From the Guidelines
The patient should be immediately evaluated in the emergency room for increased intracranial pressure, and management should focus on reducing intracranial pressure while maintaining adequate cerebral perfusion, as indicated by the guidelines from the American Heart Association/American Stroke Association 1. The patient's condition requires prompt attention due to the risk of brain damage from increased intracranial pressure. Key considerations in managing increased intracranial pressure include:
- Head positioning to facilitate venous drainage
- Avoidance of hypo-osmolar fluids
- Management of factors that exacerbate raised intracranial pressure, such as hypoxia, hypercarbia, and hyperthermia
- Potential use of osmotic agents or other treatments to reduce intracranial pressure, as guided by the patient's specific condition and the expertise of the neurologist from Mayo Clinic. The increase in Topamax dosage by Dr. Freedman suggests an attempt to manage symptoms pharmacologically, but the return to the ER indicates a need for more immediate and possibly more aggressive management of the patient's condition, considering the potential for brain edema and increased intracranial pressure as discussed in guidelines for the early management of patients with ischemic stroke 1.
From the FDA Drug Label
In pediatric patients (<16 years of age), the incidence of persistent treatment emergent decreases in serum bicarbonate in placebo-controlled trials for adjunctive treatment of Lennox-Gastaut syndrome or refractory partial onset seizures was 67% for topiramate (at approximately 6 mg/kg/day), and 10% for placebo. The incidence of a markedly abnormally low serum bicarbonate (i.e., absolute value <17 mEq/L and >5 mEq/L decrease from pretreatment) in these trials was 11% for topiramate and 0% for placebo. If metabolic acidosis develops and persists, consideration should be given to reducing the dose or discontinuing topiramate (using dose tapering) The patient's symptoms and history, along with the increase in Topamax dose by Dr. Freedman, may be related to metabolic acidosis or other adverse events associated with topiramate, such as cognitive-related dysfunction or psychiatric/behavioral disturbances. Given the patient's referral back to the ER, it is essential to closely monitor her condition and consider the potential risks associated with topiramate treatment 2.
From the Research
Patient's Condition and Treatment
- The patient visited the ER due to increased intracranial pressure and has a follow-up appointment with Dr. Freedman for evaluation.
- The patient is in communication with a neurologist from the Mayo Clinic.
- Dr. Freedman increased the patient's Topamax dosage due to her symptoms and history.
- The patient was referred back to the ER for further evaluation.
Topiramate as a Treatment for Idiopathic Intracranial Hypertension
- Studies have shown that topiramate can be effective in treating idiopathic intracranial hypertension (IIH) 3, 4, 5, 6, 7.
- Topiramate has been found to lower intracranial pressure by reducing cerebrospinal fluid (CSF) secretion and inhibiting carbonic anhydrase isoforms involved in CSF secretion 3, 6, 7.
- Compared to acetazolamide, topiramate has been shown to be more effective in lowering intracranial pressure in some studies 7.
- Topiramate may also have additional benefits, such as weight loss and improved migraine headache control, which can be beneficial for patients with IIH 4, 5.
Comparison with Acetazolamide
- Acetazolamide is commonly used as a first-line treatment for IIH, but topiramate may be considered as an alternative or additional treatment option 3, 4, 5, 6, 7.
- Studies have compared the efficacy of topiramate and acetazolamide in treating IIH, with some finding that topiramate is more effective in lowering intracranial pressure 7.
- The mechanisms of action of topiramate and acetazolamide may differ, with topiramate potentially having a more favorable effect on CSF secretion and intracranial pressure reduction 6.