Neurology Flashcards
Type of seizure most common in adults
Temporal lobe epilepsy
- virtually all are complex partial seizures (+/- secondary generalization)
Hx febrile seizures common
Partial part difficult to tx, 2ndary generalization usually responds to drugs
Psych behavioral disorders often coexist
Drugs that lower seizure threshold
Clomipramjbe Clozapine Loxapine Phenothiazine Bupropion Meperidine Inhaled anesthetics Theophylline at level >25 Cyclosporine Flumazenil Quinolones Beta lactams eg imipenem Dalfampridine
Type of seizure that often requires lifelong anticonvulsant therapy
Juvenile myoclonic
Mixed sz types myoclonic absence and/or GTC
Ppt by stress or sleep deprivation
Most refractory sz disorder
Lennox gestault
- heterogenous group of childhood epileptic encephalopathies
- start before age 4 usually
- result of brain malformations perinatal asphyxia , head injury, CNS infection
Another refractory syndrome
Infantile spasms (west syndrome) Attacks start before 6 months - from cerebral dysgenesis, hypoxic ischemic injury, intrauterine infections, or idiopathic
Causes of single seizures
Withdraw from CNS depressants
Acute illness - meningitis, abscess, encephalitis
Toxicity - uremia , lead, carbon monoxide
Drugs which Lower seizure threshold
Head trauma
Hypoxia
Fever
Metabolic - hyponatremia, hypoglycemia, dehydration
Medical procedures - ECT , brain surgery, organ tx, labor and delivery
Chronic seizure disorder causes
stroke or other vascular Mental retardation Neuro development or brain injury Neoplasms cerebral palsy Genetic predispo Head trauma
Genetically caused sz
Childhood absence,
juvenile myoclonic
Mechanism:
- mutation in ion channel function
- mutations affecting CNS development
- block neuronal apoptosis
- nerve cell metabolism dysreg
Secure prognostic factors
Good prognosis : sz free x 2 or more years, successfully tx after first sz; normalized EEG
Poor prognosis: partial sz or multiple sz types in same pt, hx of status epilepticus, polypharmacy needed, traumatic brain lesion visible
Objective data for seizures
EEG - brain electrical activity- abnormalities either before or during sz may be diagnostic
CT- detect gross hemorrhaging fx or trauma, lesions
MRI - can detect smaller lesions vs CT
Aed most significantly associated with birth defects
Valproate
Phenytoin
Some case reports: Phenobarbital Cbz Felbamate All other aed have limited data - class C
Recommendations for pregnant and aed
Single drug at lowest effective dose
Oral contraceptives - may need high estrogen product due to drug intxns
Monitor aed levels due to pk changes eg altered protein biding
Ultrasound at 16-18 weeks to check for neuronal tube defects
Preconception tx with 0.4mg folic acid daily
Daily vitamin K during las 2-4 weeks of pregnancy for prevention of neonatal cerebral hemorrhaging and give vitamin k to newborn after deliv
Aed that can worsen psych
Ethosuximide
Levitiracetam
Benzos and barbiturates
Topiramate and barbiturates
Newly diagnosed epilepsy tx recommendations:
- standard AED: CBZ , PHT, VPA, Pb
- new AED: LTG, GBP, OXC, TOP
Adults w treatment refractory epilepsy:
GBP, TOP, LTG, OXC, LVT, ZON as add-on
New AED: OXC, TOP, LTG may be used as mono therapy in tx resistant partial epilepsy
LTG in tx refractory GTC sz
Percent of costs from epilepsy that are indirect
85% due to missed work by patients and caretakers of children/elderly pts w epilepsy
Clinical diagnosis of Parkinson’s disease
2 of 3 of following:
Tremor
Rigidity
Bradykinesia
Non motor sx of PD
Psych: depression anxiety dementia hallucinations apathy
Sleep - rls
Autonomic
Speech
Sensory
Other - weight loss seborrheic dermatitis sexual dysfxn GI impaired motility
Hoehn and yahr scale
Parkinson’s dz
Stage I unilateral involvement only and minimal or no functional impairment
Stage II: bilateral involvement without impairment of balance
Stage III: postural imbalance, some reduction in activities, capable I leading independent life, mild-moderate disability
Stage IV: severely disabled must walk with assurance , marked incapacitation
Stage V: restricted to bed or wheelchair unless aided
How much daily carbidopa needed to block peripheral conversion of levodopa
75-200 mg/day
So initial carbidopa/levodopa dose is 25/100mg tid or 10/100mg qid
Titrate q 3 days PRN
If no response to 1000 mg lwop dis reconsider PD dx
Clinical use of anticholinergics in Parkinson’s -
Trihexiphenidyl and benztropine
Best in stage 1 and 2 of disease - for tremor
(With levodopa)
Inhibit muscarinic cholinergic receptors in striatum
Benztropine initial dose: 0.5-1mg qhs up to daily dose of 4-6 mg/day
Trihexyphenidyl 1-2 mg first day increase by 2mg increments q 3-5 days to 6-10 mg/day
Drugs to treat PD related psychosis
Clozapine start at 6.25mg qday and titrate slowly
Quetiapine start at 12.5 mg qday
Risperidone and olanzapine effective but reports of worsening PD
Migraine criteria for dx
At Least 5 attacks
Lasting at least 4-72 hrs (untreated or unsuccessfully treated)
2 of the following characteristics:
- unilateral location
- pulsating
- moderate or severe pain intensity
- aggravated by physical activity
Migraine with aura
Attack last 4-72 hrs untreated or unsuccessfully treated
Aura - meets criteria for one of the subforms associated with aura
Migraine scales
Migraine disability assessment questionnaire
(MIDAS)
- scores 0-21 with higher score indicating greater disability
- self rated - headache related disability
- both clin and research
Monitoring
Pain disability index (PDI)
Measures *pain * related disability
Monitoring for all pain(not just ha)
Scores 0-70 higher score more pain disability
Indications for prophylactic migraine therapy
2 or more attacks per month that produce 3 or more days per month disability
- failure of abortive tx
- abortive medication use >2x/week
- presence of uncommon migraine including hemiplegic , w prolonged aura, or migraine infarction
- after benefit: consider taper after 6-12 months of good headache control
Amount of time to get benefit from prophylactic migraine therapy
2-3 months
Take abortive medications when?
