Neuro Emergencies

Question 1

Definition of Status Epilepticus

Answer 1

≥ 5 min clinical or electrographic seizure activity OR ≥2 seizures without recovery in between

Question 2

Options for abortive therapy in Status Epilepticus

Answer 2

Ø Lorazepam 0.1 mg/kg or 4 mg IV (max 2mg/min)
Ø Midazolam 10 mg IM/buccal/IN
Ø Diazepam 0.2mg/kg PR up to 20mg

Question 3

Options for maintenance therapy in Status Epilepticus

Answer 3

Ø Phenytoin 20 mg/kg IV, max 50 mg/min
Ø Fosphenytoin 20 mg PE/kg, max 150 mg PE/min
Ø Valproic acid 40 mg/kg, at 10 mg/kg/min
Ø Levetiracetam 60 mg/kg IV, max 4500 mg over 15 min

Question 4

Options for refractory therapy in Status Epilepticus

Answer 4

Ø ICU monitoring
Ø Midazolam 0.2 mg/kg IV at 2 mg/min
Ø Propofol 1-2 mg /kg, then up to 10-12 mg/kg/h
Ø Pentobarbital 5 mg/kg, then up to 5 mg/kg/h
Ø Aim for burst suppression for 24h before tapering

Question 5

Definition of Epilepsy

Answer 5

≥2 unprovoked seizures >24h apart 
OR
1 unprovoked seizure with >60% recurrence risk
OR 
Epilepsy syndrome

Question 6

Best therapy for absence seizures?

Answer 6

Ethosuximide

Valproate

Question 7

Which AEDS should be avoided in idiopathic generalized epilepsy?

Answer 7

Carbamazepine
Phenytoin
Eslicarbazepine

Question 8

Which AEDs can be used in pregnancy?

Answer 8

Levetiracetam

Lamotrigine

Question 9

Presentation of GBS

Answer 9

Sensory loss, ascending paralysis, and areflexia

RF: Antecedent infection (C. jejuni ~30%, influenza, HIV, Zika)

Question 10

Treatment of GBS

Answer 10

Intravenous immunoglobulin (IVIG) 2g / kg divided over 2-5 days OR Plasmapheresis (PLEX)

• no role for steroids!

Question 11

20-30-40 rule for intubation in GBS?

Answer 11

Elective intubation if:
FVC < 20mL/kg
MIP 0 to –30 cm H2O
MEP < 40 cm H2O

Question 12

30% of GBS patients have respiratory failure, what are the greatest predictors?

Answer 12

Onset to admission <7d 
FVC< 60% normal predicted
Presence of facial weakness
Inability to cough
Inability to lift the head
Inability to lift the arms 
Inability to stand

Question 13

20-30-40 rule for intubation in MG?

Answer 13

Elective intubation if:
FVC < 20 mL/kg
MIP 0 to –30 cm H2O
MEP < 40 cm H2O

Question 14

Acute treatment of MG crisis

Answer 14

Plasmapheresis (PLEX)
OR
Intravenous immunoglobulin (IVIG) 2g/kg over 2-5d

Hold pyridostigmine when intubated (manage airway secretions)

High-dose prednisone CAUTION!
<50% transient worsening of respiratory status in 5-10d

Question 15

What is the role for thymectomy in MG?

Answer 15

If thymoma (10-15% of cases)- Thymectomy 
If no thymoma, still remove thymus if:
Ø <60 years
Ø AChRAb+
Ø Disease duration <5y

Benefits pay off years down the road.

Question 16

What imaging/procedural studies are required to make the diagnosis of MS. ie other than bloodwork, what do you order?

Answer 16

Ø MRI brain and cervical- thoracic spine with gadolinium
Ø LP for oligoclonal bands
Ø Visual evoked potentials

Question 17

Treatment options for an acute MS flare

Answer 17

1.Methylprednisolone 1000 mg IV daily for 3-7 days ± taper
Alternative: PO steroid 1250 mg for 3-7 days ± taper appears equally effective
However: greater recurrence of ON in oral group.

2.Plasmapheresis If poor steroid response