GUIDELINES FOR MOUNTAINEERING FOR PEOPLE WITH NEUROLOGICAL DISORDERS CORRADO ANGELINI, GUIDO GIARDINI * Neurosciences Department University of Padova; * Neurological Division Aosta

First Meeting of SIMEM Arabba,1999

Migraine (with or without aura) A definite migraine diagnosis performed from a neurologist with experience in headache treatment is necessary Every patient with migraine must know that at altitude his headache can worsen in frequency and/or intensity

Migraine (with or without aura) It’s best to have in the backpack a proven effective drug (aspirin, FANS or triptans) and a second drug to take for eventual prevention treatment (e.g. flunarizine or amitriptiline) Recent data showed safety of triptans at altitude

Migraine (xxx with aura) In case of migraine with aura we recommend before leaving: – Brain MRI with diffusion weighted study to disclose recent embolic subclinical strokes – Blood analysis to study thrombophylic state –Transcranial doppler to disclose patent foramen ovale (PFO) or other right to left shunt (also a possible trigger of AMS or HAPE)

Migraine (xxx with aura) In case of migraine with aura we recommend before montaineering: – stop smoking cigarettes – stop taking oral contraceptives – In case of PFO take aspirin 100 mg/day and move legs frequently during a very long flight (possible risk of deep vein thrombosis)

CEREBROVASCULAR ACCIDENTS Major risk factors: age, diabetes, smoking, high cholesterol: Over 3000 metres cerebral blood flow might be decreased Patients with previous carotid TIA or vertigo / ataxia should avoid mountain trekking

Cerebrovascular diseases There are no sufficient data about safety in trekking at high altitude with recent or pre- existing stroke. In cases with recent stroke there is a cerebral vasoreactivity impairment that can worsen at altitude, with hypocapnia

Cerebrovascular Diseases It is critical to verify the definite diagnosis of stroke or TIA: In case of stroke brain CT or MRI must show ischemic or haemorrhagic lesion. TIA is often a clinical diagnosis. Remember that loss of consciousness, dizziness, falls, amnesic or confusional episodes as isolated symptoms are not necessary TIAs.

Cerebrovascular Diseases 1 - For every stroke it’s imperative the control of risk factors and comorbidity before trekking: Arterial hypertension Hyperglycemia Hypercholesterolemia Stop smoking cigarettes 2 - For atherothrombotic strokes: carotid ehco- colordoppler < 6 month (risk of severe stenosis or ulcerated plaques) 3 - For cardioembolic strokes: cardiological examination and eventually ehcocardiography. Low weight heparin is better than warfarin in difficult environment

Cerebrovascular Diseases The search of other minor risk factors is indicated only in case of criptogenetic stroke or TIA (it is useful transnscranial Doppler study with monitoring, transoesophageal echocardiography, complete blood analysis to study thrombophyilic state) No climbing or trekking alone at high altitude if previous TIA A moderate or severe disability after a stroke (modified Rankin Scale>2) is a contraindication to a wild environment

DEMYELINATING DISEASES AND PERIPHERAL NEUROPATHIES Multiple Sclerosis: – Cold climate should be avoided –No mountain trekking if disability by RANKIN scale>2 –No trekking if vertigo or ataxia Peripheral neuropathies –No trekking for Charcot-Marie Tooth disease: –Stumbling might be dangerous in presence of foot drop or Stepppage Gait –Diabetic neuropathy: –Small vessel ischemia in diabetes: hypoxia is a contraindication

EPILEPSY In hypoxia some cases of status epilepticus have been reported Epileptic patients need regular drug level check Epileptics should avoid alcohol intake Sleep deprivation might be dangerous

PARKINSON DISEASE (PD) With PD it is possible to trek at medium altitude (2000 m.) if in good pharmacological control Avoid mountaineering if PD patient presents “ON-OFF” phenomena Parkinsonism e.g.. PSP (Steele-Richardson Olzewski): avoid mountaineering for neurovegetative and oculomotor failure

PSYCHIATRIC AND COGNITIVE DISORDERS Alzheimer and senile dementia: Trekking alone might expose to the risk of getting lost(according to previous cognitive conditions),avoid walking alone Emotional changes have been observed in several montaineers: –Euphoria risk : at medium and high altitude –Depression might interfere with team work

NEUROMUSCULAR DISORDERS AND MOTOR NEURON DISEASES Decrease of FVC>60% contraindication to high mountain for hypercapnia and hypoxia Decrease in bulbar central drive. Myotonic dystrophy, ALS and AMD Risk of sleep apnea is increased

Patients with ALS ( no more than 2000 metres)

Patient with respiratory insufficiency and AMD (no more than 2000 meters)

Alpine rescue in XXI century Possibility of transport by helicopter in neurological cases might help with prompt rescue