manufacturer’s product?
carbamazepine
phenytoin
phenobarbital
primidone
Features of antiepileptic hypersensitivity syndrome?
fever
rash
lymphadenopathy
liver, haematological, renal and pulmonary abnormalities, vasculitis, multi organ failure
During pregnancy, women on which anti epileptic drugs should have fetal growth monitored?
topiramate
levitiracetam (keppra)
1st line tx monotherapy for focal seizures?
carbamazepine or lamotrigine
gabapentin and pregabalin can be used as adjuncts
1st line tx for generalised tonic-clonic seziures?
sodium valproate
lamotrigine if valproate not suitable but may exacerbate myoclonic seizures
1st line tx for absence seziures?
ethosuximide or sodium valproate
lamotrigine is an alternative
1st line tx for myoclonic seziures?
sodium valproate
if unsuitable, topiramate or levetiracetam
Adjunctive treatment in atonic and tonic seizures?
lamotrigine added to sodium valproate
Dexamethasone loading dose if suspect metastatic spinal cord compression?
16mg
Drug tx for MS related fatigue?
amantadine (weak dopamine agonist), not licensed for fatigue in MS
also used in parkinsons disease
CI in epilepsy and hx of gastric ulceration
DVLA guidance on time off driving post stroke?
group 1-1 month
group 2-1 year
DVLA guidance re refraining from driving after a significant head injury?
6-12 months
NICE guidance on CT head for head injury in a person on anticoagulants?
if no other indications for a CT head but on anticoagulants then should have CT head within 8 hours of the injury, and a provisional written radiology report should be available within 1hour of the scan.
DVLA restrictions if 1st unprovoked seizure for a group 1 driver and high risk (20% or higher) of recurrence?
must not drive for 1 year
AND must notify DVLA
DVLA guidance if simple faint?
group 1-no restrictions
group 2-must inform the DVLA and must stop driving
3 most common comorbid conditions associated with restless legs syndrome?
- pregnancy-most commonly in 3rd trimester, drug tx not recommended
- iron deficiency
- stage 5 CKD
serum ferritin should be measured in all people with suspected RLS
Drugs that can precipitate or exacerbate sx of restless legs?
antidepressants antipsychotics lithium antiepileptics antihistamines beta blockers dopamine blockers e.g. metoclopramide
excessive intake of caffeine, alcohol or chocolate
Consideration of drug tx for restless legs?
if moderate or severe sx
1st line: non ergot derived dopamine agonists e.g. ropinirole, pramiprexole, rotigotine -can be given as transdermal patch if significant daytime sx
OR
pregabalin or gabapentin (off label)-preferred if hx of severe sleep disturbance, anxiety, RLS associated pain, hx of impulse control disorders
weak opioid e.g. codeine is an alternative part. if painful symptoms
Supplement that should be taken regularly for patients with PD?
Vitamin D
DVLA guidance for patients with PD?
must notify DVLA
may be able to drive as long as condition doesn’t impair driving, group 1 subject to medical reports and group 2 subject to medical reports and assessment
Dietary advice for improvement of motor sx in PD for pt on levodopa experiencing motor fluctuations?
protein redistribution diet-most protein eaten in final main meal of the day, on advice of dietician
Examples of parkinsons disease specific physiotherapy?
- The Alexander technique
- Treadmill training
Adjuvant treatments in PD?
- COMT inhibitors-given with levodopa to improve motor fluctuations
- amantadine-aid dyskinesia
- SC apomorphine (dopamine agonist)
- deep brain stimulation to subthalamic nucelus-pt must be fit, responsive to levodopa and not have any comorbid mental health conditions
Management of severe N+V in PD not associated with medication?
low dose domperidone
