Neurology update: Fast forward(for physicians)

Dr Bipin Bhimani DM ( Neuro) Well Care Hospital Rajkot

• Newer entities• Newer investigations • Newer drugs

Case

• 30 yr old lady

• h/o bilateral optic neuritis

• Now develops paraplegia, vomiting ,hiccough

• Neuro Myelitis Optica ( NMO)

Neuro Myelitis Optica

• Devic’s disease

• More in Asians & Africans

• Bilateral Optic neuritis• Long segment myelitis ( 3 or more vertebral

segments) • Relapsing course

• Aquaporin antibody (NMO antibody)

( ~70% sensitivity ;~90% specificity)

• Acute attack: Methyl prednisolone/Plex

• Long term ( indefinate) immunosupression: Rituximab/azathioprine/MM

• Prognosis: Not that good

Case

• 25 yr old patient

• Headache , more in evening , more in sitting/standing ,orthostatic vomiting

• Better in supine position

• MR : crowding at post fossa ,decent of cerebellar tonsils, decerase in pp and pc cisterns size

• Decrease in size of ventricles

• Diffuse pachymeningeal enhancement

• Spontaneous Intracranial hypotension

• Spontaneous spinal CSF leaks leading to low pressure

• POSTURAL headache + typical MR features

Treatment of SIH

• Bed rest, fluids and caffeine• Epidural autologus blood patches • Surgical repair

NMDA Encephalitis

• Psychosis, seizure, perioral dyskinesia, autonomic dysfunction, hypoventilation

• More common girls• Ovarian teratoma

• Anti NMDAR Ab

• Immunomodulation ( Plex/IVIg)

VGKC encephalitis

• Encephalopathy,seizure

• Bilateral Hippocampal abnormality on MR

• Anti-VGKC antibody

• Steroids, IVIG

Case

• 50 yr old lady

• Insomnia due to creepy-crawling sensation in legs esp both calf muscles

• Better with moving around in room

• Restless leg syndrome

RLS

• Restless Leg syndrome ( urge to move)• Most common movement disorder• Most commonly undiagnosed • Unpleasant, creepy-crawling sensation in legs• Later part of day , especially just before sleep• Better with leg movement• Anaemia,renal failure,pregnancy,drugs • Ix: Hb,Creatinine,Ferritin

• Pramipexole 0.125-0.25 mg in evening

• Pregabalin/Gabapentin• Opioids• Clonazepam

Case

• A patient with depression and migraine

• On Venlaflexine , Valproate and SOS Sumatriptan

• Develops fever, tremor, agitation , shivering and clonus

• Serotonin syndrome ( overdose/interaction of drugs acting on serotonin)

Serotonin Syndrome

• Abrupt onset in hours

• Fever, autonomic dysfunction ,altered mentation

• Agitated • Shivering, tremor, Hyperreflexia, clonus ,

myoclonus

• History/Clinical diagnosis

• Close DD : Neuroleptic Malignant syndrome

( mute, rigid)

Offender drugs :

• Antidepressnts: SSRI,SNRI• Opioids: Tramadol,pentazocaine,fentanyl• Linezolid• Ondansentron • Triptans • Valproate , lithium

• Treatment: Cyproheptadine , Benzodiazepines

Case

• Post-partum 2nd day

• Headache, seizure, DOV, drowsiness

• BP: 160/100

• Normal pupils, no focal deficits

• Posterior Reversible Encephalopathy Syndrome ( PRES)

PRES

• Headache ,seizure ,visual changes, confusion • Majority – malignant or accelerated HT ,auto

immunity • Eclampsia ,AGN,SLE,porphyria,

Chemotherapy,renal failure,transplant ,Postpartum ,IVIg Rx, nasal decongestants

PRES : MR features

• White matter vasogenic edema, predominently affecting posterior –occipital and parietal lobes

• Relatively symmetrical

• T2; Flair HI

PRES

• Common , but often overlooked

• Treatment : Removal of ppt factor ; control of HT

AnticonvulsantsMannitol

• Prognosis: good

Multiple black holes???

