Central Nervous System

Acute Inflammatory Demyelinating Neuropathy/Guillain-Barre Syndrome (GBS)

• Hospitalization is necessary for even mild cases for observation of progression of neurological deficit.
• General care includes: care of back, bowel and bladder, pressure points.
• Physiotherapy should be instituted early.
• Ventilatory support in impending respiratory failure

Pharmacological

Mild cases: No specific therapy is needed (corticosteroids have no role)
Severe cases: As indicated by progressive weakness, involvement of respiratory muscles, swallowing difficulty.
Inj. Human immunoglobulins 400 mg/kg day for 5 days.
(Contraindicated in patients with IgA deficiency).
Or
Plasmapheresis 40-50 ml/kg/exchange for a total of 4-5 exchanges over 7-10 days to a total of 250 ml/kg.
If facilities are available

• All patients to be closely monitored for (a) progression of motor weakness, (b) involvement of respiratory muscles, (c) autonomic disturbance e.g. retention of urine, hypo/hypertension.
• Catheterization and management of blood pressure changes may be undertaken if required.

Patient education

• Explain the natural course of the disease. It can progress to involve all the four limbs, respiration and swallowing.
• Disability can be reduced with treatment and most patients achieve complete or nearly complete recovery.
• Prognosis is bad in old age, rapidly progressive weakness and previous history of diarrhoea.
• Role of physiotherapy to be stressed.
• Provide psychological support.

References

Neurology in Clinical Practice. Walter G. Bradley; Robert B. Daroff; Gerald M. Fenichel; C. David Mardson (eds), 3rd Edition.

Stroke

• All patients with acute stroke should undergo CT brain scanning as soon as possible preferably within 48 hours and not later than 7 days.
• A swallowing assessment should be undertaken at home or hospital.
• Urgent neurosurgical assessment should be available for patients with large cerebellar infarcts or hydrocephalus, and for selected cases of cerebral haemorrhage.
• Identify and treat the underlying cause.
• High blood pressure should normally be lowered in the acute phase of stroke as follows:

Blood pressure management in an Intensive Care Unit

Elevated blood pressure

The following algorithm for antihypertensive therapy in patients with acute stroke may be applied in the first few hours of intracranial haemorrhage

1. If systolic BP >230 mmHg or diastolic BP >140 mmHg on two readings 5 minutes apart, institute Nitroprusside 0.5-1.5 mcg/kg/min then increased in steps of 500 mg/kg/min every 5 minutes within a range of 0.5-0.8 mcg/kg/min. Stop, if response is unsatisfactorry with maximum dose in 10 minutes.
2. If systolic BP is 180-230 mmHg, diastolic BP is 105-140 mmHg, or mean arterial BP is >130 mmHg on two readings 20 minutes apart, institute intravenous Nitroprusside (0.5-1.5 mcg/kg/min).
3. If systolic BP is <180 mm Hg and diastolic BP is <105 mm Hg, defer antihypertensive therapy.

Low blood pressure
Volume replenishment is the first line of approach. Isotonic saline or colloids can be used and monitored with the central venous pressure or pulmonary artery wedge pressure. If hypotension persists after correction of volume deficit, continuous infusions of pressors (Dopamine 2-20 mcg/kg/min) should be considered, particularly for low systolic blood pressure, such as systolic BP<90 mmHg.

Cerebral Infarction
No therapy has yet been confirmed to limit the neuronal damage associated with acute cerebral infarction.

• Management of patients with acute ischaemic stroke using thrombolytic therapy carries the risk of catastrophic intracerebral haemorrhage.
• Rt-PA in cerebral infarction demonstrates significant improvement in functional outcome in carefully selected patients treated in specialist units within 3 hours of stroke onset. This should not yet be regarded as a routine therapy, particularly without specialist centres.
• No benefit has been demonstrated for heparin, corticosteroids, nimodipine or other calcium channel antagonists, barbiturates, streptokinase, plasma volume expanders or haemodilution techniques in mortality in patients with acute ischaemic attack.

