Abstract
Not long ago, neurologists had hardly anything else to offer patients than a diagnosis and words of comfort. Indeed, the discrepancy between the elegance and precision of the clinical neurological diagnosis on one hand and the heartbreaking lack of any substantial therapeutic opportunities on the other was painfully clear to everyone. Fortunately, this situation has completely changed. Advances in our understanding of neurological disease due to modern neuroimaging, molecular neuroscience, and genetic testing, as well as more rigorous standards for the conduction of clinical trials, have translated into striking new therapeutic options. Apart from an ever-increasing drug arsenal, these include surgical therapies (e.g., deep brain stimulation for Parkinson’s disease and hemicraniectomy for middle cerebral artery stroke), intravenous thrombolysis and mechanical thrombectomy for ischemic stroke, and a variety of immunomodulatory biological agents. Although many neurological diseases remain incurable, nowadays practically no disorder is untreatable. This chapter provides an overview of available medical and selected nonmedical treatment options in neurological diseases. Due to space limitations, the information is restricted to indications and, where feasible, suggestions for drug dosages. The treatment of cerebrovascular disorders and epilepsy, however, is covered in greater detail since it usually constitutes the largest and most urgent part of the workload for neurology residents on call. Many neurological disorders may have implications for driving and medicolegal issues. Specific rehabilitation programs may improve motor or cognitive functions significantly and are important for improving quality of life and for preventing functional decline. Counseling and regular follow-up should be an integral part of neurological management. Although not covered by this book, the neurologist should therefore be aware of local regulations and programs for medicolegal issues, neurorehabilitation, counseling, as well as primary prevention of neurological disorders and palliative end-of-life care.
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- 1.
CPP equals MAP minus ICP.
- 2.
Minor variations across countries exist regarding approved indications (concerning the severity and range of specific dementia syndromes).
- 3.
For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizures (Silbergleit et al. 2012).
- 4.
Propofol infusion syndrome is a rare, but potentially fatal, complication of prolonged administration (≥48 h) of high doses of propofol (≥4 mg/kg/h). It leads to metabolic acidosis, hypertriglyceridemia, rhabdomyolysis, cardiac arrhythmias, and multiorgan failure.
References and Suggested Reading
Baker GA. Depression and suicide in adolescents with epilepsy. Neurology. 2006;66(Suppl):S5–12.
Baker WL, Colby JA, Tongbram V. Neurothrombectomy devices for the treatment of acute ischemic stroke: state of the evidence. Ann Intern Med. 2011;154:243–52.
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.
Boylan LS, Flint LA, Labovitz DL, et al. Depression but not seizure frequency predicts quality of life in treatment resistant epilepsy. Neurology. 2004;62:258–61.
Bråthen G, Ben-Menachem E, Brodtkorb E, et al. EFNS Task Force on Diagnosis and Treatment of Alcohol-Related Seizures. EFNS guideline on the diagnosis and management of alcohol-related seizures: report of an EFNS task force. Eur J Neurol. 2005;12:575–81.
Burns A, editor. Standards in dementia care. London: Taylor & Francis; 2005.
Calabresi PA, Radue EW, Goodin D, et al. Safety and efficacy of fingolimod in patients with relapsing-remitting multiple sclerosis (FREEDOMS II): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Neurol. 2014;13:545–56.
Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.
Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15:649–59.
Chernyshev OY, Martin-Schild S, Albright KC, et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology. 2010;74:1340–5.
Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993–1003.
Chollet F, Tardy J, Albucher JF, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol. 2011;10:123–30.
CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013;382:516–24.
CLOTS Trials Collaboration, Dennis M, Sandercock PA, et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 2009;373(9679):1958–65.
Compter A, van der Worp HB, Schonewille WJ, et al. Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial. Lancet Neurol. 2015;14:606–14.
Confavreux C, O’Connor P, Comi G, et al. Oral teriflunomide for patients with relapsing-remitting multiple sclerosis (TOWER): a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol. 2014;13:247–56.
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331–7.
Etninan N, Brown Jr RD, Breseoglo K, et al. The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus. Neurology. 2015;85:881–9.
European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, et al. ESC Committee for Practice Guidelines. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;12:1360–420.
Glauser T, Ben-Menachem E, Bourgeois B, et al. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia. 2013;54:551–63.
Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.
Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–60.
Hofmeijer J, Kappelle LJ, Algra A, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009;8:326–33.
Hort J, O’Brien JT, Gainotti G, et al. EFNS guidelines for the diagnosis and management of Alzheimer’s disease. Eur J Neurol. 2010;17:1236–48.
Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.
Jüttler E, Schwab S, Schmiedek P, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38:2518–25.
Jüttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;279:1091–100.
Kanner AM. Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms, and treatment. Biol Psychiatry. 2003;54:388–98.
Kondziella D, Cortsen M, Eskesen V, Hansen K, Holtmannspötter M, Højgaard J, Stavngaard T, Søndergaard H, Wagner A, Welling KL. Update on acute endovascular and surgical stroke treatment. Acta Neurol Scand. 2013;127:1–9.
Lansberg MG, Schrooten M, Bluhmki E, Thijs VN, Saver JL. Treatment time-specific number needed to treat estimates for tissue plasminogen activator therapy in acute stroke based on shifts over the entire range of the modified Rankin Scale. Stroke. 2009;40:2079–84.
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6:953–60.
Lip GY. Using the CHA2DS2-VASc score for stroke risk stratification in atrial fibrillation: a clinical perspective. Expert Rev Cardiovasc Ther. 2013;11:259–62.
Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–97.
Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383:614–21.
Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial. Lancet Neurol. 2008;7(6):500.
Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess one-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138:1093–100.
Pompili M, Girardi P, Tatarelli R. Death from suicide versus mortality from epilepsy in the epilepsies: a metaanalysis. Epilepsy Behav. 2006;9:641–8.
Powers WJ, Clarke WR, Grubb Jr RL, et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA. 2011;306:1983–92.
Rhea J, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–73.
Riedel CH, Zimmermann P, Jensen-Kondering U, et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke. Stroke. 2011;42:1775–7.
Samuels MA, Ropper AH. Samuels’s manual of neurologic therapeutics. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.
Sandset EC, Murray GD, Bath PM, et al. Scandinavian Candesartan Acute Stroke Trial (SCAST) Study Group. Relation between change in blood pressure in acute stroke and risk of early adverse events and poor outcome. Stroke. 2012;43:2108–14.
Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–95.
Schmidt R, Hofer E, Bouwman FH, et al. EFNS-ENS/EAN Guideline on concomitant use of cholinesterase inhibitors and memantine in moderate to severe Alzheimer’s disease. Eur J Neurol. 2015;22:889–98.
Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366:591–600.
Skoglund TS, Eriksson-Ritzén C, Sörbo A, et al. Health status and life satisfaction after decompressive craniectomy for malignant middle cerebral artery infarction. Acta Neurol Scand. 2008;117:305–10.
Sorbi S, Hort J, Erkinjuntti T, Fladby T, et al. EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol. 2012;19:1159–79.
Sorensen PS. Safety concerns and risk management of multiple sclerosis therapies. Acta Neurol Scand. 2016; doi:10.1111/ane.12712.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7.
Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007a;38:2506–17.
Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomized controlled trials. Lancet Neurol. 2007b;6:215–22.
Wang Y, Zhao X, Liu L, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–9.
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Kondziella, D., Waldemar, G. (2017). Treatment of Neurological Disorders. In: Neurology at the Bedside. Springer, Cham. https://doi.org/10.1007/978-3-319-55991-9_6
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