Neuro

Question 1

Epilepsy

Answer 1

When to start antiepileptics

• Start antiepileptics after second seizure
• Start after first seizure if any of the following are present:
  § Neurological deficit
  § Structural abnormality of brain on imagine
  § EEG shows unequivocal epileptic activity
  § Patient or family considers risk of another seizure unacceptable

First line treatment based on subtype

• Generalised tonic-clonic seizure à sodium valproate
• Myoclonic seizure à sodium valproate
• Focal seizure à carbamazepine
• Absence seizure à ethosuximide
• Pregnancy à lamotrigine no matter what

Question 2

Parkinson’s

Answer 2

o If motor symptoms are affecting life, first line if levodopa (with carbidopa or benserazide) – beware

of impulse behaviour, dyskinesia and hallucinations, but best affects overall
o If not affecting life, choose from:
§ Non-ergot derived dopamine agonists (bromocriptine, cabergiline, pergolide)
§ MAO-B inhibitors (seleginine)
§ Levodopa/carbidopa
o 2nd line = one of the others above or a COMT inhibitor (entacapone)
o Antimuscarinics (procyclidine) = drug induced parkinsonism

Question 3

MS - acute relapse

Answer 3

high dose IV methylprednislone shortens lengths of flare but doesn’t change
likelihood of returning to baseline

Question 4

MS - chronic management

Answer 4

First line if criteria met: Beta-interferon reduces relapse rate by 30%
§ Glatiramer acetate = immune decoy à immunosuppression
§ Natalizumab = mAB for alpha4beta1 integrin on leucocytes, inhibiting their crossing
through BBB
§ Alemtuzumab = mAB for surface glycoprotein CD52
§ Fingolimod = sphingosine 1-phosphate receptor modulator, preventing lymphocytes
from leaving lymph nodes

Question 5

Stroke

Answer 5

o All patients:
§ Control glucose, oxygen, hydration
§ Arrange immediate CT head
§ Swallowing assessment

o Ischaemic:
§ 300mg oral or rectal aspirin
§ If within 4.5 hours of onset of symptoms à thrombolysis (alteplase) unless it is
contraindicated (previous cerebral haemorrhage, seizure with stroke, brain neoplasm,
stroke in previous 3 months, lumbar puncture in last week, active bleeding, pregnancy,
oesophageal varices, hypertension >200/120)

§ Secondary prevention:
Ø Whilst in hospital: intermittent pneumatic calf device as thromboprophylaxis (not
heparin as stroke brain will bleed)
Ø After 2 weeks: Clopidogrel 75mg for life. If CI, use aspirin + modified release
dipyridamole for life.
Ø Carotid endarterectomy if carotid stenosis
Ø If cholesterol >3.5 à statin
Ø Control BP

o Haemorrhagic:
§ Control BP to 100-120mmHg
§ Reverse anticoagulation
§ Consult neurosurgery

Question 6

TIA

Answer 6

o Immediate treatment:
§ All patients à Give 300mg aspirin immediately (unless CI due to taking an anticoagulant
or bleeding disorder, in which case they need admitting and scanning) + discuss with
specialist
§ If crescendo TIA à discuss need for admission
o Secondary prevention:
§ Whilst in hospital: intermittent pneumatic calf device as thromboprophylaxis (not
heparin as stroke brain will bleed)
§ After 2 weeks: Clopidogrel 75mg for life. If CI, use aspirin + modified release dipyridamole
for life.
§ Carotid endarterectomy if carotid stenosis
§ If cholesterol >3.5 à statin
§ Control BP

Question 7

Delirium

Answer 7

• Treat underlying cause

- Haloperidol is first line sedative (olanzapine also used)

Question 8

Status epilepticus

Answer 8

o Buccal midazolam or IV lorazepam then;
o IV lorazepam then;
o IV phenytopin then;
o Rapid sequence anaesthesia
o Adjuncts = oxygen, hyperthermia correction, thiamine (reduce Wernickes), dextrose

Question 9

SAH

Answer 9

o ABCDE resuscitation

o Neurosurgical review (coil ir clipping)
o Aftermath:
§ Nimodipine reduces severity of neurological deficits
§ Stools softners, anti-tussives, CCB reduce chance of re-bleed

Question 10

acute migraine

Answer 10

o Acute

§ 1st line = oral triptain + paracetemol/NSAID
§ 1st line in 12-17 year olds = nasal triptan
§ 2nd line = non-oral metoclopramide/prochlorpromazine

Question 11

migraine prophylaxis

Answer 11

o If getting 2+ attacks per month à Prophylaxis (60% effective):
§ 1st line = Topiramate (anticonvulsant) OR propranolol
§ 2nd line = gabapentin OR 10 sessions of acupuncture over 5-8 weeks
§ If menstrual migraine à triptan peri-menses as ‘mini-prophylaxis’
§ Pizotifen no longer recommended (weight gain and drowsiness too common)
§ Notice how acute = 5HT agonist (triptans); prophylaxis = 5HT antagonist (pizotifen)