Subarachnoid haemorrhage

Acute headache with vomiting and altered sensorium and CT scan shows blood in the cisterns and CSFs uniformly blood stained.

Treatment

Immediately transfer the patient to a tertiary care centre with a neurosurgery set up after securing patent airway and blood pressure.

Secondary prevention
Tab. Aspirin (325 mg once daily) should be prescribed as early as possible.
In patients with non-valvular atrial fibrillation and also after cardioembolic stroke from valvular heart disease and recent myocardial infarction.
Tab. Warfarin 5 to 7.5 mg/daily to keep patients (International Normalized Ratio between 2-2.5).

Patient education

• Control of risk factors such as hypertension, hyperlipidaemia and cessation of cigarette smoking.

References

1. The International Stroke Trial Collaborative Group. The International Stroke Trial (IST): A Randomised Trial of Aspirin, Subcutaneous Heparin, both, or neither among 19435 patients with Acute Ischaemic Stroke. Lancet 1997; 349: pp 1569-1581.
2. Primary and Secondary Prevention of Stroke. In: Clin Exp Hyperten, 1996;18: pp 537-546.
3. Pharmacological Elevation of Blood Pressure in Acute Stroke. Clinical Effects and Safety. Stroke 1997;28: pp 2133-2138.
4. CAST. Randomised Placebo-Controlled Trial of Early Aspirin Use in 20,000 Patients with Acute Ischaemic Stroke. CAST (Chinese Acute Stroke Trial). Lancet 1997;349: pp 1641-1649.

Tuberculous Meningitis

Salient features

TB meningitis should be staged depending on the clinical symptomatology (Table 1)

• Typically, the CSF is clear or slightly opalescent. There is a moderate degree of pleocytosis (usually less than 500 cells), with a predominant lymphocyte response. Biochemical examination reveals raised protein, usually below 200 mg%. But in late cases and particularly when a spinal block develops the protein content may be as high as 1 to 1.5 g%. Sugar is reduced to 40 mg% or below. Smear-positivity has been reported in less than 10% of samples.
• A diagnosis of tuberculous meningitis is often made if a consistent clinical syndrome is accompanied by a consistent CSF profile, evidence of tuberculosis elsewhere in the body or response to specific antimycobacterial therapy in the absence of evidence for other diagnosis.

1. Duration of therapy should be adjusted depending upon disease severity at diagnosis, treating stage I and II disease with INH, Rifampicin, and PZA for 9 to 12 months, stage III disease with all three drugs for 12 to 18 months, and tuberculomas with all three drugs for 18 to 24 months.
   (For details of therapy see tuberculosis in Chapter 1)
2. Corticosteroids are indicated in stage 2 or 3 disease or in case of the impending or established spinal block and are given for 3-6 weeks and tapered slowly over 2-4 weeks.
   Tab. Prednisolone 60 mg/day or 1 mg/kg day .
   Or
   Tab. Dexamethasone 8-16 mg/day in divided doses in adults.
   In children 8 mg/day or 0.3-0.6 mg/kg/day.

1. Adjunctive Corticosteroid Therapy for Tuberculosis: A Critical Reappraisal of the Literature. In: Clin Infect Dis., 1997;25: pp 872-887.
2. Tuberculosis. Part II. The Treatment of Tuberculosis. Dis Mon 1997;43: pp 247-276.
3. Tuberculosis. Part II. The Diagnosis of Tuberculosis. Dis Mon 1997;43: pp 185-246.

Encephalitis

1. Inj. Mannitol 20% 1 g/kg stat followed by 0.5 g/kg every 4-6 hours
   Or
   Sol Glycerol 30 ml 6 hourly orally
2. Start empirical treatment with Acyclovir in all cases at a very early stage or suspected of HSE pending confirmation of the diagnosis.
   (Role of steroids is controversial)
   Inj. Acyclovir 10 mg/kg 8 hourly for 10 days. The drug should be diluted to a concentration not exceeding 7 mg/ml and infused slowly over 60 minutes. (Can cause local phlebitis if extravasation occurs).
   If diagnosis of HSE is definite give treatment for 21 days to prevent relapse.
   However, in a stable patient without documented evidence of HSE including negative CSF-PCR and a normal MRI, acyclovir can be discontinued after 5 days of presumptive treatment.

