Emergency management in chronic neurologic disease

Emergency Management in Emergency Management in Chronic Neurologic DiseaseChronic Neurologic Disease

Tipa Chakorn, M D . Faculty of M edicine, Siriraj

H ospital

Chronic neurologic disease

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Provoked factor

• Metabolic: hyper-hypoglycemia, hyponatremia, hypoxia• Drug withdrawal: AEDs, Sedative drugs (BZDs, Alcohol)• Drug intoxication: Aminophylline, TCA

• Unprovoked seizure• Clinical diagnosis– Partial seizure: simple partial seizure, complex partial

seizure– Generalized seizure: GTC, Tonic seizure, Clonic

seizure, Myotonic seizure, absence etc.

• Investigation: Imaging, EEG• Treatment

Common Errors in Diagnosis

• Failure to get a good detail history• Syncope, movement disorder, psychogenic• First identified epileptic seizure may not be

the first seizure• Seizure type: GTC, Complex partial seizure,

Absence

Investigation

• EEG: Less sensitive, more specific– Sleep deprivation: increase sensitivity– VDO monitored EEG: increase sensitivity

• Imaging: Recommended in late onset epilepsy– Partial seizure/localization related epilepsy– Normal imaging does not mean normal brain–MRI is better than CT

Consideration in the treatment of a first unprovoked seizure

• 1/3-1/2 of patient with seizures will present following a single seizure1

• 10 to 12% of the first unprovoked seizure will be status epilepticus2

• Recurrence rate after a first seizure is 27 to 52%3

1. National General Practice Study of Epilepsy. Lancet 1990;336:1267–12712. Guidelines for epidemiologic studies on epilepsy. Epilepsia 1993;34:592–596

3. Pediatrics 1990;85:1076–1085

Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures:

A randomised controlled trial

Lancet 2005; 365: 2007–13

Lancet 2005; 365: 2007–13

Risk of recurrence

• Age of onset• Duration of the initial seizure in children• Multiple seizures at first seizure presentation• Abnormal EEG• Being asleep during a first seizure in children• Seizures that occur at night in adults

Risk of treating

• Adverse side effects: idiosyncratic• Chronic toxicity: cognitive and behavioral

effects, bone loss, neuropathy• Teratogenicity effect• AED therapy implies chronic illness

Risk of not treating

• Treatment will reduce risk of recurrent seizure by 50%

• Serious injury from brief seizure: driving, riding, swimming, cooking

• Psychosocial impact: loss of driving privileges• Social stigmata

Seminars in neurology 2008

Anti-epileptic drugs

Anti-epileptic drug and seizure type

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ไม$ร�เร��อง ไม$เคยม�อาการเช$นน��มาก$อน 1. Emergency condition? (consciousness, A, B, C)

2. Seizure?

3. Investigation?

4. Treatment: AED? (IV or oral route)

Parenteral doses VS. oral doses

• New onset epilepsy with – Stroke with brain edema– Brain tumor with edema– Acute infectious process: encephalitis, meningitis,

brain abscess

• Depend on type of seizure, comorbid medical• Unnecessary use of high dose: increases

adverse event

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ไม$ร�เร��อง เป+นโรคลมช�กอย$เด�ม ก�นยา Phenytoin 300 mg/day

เคย CT brain แล�วปกต�

1. Emergency condition? (consciousness, A, B, C)

2. Seizure?

3. Investigation?

• No provoked factor

• Phenytoin level 10.5 mg/dL

• Treatment: Increase dose VS. add second line drug

Serum concentration of AED

• Therapeutic range • Best seizure control and absence of adverse

events• Blood level of highly bound to albumin AEDs:

Phenytoin

Hypoalbuminemia Increased free fraction

C adj = Creported /(0.2 x serum albumin) + 0.1

If the first AED fails

• Due to lack of tolerability:

• If the first AED is totally ineffective:

