Neurology

Typically, epilepsy patients have brain imaging at the time of diagnosis to investigate for a structural cause for seizures. Seizures in these patients are unlikely a result of new structural changes. Neuroimaging in can be considered in patients with longstanding epilepsy without prior imaging studies, or in patients who are candidates for neurosurgery with seizures refractory to medical management.

Sources:

Cendes F, et al. Neuroimaging of epilepsy. Handbook of Clinical Neurology. 2016;136:985-1014. PMID: 27430454.

Commission on Neuroimaging of the International League Against Epilepsy. Recommendations for neuroimaging of patients with epilepsy. Epilepsia. 1997 Nov;38(11):1255-6. PMID: 9579930.

Epilepsy Implementation Task Force. Provincial Guidelines for the Management of Epilepsy in Adults and Children. Critical Care Services Ontario. January 2015. [Internet].

Harden CL, et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Oct 30;69(18):1772-80. PMID: 17967993.

Lapalme-Remis S, and Cascino GD. Imaging for Adults with Seizures and Epilepsy. Continuum (Minneap Minn). 2016 Oct;22(5, Neuroimaging):1451-1479. PMID: 27740984.

Valproic acid is teratogenic for a developing fetus and should be avoided. Valproic acid increases the risk of diminished IQ as well as major congenital malformations including neural tube defects and cardiovascular abnormalities for a developing fetus. If valproic acid treatment is deemed necessary, patients should be counselled regarding contraception and the risks of conception. In this case, the lowest effective dose should be used.

Sources:

Bansal R, et al. Maternal and neonatal complications during pregnancy in women with epilepsy. International Journal of Epilepsy. 2016 July;3(2):80-85.

Campbell E, et al. Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers. J Neurol Neurosurg Psychiatry. 2014 Sep;85(9):1029-34. PMID: 24444855.

Hernández-Díaz S, et al for the North American AED Pregnancy Registry. Comparative safety of antiepileptic drugs during pregnancy. Neurology. 2012 May;78(21):1692-9. PMID: 22551726.

Voinescu PE and Pennell PB. Management of epilepsy during pregnancy. Expert Rev Neurother. 2015 Oct;15(10):1171-87. PMID: 26416395.

Opioids and cannabinoids have weak or inconclusive evidence in effective treatment of neuropathic pain. The well documented risks of opioid and cannabinoids include nausea, sleepiness, impairment, dependence, and development of substance use disorders. With impairment comes further risks to oneself and others in altered judgement in the workplace or while operating a vehicle. Opioids come with an additional risk of decreased respiratory drive and fatality with overdose. Neuropathic pain can be treated effectively using agents with demonstrated efficacy and significantly less risks compared to opioids and cannabinoids.

Sources:

Moulin DE, et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014 Nov-Dec;19(6):328-35. PMID: 25479151.

Finnerup NB, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73. PMID: 25575710.

Syncope, and pre-syncope with observed convulsions are very common and frequently investigated in the emergency department. Typical syncope with a normal examination requires minimal investigation. Neuroimaging and EEG will not help in determining the etiology or management of patients with typical syncope in the absence of focal neurologic symptoms or findings on examination.

Sources:

İdil H and Yilmaz K. Diagnostic yield of neuroimaging in syncope patients without high-risk symptoms indicating neurological syncope. Am J Emerg Med. 2018 May 16. pii: S0735-6757(18)30410-8. PMID: 29802003.

Sanatani S et al. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient. Can J Cardiol. Feb 2017;33(2):189-198. PMID: 27838109.

Shenk MER and Anilkumar A. Syncope in Children: Etiology, Positive and Negative Predictors, and Utilization and Utility of Diagnostic Testing. Neurology. Apr 2017;88(16):P3.204.

Head injuries in children and adults are common presentations to the emergency department. Minor head injury is characterized by: Glasgow Coma Scale (GCS) 13-15, associated with either witnessed loss of consciousness, definite amnesia, or witnessed disorientation. Most adults and children with minor head injuries do not suffer from serious brain injuries that require hospitalization or surgery. CT head scans performed on patients without signs of significant injuries can expose patients to unnecessary ionizing radiation that has the potential to increase patients’ lifetime risk of cancer. They also increase length of stay and misdiagnosis. There is strong evidence that physicians should not order CT head scans for patients with minor head injury unless validated clinical decision rules suggest otherwise (i.e., Canadian CT head rule for adults, and CATCH or PECARN rules for children). Despite their validity, these rules are never 100% sensitive and are meant to assist and not replace, clinical judgement.

Sources:

Easter JS, et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014; 64(2):145-52, 152.e1-5. PMID: 24635987.

Osmond MH, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182(4):341-8. PMID: 20142371.

Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357(9266):1391-6. PMID: 11356436.

Opioids are not adequate for pain control for patients with migraines. The risk for harm, including impairment, dependence, tolerance, medication overuse headaches, and opioid use disorder with opioids is greater than the documented benefit. Additionally, opioids may worsen nausea and vomiting associated with the migraine. Prescription opioids for migraines would have minimal to no benefit with the excess of risk, and contribute to the opioid crisis.

Sources:

Tepper S & Spears RC. Acute treatment of migraine. Neurologic Clinics. 2009 May;27(2):417-27. PMID: 19289223.

Worthington I, et al. Canadian Headache Society Guideline: Acute Drug Therapy for Migraine Headache. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques. Sept 2013;40(S3):S1-S3. PMID: 23968886.

Butalbital, butorphanol, and ergotamine are not adequate abortive or preventative treatments for patients who suffer with migraines. Butalbital and butorphanol are barbiturate containing medications which carry the risks of sedation, intoxication, dependence, abuse potential, severe withdrawal, and substance use disorders. The risk of medication overuse headache with these medications is also significant. These medications are only helpful in refractory cases of migraines as a last resort. There are more effective and less harmful first line agents available for prophylactic and abortive treatment of migraine headaches.

Sources:

Tepper S & Spears RC. Acute treatment of migraine. Neurologic Clinics. 2009 May;27(2):417-27. PMID: 19289223.

Worthington I, et al. Canadian Headache Society Guideline: Acute Drug Therapy for Migraine Headache. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques. Sept 2013;40(S3):S1-S3. PMID: 23968886.