1) Multiple neurocysticercosis

2) Fat embolism

3) Diffuse axonal injury

4) Micro bleeds

• Cerebral microbleeds

Cerebral Microbleed

• Counterpart of lacunar infarcts

• HT, amyloid angiopathy

• Diagnosed by MR (SW/GRE) imaging

• Avoid unnecessary use of double/triple antiplatelets

Case

• 68 yrs old gentleman

• Had cortical infarct ,aspiration pneumonia • Was given Levofloxacin, Cefipime

• Becomes stuporous , eyelid & finger twitching, • MRI/CSF/Metabolic parameters - normal

EEG

• Non Convulsive Status Epilepticus (due to Levofloxacin/ Cefipime neurotoxicity )

NCSE

• Level of sensorium is not explained by imaging/CSF/Chemistry and drugs

• Subtle eyelid flickering and finger twithching • Offenders: Ciprofloxacin group, Cefipime

,Tiagabine

• Bed side EEG • Midazolam makes patient alert!!

Case

• A young lady• 30 yrs old• Found out unconscious in bath room• Suspicious tongue bite ( at tip)• Slowly recovered with slowness of gait and

cognitive problems in earlier stage

• No past history of any significance

• Gas geyser encephalopathy

Gas Geyser Encephalopathy

• Various toxic gases ( CO,NO,HC) • Winter season• Small bathroom• Ill ventilated/ closed windows• Poor manufacturing ( substanderd brand)• Female • Tandem bathing pattern

• Newer investigations

Imaging

• 3.0 Tesla MR

• SW imaging for blood

Antibodies

• Aquaporin antibody ( NMO)

• Anti-MuSK for AChRAb negative MG

• NMDAR antibody• VGKC antibody• GAD antibody• TPO antibody

• Continuous EEG monitoring in Neuro ICU

• Newer theraputic weapons

• Unquestionably established( level A, class 1)

• Restrictions lightenedAgeMild stroke Wake-up stroke ( MR Dw/P mismatch)Don’t wait for blood investigationsPregnancy • Door to needle time shortened / telemedicine

• Not offering tPA can have medicolegal problems

IV tPA

Dabigatran • Newer anticoagulant In pt with NVAF ; to prevent stroke

• Advantages: better Pkinetics than Warfarin ; as efficacious /superior ; no monitoring ; less ICH

• Disadvantages : cost ( > warfarin+monitoring)

More GI bleed ; general bleed Dyspepsia

Renal dysfunction ( CrCl < 30 mL/min) how to reverse ( antidote)?? Twice daily

Don’t miss paroxysmal AF

• Atrial tachyarrythmia must be considered as a new source of embolism in patient with cryptogenic stroke (~ 30%)

• Order Holter or such other monitoring

• Anti platelet agents ---- Anticoagulants

Problems with Anti epileptic drugs • Narrow Spectrum • Oral or parentral• Not effective from first day ( long titration)• Serious side effects• Enzyme inducer or inhibitor, interactions ;auto induction• Hormonal /bone side effects• No Linear kinetics, no good bioavailavility, protein binding • Not Liver / renal friendly • Not children, women( OCP,pregnancy), elderly friendly • Few Useful in SE• Contraindicated in various comorbidities • Requires CBC/SGPT monitoring • Paradoxical aggravation of seizures

Levetiracetam like newer AEDs

• No titration required, ~ 100% bioavailable orally• Faster onset of action ( 1 hr)• Rare SJ syndrome • broad spectrum• Easily available• Parentral, useful in SE • No drug interactions• No bone/hormonal side effects• OCP/Pregnancy • elderly /kids • Cognition –maintained• No blood monitoring

• Cost of newer AEDs ( reduced now)

Neuroprotectives like Citicholine

• Saga ends

Divalos,A.et al.Citicoline in the treatment of acute ischaemic stroke:an international, randomised, multicentre, placebo-controlled study (ICTUS trial). Lancet 380, 349-357 (2012).

• ( a large study with negative results)

Monoclonal antibodies

• Natalizumab ---MS

• Rituximab—NMO

Stem cells & Neurolgical disorders

• Will you marry me?

• Much hopeful, but yet in experimental stage

Thank you