Onset of headache pain (not aura)
Pregnancy and headache meds
Ergot derivatives - category X !!
- due to uterine vasoconstriction causing fetal growth retardation
Triptans - category C - limited data in humans, some decreased fetal weight in animal studies
- hold prophy therapies during pg and breast feeding
- use prochlorperazine for nausea
Tension headache dx (contrast with migraine)
Bilateral (migraine=unilateral) Pressing tightening (non pulsating) Mild-moderate intensity Not aggravated by routine physical activity
Both:
Not n/v (may be anorexia)
Possibly photo or phono phobia, not both
Tension headache pain assessment
Typical scales analog for pain
Prophy for tension headaches
Amitriptyline - doc 50-100mg SSRI (fluox, sert) * diff from migraine Botox A * diff from migraine Propranolol Bzd
Dx criteria for cluster headache
At least 5 attacks fulfilling criteria
- severe or very severe
Unilateral orbital, supraorbital or temporal area lasting 15-180 min if untreated
- has to have ipsilateral facial sx or restlessness
- frequency from 1 q other day to 8/day
Abortive tx of cluster headache
100% oxygen 8-10 L/min for 20 min
May be given several times per day
- sumatriptan 6mg SQ or Nasal
DHE = 2nd line abortive
Transitional tx for cluster ha
short term preventive tx while awaiting full effect of prophy:
- prednisone 60-80mg per day for 3 days then taper over 14 days
DHE: daily IM injections for 1 week or 3 day IV infusion
Naratriptan 2.5mg bid
Prophylactic therapy of cluster headache
Use abortive and transitional treatment while awaiting effect
- use ONLY while pt in a cluster cycle, continuous use may not prevent cluster cycles
Verapamil 120-480mg daily
Lithium 600-1500 mg/day (levels 0.3-0.8 mmol/L) - about as effective as verapamil but not as well tolerated)
Valproic 600-2000mg/day
Melatonin may reduce doses needed for other
Topiramate 50-400 mg/day
United huntingtons disease rating scale (UHDRS)
Scores range from 0-128 with higher scores meaning higher motor impairment
Huntingtons tx
Tetrabenazine - see card
- response in 3 weeks then full in 6 weeks
Other
Olanzapine - some evidence
Risperidone - case studies effective for motor and psych effectiveness
Clozapine - best evidence but high doses most effective but still tolerability problems
Glasgow coma scale
Use in tbi
Score 14-15 more mild brain injury - full recover but may have short term memory problems and concentration difficulties
9-13 moderate - pt lethargic and stupendous
3-8 severe injury pt comatose, cannot follow commands
Dx criteria for fibromyalgia acr
Widespread pain index
Symptom severity based on fatigue and waking unrefreshed
* WPI 7 and SS of 5 or WPI 3-6 and SS 9 dx fibro
Hoehn and yahr pd scale
Stage I unilateral invovment no or minimal fxn impair
Stage II bilateral involvement but balance ok
Stage III evidence of postural imbalance some reduction activity but still independent life, mild-moderate disability
Stage IV severely disabled unable to stand and walk unassisted marked incapacitation
Stage V restricted to bed or wheelchair unless stated
Beta blockers for migraine Px
Propranolol
Timolol
Options for transitional tx of cluster headache
Prednisone 60-80mg qday x 3 days then taper over 14
DHE daily IM injectors for 1 week or 3 day IV infusion
Naratriptan 2.5mg bid
Prophylactic therapy options
Verapamil
lithium 600-1500 mg/day levels 0.3-0.8 mmol/L
About as effective as verapamil but not as well tolerated
VPA
Melatonin
Topiramate
Fastest acting triptan
Rizatriptan
Longest acting triptan but slowest onset
Frovatriptan
Prophy use
Natatriptan - has longer t1/2 but minimal recurrence slower onset (not as long acting as Frovatriptan though
Lipophilic drug with rapid oral absorption and ODT form
Zolmitriptan
Duration of Px for cluster headache
2 months of cluster cycle
Fibromyalgia scale WPI widespread pain index
Based on number of regions that pt experiences pain (0-19)
Fibromyalgia dx:
WPI of 7 and SS of 5
Or
WPI of 3-6 and SS of 9
SS symptom severity score for fibromyalgia
Presence and severity of fatigue
Waking from sleep unrefreshed
Cognitive symptoms (0-12)
Sign and sx of fibromyalgia
Widespread musculoskeletal pain
Non restorative sleep and daytime fatigue
Psychological fog- depress/anxiety
Localized tenderness in 11 or more of 18 specified tender points
No apparent organic disease
Rating scales ( different than diagnostic SS and WPI)
Fibro fatigue scale- clinician Fibromyalgia impact questionnaire - self rated
Milnacipram dose
Start 12.5 mg once Day two bid Day 4-7 25mg bid After day 7 50mg bid Can increase to 100mg bid based on response
Comparing alpha 2 agonist and SGA in tx of tics in Tourette’s
One study shows clonidine = risperidone
