Neuro guidelines Flashcards
investigations following first seizure
EEG and brain MRI
investigation to determine true from pseudoseizure
raised serum prolactin for a couple hours
when do you NORMALLY start AEDs?
After second seizurE
what would make you start AEDs after a first seizure
EEG shows unequivocal epileptiform activity
There is a structural abnormality on brain MRI
There is a persisting neurological deficit
Family or family considers risk of second seizure unacceptable
driving ban after 1st seizure
6 months
how long do you need to be seizure free for to drive if you have epilepsy
12 months
1st line epilepsy meds:
- generalised
- absence
- partial
- pregnancy
generalised = valproate absence = valproate or ethosuximide partial = carbamazepine pregnancy = lamotrigine (usually 2nd line as well)
status epilepticus and timing
0m = O2 and ABCDE 5m = buccal midaz or IV loraz 10m = IV lorazepam 15m = escalate + phenytoin 45m = intubate
Parkinson’s investigations
clinical diagnosis
Use DaT scan (SPECT) and MRI brian to exclude P+ syndromes and to ensure diagnosis if unsure
1st line for PD and SE
if motor Sx = levodopa and carbidopa/benserazide
if no motor Sx predominate = can chose from any
SE = dyskinesia
2nd line PD and SE
non-ergot derived dopamine agonists (bromocriptine, cabergoline, pergolide, ropinorole) SE = impulse, hallucinations
MAO-Bi = seleginine. SE = ?
COMTi = entacapone. SE = orange urine and diarrhoea
Mx for drug induced parkinsonism
procyclidine
investigations that help MS diagnosis
contrast brain MRI shows dawson fingers and periventricular plaques. McDonald criteria.
CSF shows oligoclonal bands (doesn’t NEED to be present for diagnosis)
Acute relapse of MS Mx
IV methylprednisolone for 5d, shortens flares
1st line DMARD for MS and criteria to get it
beta interferon
need 2 relapses in past 2 years and also be able to walk 10-100m unaided
2nd line drugs for MS
- glatiramer
- natalizumab
- fingolimod
glatiramer = immune decoy natalizumab = alpha4beta1 inhibitor preventing leucocyte transmission through the BBB fingolimod = sphingosine receptor modulator preventing lymphocytes leaving the lymph nodes
Symptom treatment for MS:
- fatigue
- spasticity
- bladder dysfunction
- ossciloscopia
- fatigue = amantadine + CBT
- spasticity = baclofen + gabapentin
- bladder dysfunction
- -> residual volume = self catherisation
- -> no residual volume = anticholinergics
- ossciloscopia = gabapentin
when are anticholinesterses CI in alzheimers
DONEPEZIL is CI bradycardia. not the others
name 3 anticholinesterases for AD
galantaine
rivastigmine
donepezil
what is 1st and 2nd line in AD
1st = anticholinesterases 2nd = memantine
How do you treat FTD
You cant really. acetylcholinesterases/memantine don’t work because those systems aren’t affected the same way as AD and LBD
Lewy body dementia Tx
same as AD
ROSIER score
rule out of stroke in the emergency room
any score of >0 means stroke is likely
+1 = speech problem, face/arm/leg weakness, vision problem
-1 = TLOC, seizure, syncope
Immediate Mx of ischaemic stroke
Always = 300mg aspirin for 2 weeks
within 4.5 hours = thrombolyse
within 6 hours (or 24 if have done scan and ischaemic bit is still small) if MCA/ACA proximal = thrombectomy ALONGSIDE thrombolysis
Immediate Mx of haemorhagic stroke
control BP to 100-120 with labetolol and consult neurosurgery
Ongoing Mx of ischaemic stroke
After 2w, stop aspirin and give clopidogrel lifelong 75mg
What is clopidogrel is CI, what do you give for long term secondary preventions
aspirin + dipyridamole
DVT prophylaxis of stroke in hospital
intermitten pneumatic calf devices
when do you do a carotid endarterectomy after a stroke
if stenosis >50%
when do you start a statin after a stroke
if cholesterol >3.5
ABCD2 score
for TIA age >60 BP 140>90 clinical features = speech 1p, unilateral weakness 2p duration (10-59m, 60+m) = 1 and 2 points diabetes
immediate management of TIA
300mg aspirin
when do you NOT give 300mg aspirin in a TIA and what do you do in those cases
anti coagulated/bleeding disorder –> admit for head CT
already on low dose aspirin –> just continue at same dose until TIA appointment
when do you arrange TIA appointment
crescendo TIA = discuss admission now
TIA in last 7d = assessment within 24 hours
TIA >7d ago = assessment within 7d
drug for life in TIA?
