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Neurological Problems Flashcards

1
Q

1st line pharmacological treatment for muscle cramps in patient with motor neurone disease?

A

quinine
(2nd line is baclofen)
(other options-tizanidine, gabapentin, dantrolene)

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2
Q

Pharmacological treatments for muscle stiffness/spasticity/hypertonia associated with motor neurone disease?

A

baclofen, tizanidine, gabapentin, dantrolene

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3
Q

1st line pharmacological tx for excessive salivation in pt with motor neurone disease and cognitive impairment?

A

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

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4
Q

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?

A

SPECT-single photon emission CT

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5
Q

Only licensed drug treatment in UK for MND?

A

Riluzole-started at 50mg BD
this is a disease modifying drug and acts to inhibit the release of glutamate
only licensed for ALS

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6
Q

Blood test monitoring for Riluzole?

A

Monthly FBC and LFTs in first 3 months, then every 3 months for further 9 months, then annually

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7
Q

Which are the only treatments to improve prognosis in MND?

A

Riluzole and NIV

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8
Q

DVLA guidance for drivers of cars who have had a first unprovoked epileptic seizure or a single isolated seizure?

A

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

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9
Q

How long must patients with established epilepsy be seizure free for to continue driving a car?

A 
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

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10
Q

How long must patients who drive cars not drive for if had a seizure while asleep?

A

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

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11
Q

DVLA guidance for drivers with epilepsy with regards to medication changes or withdrawal?

A

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

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12
Q

Lamotrigine is 2nd line tx for generalised tonic-clonic seizures, but what type of seizures might it exacerbate?

A

myoclonic

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13
Q

What type of seizures is ethosuximide a 1st line tx option for?

A

absence seizures (type of generalised)

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14
Q

Which drug has a specific role in treating epilepsy associated with menstruation?

A

Acetazolamide (carbonic anhydrase inhibitor)

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15
Q

Which is the most common atypical parkinsonian syndrome?

A

PSP-progressive supranuclear palsy

*vertical gaze palsy (downward), frequent falls especially backward, subtle personality changes

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16
Q

3 commonest presentations of multisystem atrophy (MSA)?

A
  • urogenital dysfunction-ED, incontinence
  • postural hypotension
  • ataxia
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17
Q

Non-motor sx associated with essential tremor?

A

cognitive decline

mental health problems

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18
Q

Pharmacological tx of essential tremor?

A

if functional disability can treat with a beta blocker (propranolol, atenolol)
or primidone

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19
Q

Why should a throat swab be considered with abrupt onset tics in a child or adolescent patient?

A

to check for streptococcus-look for PANDAS-paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections

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20
Q

Most helpful intervention for mild tics?

A

habit reversal training

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21
Q

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?

A

dopamine agonists
MAO-B inhibitors
COMT inhibitors

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22
Q

Examples of non-ergot derived dopamine agonists?

A

ropinirole
rotigotine
pramipexole

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23
Q

Examples of ergot derived dopamine agonists?

A

bromocriptine
cabergoline
pergolide

*rarely used now due to risk of fibrotic reactions

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24
Q

Examples of MAO-B inhibtors?

A

Rasagiline

Selegiline

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25
Examples of COMT inhibitors?
Entacapone Opicapone Tolcapone
26
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
27
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
28
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**
29
1st line pharmacological tx of postural hypotension in patients with PD?
midodrine
30
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
31
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
32
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
33
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
34
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
35
Minimum duration recommended for keeping a headache diary in evaluation of a primary headache?
8 weeks
36
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
37
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
38
Which Abx can lower seizure threshold in epilepsy?
quinolones-ciprofloxacin, levofloxacin
39
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
40
Time off driving a car if multiple TIAs over short time period?
3 months | must inform the DVLA
41
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
42
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
43
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
44
Most common type of cerebral palsy?
spastic diplegia
45
Most severe form of cerebral palsy, often associated with generalised tonic-clonic seziures?
spastic quadriplegia
46
When can AEDs be considered to start to be withdrawn?
if seizure free for at least 2 years
47
Most common cause of epilepsy related death in young adults with uncontrolled epilepsy?
SUDEP-sudden unexpected death in epilepsy significant RF=nocturnal seizures
48
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
49
Baseline tests arranged by GP for adults with suspected epilepsy?
- ECG | - Bloods-FBC, U+Es, LFTs, glucose and calcium
50
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
51
Anti epileptic drugs which increase risk of osteoporosis?
``` sodium valproate carbamazepine phenobarbitol phenytoin primidone ```
52
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
53
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
54
For which drugs used in epilepsy should patient be kept on a specific manufacturer's product?
carbamazepine phenytoin phenobarbital primidone
55
Features of antiepileptic hypersensitivity syndrome?
fever rash lymphadenopathy liver, haematological, renal and pulmonary abnormalities, vasculitis, multi organ failure
56
During pregnancy, women on which anti epileptic drugs should have fetal growth monitored?
topiramate | levitiracetam (keppra)
57
1st line tx monotherapy for focal seizures?
carbamazepine or lamotrigine gabapentin and pregabalin can be used as adjuncts
58
1st line tx for generalised tonic-clonic seziures?
sodium valproate | lamotrigine if valproate not suitable but may exacerbate myoclonic seizures
59
1st line tx for absence seziures?
ethosuximide or sodium valproate | lamotrigine is an alternative
60
1st line tx for myoclonic seziures?
sodium valproate | if unsuitable, topiramate or levetiracetam
61
Adjunctive treatment in atonic and tonic seizures?
lamotrigine added to sodium valproate
62
Dexamethasone loading dose if suspect metastatic spinal cord compression?
16mg
63
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
64
DVLA guidance on time off driving post stroke?
group 1-1 month | group 2-1 year
65
DVLA guidance re refraining from driving after a significant head injury?
6-12 months
66
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.
67
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
68
DVLA guidance if simple faint?
group 1-no restrictions | group 2-must inform the DVLA and must stop driving
69
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
70
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
71
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
72
Supplement that should be taken regularly for patients with PD?
Vitamin D
73
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
74
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
75
Examples of parkinsons disease specific physiotherapy?
- The Alexander technique | - Treadmill training
76
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
77
Management of severe N+V in PD not associated with medication?
low dose domperidone

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