Intrathecal medications
Nusinersen (Spinraza) was approved by US FDA for the treatment of SMA in
December 2016, and The European Medicines Agency in June 2017, that is
administered intrathecally. In 26 patients of SMA, Mousa et al. were
able to successfully perform a total of 104 intrathecal nusinersen
injections, even in patients with sophisticated spinal instrumentation
(44 of 104). There were no immediate or long-term
complications.46 In SMA type 2 and 3 patients, who
constitute the adolescent and adult group and more likely to be having
complex spinal anatomy and surgery and respiratory insufficiency,
Wurster et al. evaluated practicability and safety of intrathecal
nusinersen injection in these patients. They analyzed 93 lumbar
punctures in 20 patients, surveyed the duration of the procedure, site
of LP, oxygen saturation, number of attempts, need for sedation and
analgesia.47 Intrathecal nusinersen was found to be
safe, feasible and well tolerated(complication rate was 5% and
consisted of mild PLPH) , even in adult onset SMA patients, both with
standard and image guided LPs.47 Shortly, nusinersen
use will be widespread and physicians will need to well be conversed
with these procedures.
Many intracranial infections are smoldering infections which carry high
mortality if not promptly and aggressively treated. Unfortunately, very
few antibiotics cross the blood-brain barrier to reach concentrations
enough to be effective. Intrathecal (ITH) and intraventricular (IVT)
administration of antibiotics can be lifesaving in such situations.
Bargiacchi et al. did a systematic review of 51 case studies of
Gram-negative CNS infections in adults treated with intrathecal or
intraventricular colistin.12 They found that
Intrathecal or intraventricular Colistin at a dose of 125,000 IU,
suggested by IDSA Guidelines administered once daily for at least 14
days is safe and effective. No nephrotoxicity was reported with ITH/IVT
colistin.12
However, there is no standard criterion for dosing for IVT/ITH
vancomycin. Wombell et al. did the systemic review of cases reported on
IVT/ITH vancomycin, and recommended that a daily dose of 10-mg, aiming
for a trough level of 15 to 20 mg/L48 is safe and
effective.
Various other combinations of antibiotics have been used. Zhang et al.
reported 86 patients with intracranial infections with severe traumatic
brain injury (STBI).49The group treated with ITH
meropenem and vancomycin had better cure time compared to patients
treated with intravenous meropenem and vancomycin (p- 0.004), lesser
adverse reactions (p-0.035) and less severe sequelae
(p-0.007).49
Intrathecal Interferon has been used since ages to treat
SSPE,50 but there are still no clear-cut guidelines
regarding the dosing schedule. The various reported studies with their
dosing schedule are detailed in Table 151,52,53,54,55,56,13. Based on studied by
Kurta et al., Steiner et al. and Thurner et al., we recommend continuous
intrathecal infusion of interferon at a rate of 3 million U/week as more
effective than intermittent bolus infusion.55,54,57