Patient education

• Unlike most viral infections this is treatable and the drug used is quite safe.

References

Viral Meningitis and Encephalitis. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 2471-2481.

Bacterial Meningitis

• Hospitalize in a quiet place with no bright lights.
• Maintain the vitals, endotracheal intubation in patient with poor respiratory effort.
• Elevation of head to 30 degree.
• Hyperventilation.

1. Inj. Ceftriaxone 4 g/day in 2 doses administered every 12 hours. It can also be administered as a single dose.
   Or
   Inj. Cefotaxime 8-12 g/day, in divided doses administered every 4 hours.
   If age is more than 50 years to cover Listeria monocytogenes and Pseudomonas or in immunocompromised patients.
   Inj. Ceftazidime 8 g/day in divided doses administered every 6 hours plus
   Inj. Ampicillin 10-12 g/day in divided doses every 4 hours.
2. In case of head trauma, CSF rhinorrhoea, intracranial shunt or history of neurosurgical intervention. Also when highly penicilline or cephalosporin resistant strains of Streptococcus pneumoniae are suspected
   Inj. Vancomycin 500 mg IV 6 hourly.
3. In H. influenzae type-B meningitis, pneumococcal meningitis in children and in children over 2 month of age with neurological sequalae
   Inj. Dexamethasone 0.15 mg/kg every 6 hour IV for 2 days. It should be started at the same time or shortly before, the first dose of antibiotic.
   (see also meningoencephalitis in paediatric section)
4. In patient with papilloedema, altered sensorium, 6th nerve palsy, convulsions or decerbate posturing
   Inj. Mannitol 20% 1 g/kg stat followed by 0.5 g/kg every 4-6 hours.
   Continue treatment for 10-14 days with antibiotics. Clinical response is observed within 24-48 hours. Repeat lumbar puncture after 48 hours especially if on dexamethasone.

• Explain to the relative that in unconscious patient nothing should be administered orally until patient recovers his level of consciousness.

References

1. Bacterial Infections. In: Neurology In Clinical Practice. WG Bradley, RB Daroff, GM Fenichel et al (eds), 1996, Boston: Butterworth-Heinemann, pp 1181-1243.
2. Dexamethasone as Adjunctive Therapy in Bacterial Meningitis: A Meta-analysis of Randomized Clinical Trials Since 1988. In: JAMA 1997;278:pp 925-931.
3. Treatment of Bacterial Meningitis. N Engl J Med 1997;336: pp 708-716.
4. Acute Bacterial Meningitis in Adults. In: Current Clinical Topics in infectious diseases. Leemington JS anjd Swartz MN (eds), 1999, Blackwell Sciences, pp 215-239.

Neurocysticercosis

• Prolonged freezing or thorough cooking of pork to kill the parasite.
• Personal hygiene and thorough washing and avoiding unpeeled fruits and vegetables in areas endemic for T. solium helps prevent ingestion of eggs.
• All members of a family of an index case of cysticercosis should be examined for the presence of eggs or signs of disease.

References

1. Cestodiasis. In: Nelson Textbook of Paediatrics, 15th Edition, pp 993-995.
2. Therapy of Neurocysticercosis. In: Clin. Inf. Dis. 1993; 17: pp 730-735.
3. Medical Treatment of Neurocysticercosis. In: Arch. of Neurol. Vol. 324, 1995, pp 1137-1139.
4. Albendazole Versus Praziquantel in the treatment of Cerebral Cysticercosis. In: Transactions of Royal Soc. Of Trop. Med. & Hyg. Vol. 85, 1991, pp 244-247.
5. Dexamethasone with Albendazole. In: J. of Neurol., Vol. 237, 1990, pp 279-280.
6. Etiology and Management of Single Enhanced CT lesion. In: Act. Neurol. Scand. 1991; 84: pp 465-470.
7. Cestodes. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, Mc-Graw Hill Company Inc., New York, pp 1248-1252.