• If the first AED is incompletely effective

substitution monotherapy

Replace AED

Adjunctive therapy

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• Diagnosis: Partial seizureEpilepsia partialis continua

• Investigation: Blood sugar etc.• Imaging• Treatment

Childbearing Potential and Pregnancy Patient

• Valproate: alter endogenous steroid– Associated with higher risk of polycystic ovaries– Does not interfere with oral contraceptives– Highest risk of malformation

• Topiramate/oxcarbazepine reduce oral contraceptive efficacy

• Lamotrigine: not associated with overall birth defect

Movement Disorder

Movement disorder

• Hypokinetic movement– Parkinson’s disease– Parkinsonism

• Hyperkinetic movement– Tremor– Chorea– Dyskinesia– Dystonia

Abnormal movementEXCESS MOVEMENT

No

Bradykinesia

Cognitive, language, upper motor neuron, or sensory signs

Only cogwheel rigidity or rest tremor

Rhythmical

Yes

YesNo

Slow or sustained

Rapid

Athetosis or dystonia

Tremor

PosturalParkinsonism

RestIntention

Controllable UncontrollableMetabolic, essential or enhanced physiologic

Cerebellar or brainstem Tic

Distal Proximal Multifocal

Chorea Ballismus Myoclonus

Degenerative disease with parkinsonism

Parkinsonism

• Bradykinesia• Tremor• Cogwheel rigidity• Postural instability

Idiopathic Parkinson’s disease

• Age > 55 years• Unilateral disease• Involve upper part > lower part• Response to Dopamine treatment• Normal cognitive function

Parkinsonism

• Drug-induced (Neuroleptics drug, antiemetics)

• Toxic-induced (CO, Mn)• Vascular parkinsonism• Normal pressure hydrocephalus• Wilson’s disease

• Review history of drug and toxin exposure• Family history• Neuroimaging: post stroke, NPH, etc• Slit lamp examination• Laboratory: – LFT, serum ceruloplasmin, 24 hr urine copper

excretion (Wilson’s disease)– Serum calcium, phosphorus, parathyroid (for bilateral

basal ganglia calcification)– Lumbar puncture (in selected cases eg. Suspect

chronic infection, NPH)

Imbalance primarily between the excitatory neurotransmitter and inhibitory neurotransmitter in the Basal Ganglia

AChDA

Wearing off

• Stiffness• Full consciousness: awake• Relate with L-dopa treatment

Delayed on

Peak dosed dyskinesia


No

Bradykinesia



Rhythmical

Yes

YesNo

Slow or sustained

Rapid


Tremor


RestIntention






Hyperkinetic movement

• Tremor– Resting tremor– Postural tremor– Action tremor

• Physiologic tremor• Essential tremor• Drug-induced tremor: TCA, Lithium etc.• Metabolic disorder: thyrotoxicosis,

hypoglycemia, pheochromocytoma


No

Bradykinesia



Rhythmical

Yes

YesNo

Slow or sustained

Rapid


Tremor


RestIntention






Dystonia

• Abnormal posture of one or more portion of the body

• Stereotyped

• Dopaminergic drugs• Anticholinergic drug• Benzodiazepine• Baclofen• Anticonvulsant• Botulinum toxin


No

Bradykinesia



Rhythmical

Yes

YesNo

Slow or sustained

Rapid


Tremor


RestIntention






Chorea

• Nonstereotyped, free flowing movement• Random in space

Tardive dyskinesia

• Mixed dystonia & chorea• Abnormal movement devolop in some

patients receiving long term treatment with DA blocking agent

• Most frequently: Orobuccolingual dyskinesia

VDO clip

• Trihexyphenidyl• Clonazepam• Baclofen• Reserpine• Botulinum toxin

EXCESS MOVEMENT

No

Bradykinesia



Rhythmical

Yes

YesNo

Slow or sustained

Rapid


Tremor


RestIntention






Thank you

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Emergency management in chronic neurologic disease