Neuro

Question 1

What is the management plan for Bell’s Palsy?

Answer 1

• All patients
  
  • 1st Line - oral prednisolone
  • Eye protection - Tape + opthalmic lube
• Severe/complete facial paralysis
  
  • Consider acycolivir
  • If complete - surgical decompression can help

Question 2

What is the management plan for Status Epilepticus?

Answer 2

Treatment initiated after 5-10 mins of seizure

• 1st Line - supportive care + oxygen
  
  • Thiamine then glucose (if hypoglycaemic)
  • IV Lorazepam or Diazepam - repeat after 10 mins
• 2nd Line - Phenytoin/ Sodium Valproate or Levetiracetam
• 3rd Line - Phenobarbitol
• 4th Line - Propofol GA with airway support

Question 3

What is the management plan for Epilepsy?

Answer 3

Only start medication >2 seizures, or 1 seizure with abnormal test

Before changing medicationd, first increase dosage

• Conservative - educate to avoid triggers + keep seizure diary
• Generalised Seizures:
  
  • 1st Line - Sodium valproate or Lamotrigine (if pregnant due to teratogenic effects
  • 2nd Line - Levetiracetam or Lamotrigine
  • 3rd Line - Lamotrigine + Topirimate (dual therapy)
• Focal Seizures:
  
  • 1st Line - Carbamezipine
  • 2nd Line - Levetiracetam
  • 3rd Line - antiepileptic polytherapy

Question 4

What is the management plan for Horner’s Syndrome?

Answer 4

• Horner’s syndrome is a sign not a disease in itself
• So, the management depends on the cause
  
  • Management for carotid dissection is very different to management of apical lung tumours

Question 5

What is the management plan for Meningitis?

Answer 5

Viral Meningitis - generally self-limiting

Bacterial Meningitis

• Acute - Immediately treat with IV/IM Benzylpenicillin + IV dexamethasome (unless <1 month)
  
  • <1 month - Ampicillin + Cefatoxime/Ceftriaxone
  • >1 month - Vancomycin + Cefatoxime/Ceftriaxone
  • >55 or immunocomprimised - Vancomycin + Cefatoxime/Ceftriaxone + Ampicillin
  • For all patients supportive care - O2, Vasopressors, IV Fluid (careful in raised ICP)
• Once LP performed and bacterium confirmed
  
  • Targeted Abx therapy and supportive care
    
    • Strep Pneumoniae - Benzylpenicllin

Question 6

What is the management plan for Migraine?

Answer 6

• Note - analgesia overdose can actually lead to headache
• Acute management
  
  • Mild = NSAIDs
    
    • consider anti-emetics + hydration
  • Severe = Sumatriptan
    
    • consider anti-emetics, hydration + NSAIDs
    • 2nd Line = ergotamine/ caffeine
    • 3rd Line = corticosteroids
• Ongoing - avoidance of triggers
  
  • Without aura = Topiramate/ TCA/ BBs
  • With aura = verapamil
  • If menstrual cycle related - OCP can help

Question 7

What is the management plan for Ischaemic stroke?

Answer 7

• Hyperacute stroke - <4.5 hrs
  
  • Initially rule out haemorrhagic cause with CT Head
  • IV alteplase followed by aspirin 24 hrs later
    
    • Supportive care and swallowing assessment
• Acute stroke - >4.5 hrs or thrombolysis contraindicated
  
  • Daily aspirin (300mg) + supportive care and swallowing assessment
  • Consider DVT prophylaxis and mobilization
  • If cerebral venous sinus thrombosis - heparin/warfarin
• Secondary prevention
  
  • Standard - 75mg clopidogrel daily
  • If AF - Warfarin indicated
  • Manage RF where possible

Question 8

What is the management plan for Haemorrhagic stroke?

Answer 8

• 1st Line = Neurosurgical + critical care evaluation
  
  • Admission to neuro ICU or stroke unit
  • Protect airway + supportive care e.g. BP management
• If pyrexic - anti-pyretics
• If raised ICP = supportive management +/- External ventricular drainage

Question 9

What is the management plan for Tension Headache?

Answer 9

• Acute - Simple analgesia e.g. paracetomol or aspirin
  
  • Reassurance and avoidance of triggers
  • Medication review e.g. opioids
• Chronic (>7/month)
  
  • 1st Line = Amitryptiline +/- CBT/ relaxation training
  • 2nd Line = Muscle relaxants

Question 10

What is the management plan for TIA?

Answer 10

• 1st Line - 75 mg antiplatelets daily <24 hours
  
  • Neurological assessment + statin therapy
  • If alreay on HD statin use ezetimibe
  • Lifestyle modifications + 1 month driving abstinence
• If hypertensive - review anti-HTN medication
• If >70% carotid stenosis = carotid endarterectomy
• If cardioembolic cause manage AF - warfarin or DOAC

Question 11

What is the management plan for Subdural Haemorrhage?

Answer 11

Acute

• <10mm size or <5mm midline shift
  
  • 1st Line = observation + follow-up imaging
  • Prophylactic anti-epileptics
• >10mm size or >5mm midline shift
  
  • Surgery requried
    
    • 1st line = burr hole craniotomy
    • 2nd Line = Standard craniotomy
    • 3rd Line = subdural peritoneal shunting
  • Alwats monitor + prophylactic anti-epileptics
• Consider coagulopathy correction + raised ICP management

Chronic

• 1st Line = anti-epileptics
• Consider elective surgery = same guidelines as above
• Consider coagulopathy correction + raised ICP management