Migraine

1. Tab. Aspirin 650 mg stat; if required can be repeated after 4 hours.
   Or
   Tab. Ibuprofen 400-800 mg stat; if required can be repeated after 6 hours; maximum 3 times/day.
   Or
   Tab. Paracetamol 1000 mg stat; if required can be repeated after 4 hours.
   Or
   Tab. Indomethacin 50 mg stat; If required can be administered 3 times a day.
2. If associated nausea and vomiting Tab. Metoclopramide 10 mg stat.

In case of moderate to severe headache i.e., three severe headaches a month with significant impairment of functioning and marked nausea or vomiting.
Tab. Ergotamine 2 mg sublingual at onset and after half an hour (maximum 6/day, 10/week).
Or
Tab. Ergotamine (1 mg) + Caffeine (100 mg). 1/2 tab at onset, then 1 tab half hourly (maximum 6/day, 10/week).
Or
Tab. Ergotamine (2 mg) + Caffeine (100 mg) suppository; I suppository at onset (max 6/day, 10/week).
(A subnauseating dose should be determined preferably during headache free period).
Or
Tab. Sumatriptan 25 – 100 mg orally at onset.
Or
Inj. Sumatriptan 6 mg SC at onset (may repeat once in 24 hours)
(Contraindicated in ischaemic heart disease and hypertension).
Refer patient with severe migraine to hospital if attack is not controlled by above and if the patient is dehydrated. Also consider prophylactic medications.

Hospital management of acute migraine

1. Inj. Metoclopramide 10 mg IV.
2. Inj. Sumatriptan 6 mg SC (may repeat once in 24 hours).
   (CAUTION:Contraindicated in ischaemic heart disease and hypertension).
   Or
   Inj. Prochlorperazine 10 mg in 25-50 ml saline slow push over 2 minutes can be given twice or thrice a day.
   Or
   Inj. Chlorpromazine 7.5-20 mg in 25-50 ml saline slow push over 2 minutes can be given twice or thrice a day.
   (Monitor carefully for orthostatic hypotension. Administer IV diphenhydramine if acute dystonic reaction occurs).
3. In severe headache unresponsive to other drugs, Inj. Pethidine 50-100 mg IM as a single dose.

Prophylaxis

Consider prophylactic treatment if number of attacks is more than 3 per month or each attack is very severe necessitating loss of work time.

Treatment

In addition to the above nonpharmacological treatment and pharmacological treatment of the acute episode, consider
Tab. Atenolol 80-320 mg daily.
Or
Tab. Metoprolol 100-450 mg daily.
Or
Tab. Propranolol 80-320 mg daily.
Or
Tab. Amitriptyline 10-50 mg at bed time.
Or
Tab. Cyproheptadine 4-16 mg daily.
Continue treatment for 6-12 weeks before considering it ineffective. If found to be effective it should be continued for at least 6 months and then slowly tapered to assess its continued need. If headache recurs after discontinuation of prophylactic therapy, the medication regime should be reinstated for another 6 months trial.

Patient education

• Avoid precipitating factors like lack of sleep, glare, anxiety, hunger, foods like processed cheese, banana, chocolates, wine etc.
• Avoid overdose or frequent use of ergot preparation as these can cause hypertension and precipitate vascular disease.
• Drug for acute migraine should be taken as early as possible at the onset.

References

1. Headache Classification Committee of the International Headache Society. Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain. Cephalalgia 1988; 8 (Suppl 7): 1-96.
2. The Trigeminovascular System in Humans. In: Pathophysiologic Implications for Primary Headache Syndromes of the Neural Influences on the Cerebral Circulation. [Review]. J Cereb Blood Flow Metab 1999; 19: 115-127.
3. Headache, including Migraine and Cluster Headache. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 70-79.