Yes, clopidogrel 75mg as in stroke
first line sedative in delerium
0.5mg haloperidol
CI in PD so use lorazepam instead
investigation for meningitis
Serum PCR and blood culture
LP unless CI (meningococcal septicaemia or raised ICP)
think its meningitis and you’re a GP?
Give IM benzylpenicillin as long as it doesn’t delay transfer to hospital
empirical Abx for menignitis in hospital depending on age
<3m = cefotaxime + amoxicillin 3m-50y = ceftriaxone/cefotaxime >50y = ceftriaxone/cefotaxime + amoxicillin
IV antibiotic for specific meningitis bug:
- meningiococcal
- pneumococcal/hamophilus
- listeria
–what else do you give to everyone
- M = benzylpenicillin + cefotaxime
- P/H = cefotaxime
- L = amoxicillin + gentamicin
You give dexamethasone alongside first dose of antibiotic to everyone to reduce neuro complication rate
how do you confirm a SAH has occurred
1st do CT head
if negative, check CSF for xanthchromia at least 12 hours later
management for SAH when waiting for surgery
strict bed rest, stool softness, no straining, BP control
medical management for SAH after surgery
21 days nimodipine (CCB) to prevent vasospasm
presentation and Mx of vasospasm post SAH
presents 4-9d after surgery for SAH with focal deficits +/- reduced cognitive function
triple H therapy
- hypervolaemia, induced hypertension, haemodilution
1st line Ix for Lyme disease
ELISA for antibodies against burrelia burgdorferi
can diagnose clinically if symptoms present and bull eye erythema migrans present
Mx of Lyme:
- early
- disseminated
early = doxycycline disseminated = ceftriaxone
beware of Jarisch-Herxheimer reaction
Encephalitis best Ix
two other Ixs
Best = MRI shows hyperdensitiy in temporal lobe
EEG shows lateralised periodic discharges at 2Hz
CSF shows lymphocytosis and elevated protein
Mx of encephalitis
IV aciclovir as most common cause is HSV1
trigeminal neuralgia Mx
when do you refer
carbamazepine
refer if <50yo or fails to respond to above
Bells palsy Mx
time cutoff for Tx
1mg/kg 10d prednisolone
eye care
give within 72 hours for best effect
Best Ix for myasthenia gravis
other Ix needed
Best = single fibre EMG (trace decreases in amplitude with receptive stimulation) others = CT chest to exclude thymoma Tension test (IV edrophinium) NOT used anymore
Mx for Myaesthenia gravis
- flare
flare = prednisolone
Mx for Myaesthenia gravis
- ongoing
- how do you monitor respiratory function
ongoing = antcholinesterase inhibitor long acting pyridostigmine
Monitor with FVC
Mx for Myaesthenia gravis
- crisis
plasmapheresis and IVIG
Guillain barre syndrome:
- LP
- nerve conduction studies
- antibody
- LP shows isolated protein rise
- nerve conduction studies (slow response due to demyelination)
- anti-GM1
GBS Mx
IVIG
MND Ix
Normal nerve conduction study
EMG shows few APs with normal amplitude + fibrillation
Mx for MND
riluzole and BiPAP at night
acute Mx of migraine 1st and 2nd line
1st = NSAID + oral triptan + paracetamol
——-> if <17yrs old use nasal triptan instead
2nd = non-ral metoclopromide/prochlorperazine (beware of dystonic reaction)
cutoff for migraine prophylaxis frequency
2+ per month
migraine prophylaxis Mx
1st and 2nd line
adjunct?
1 = propranolol (or topiramate if not woman of childbearing age)
2 = acupuncture
—> can also use riboflavin as adjunct
cluster headache acute Mx
100% oxygen and subcut triptan
prophylaxis cluster headache
verapamil
tension headache acute Mx
NSAID, paracetamol
Tension headache propylaxis
acupuncture (NOT amitriptyline which is often used)
When do you do a head CT within 1 hour after a head injury
GCS <15 2 hours after injury GCS <13 on clerking focal neurological deficit post-traumatic seizure 2+ episodes of vomiting open or depressed skull fracture
when do you do a head CT within 8 hours after a head injury
Need to have some loss of consciousness and:
- be over 65
- be on warfarin or have bleeding disorder
- have 30mins amnesia before event
- dangerous mechanism of injury (struck by vehicle, ejected from vehicle, fall >1m/5 stairs)
