Neurology - Management

Question 1

Management of stroke

Answer 1

Exclude hypoglycaemia CT to exclude haemorrhage Aspirin 300mg after CT (2 weeks) 4.5 hours= Thrombolysis with alteplase (tissue plasminogen activator) Lower BP

Question 2

Secondary prevention of stroke

Answer 2

Clopidogrel 75mg OD / Dipyrmidamole 200mg TD Atorvastatin 80mg Carotid endarterectomy if carotid artery disease Modifiable RF- diabetes, HTN

Question 3

GCS EYES VERBAL MOTOR

Answer 3

EYES (4) 4= spontaenous 3= verbal 2= pain/pressure 1= none VERBAL (5) 5= orientated 4= confused 3= words 2= sounds 1= none MOTOR (6) 6= obeys commands 5= localises 4= normal flexion 3= abnormal flexion 2= extends 1= none 3/15 lowest, 8/15 consider intubation

Question 4

Subarachnoid haemorrhage investigations

Answer 4

CT head = hyperattenuation (white) if blood Lumbar puncture= CSF raised RBC, Xanthochromia yellow caused by bilirubin Angiography

Question 5

Subarachnoid haemorrhage management

Answer 5

Surgical intervention- coiling Nimodipine- Ca2+ channel blocker to prevent vasospasm (a common complication which can result in ischaemia) Lumbar puncture/shunt to treat hydrocephalus Antiepileptic meds

Question 6

MS Management

Answer 6

Relapses- methylprednisolone (500mg orallly daily for 5 days or 1g IV for 3-5 days) Symptomatic- neuropathic pain- amitryptline, gabapentin depression -SSRI urge incontinence - anticholinergics .g tolterodoine, oxybutin

Question 7

Motor neurone disease management

Answer 7

Riluozole NIV

Question 8

Parkinson’s Disease

treatment

Answer 8

Levodopa (synthetic dopamine) Carbidopa / Benserazide- peripheral decarboxylase inhibitors (drugs that stops levodopa being broken down in the body before it enters the brain) *Co-benyldopa *Co-careldopa Entacapone- COMT inhibitors (the COMT enzyme meabolises levodopa in the body and brain) Bromocriptine / Pergoglide / Carbergoline- mimic dopamine and stimualte dopamine receptors. side effect is pulmonary fibrosis Selegilin / Rasaglinine- monoamine oxidase B inhibitors stop the break down neurotransmitters like dopamine

Question 9

Benign Essential Tremor- management

Answer 9

Propanolol (non-selective beta blocker) Primidone (barbiturate anti-epileptic medication)

Question 10

Epilepsy Maintenance meds

Answer 10

1st line: sodium valproate (except for focal seizures) *side effects- teratogenic, liver damage, hair loss, tremor carbamezipine 1st line for focal seizures *side effects: agranulocytosis, aplastic anaemia, induces P450 systems phenytoin ethosuximade lamotrigine

Question 11

Hospital management of status epilepticus

Answer 11

S-R O2 blood glucose IV lorazepam 4mg repeated after 10 min if continues IV phenobarbital or phenytoin if seizures persist in community: buccal midazolam rectal diazepam

Question 12

neuropathic pain management

Answer 12

amitryptiline- TAC duloxetine- SRNI gabapentin- anticonvulsant pregabalin- anticonvulsant tramadol - short term to control flares capsaicin cream physiotherapy

Question 13

Bell’s Palsy management

Answer 13

prednisolone 50mg for 10 days 60mg for 5 das followed by a 5-day reducing regime of 10mg a day lubrication eye drops

Question 14

Ramsay-Hunt syndrome

Answer 14

prednisolone aciclovir lubricating eye drops

Question 15

Huntington’s management

Answer 15

to suppress the disordered movement antipsychotics- olanzapine benzodiazepines- diazepam dopamine-depleting agents - tetrabenazine

Question 16

Myasthenia gravis diagnosis antibodies and edrophonium test

Answer 16

antibodies: ACh-R antibodies MuSK antibodies LRP4 antibodies Edrophonium test: give IV dose of edrophonium chloride (neostigmine) edrophonium chloride blocks enzymes cholinesterase enzymes in the NMJ which usually breakdown acetylcholine. by blocking acetylcholinesterase, this stop Ach from being broken down so levels of Ach at the NMJ briefly and temporarily relieves weakness

Question 17

Myasthenia Gravis- treatment

Answer 17

1. reversible acetylcholinesterase inhibitors- pyridostigmine, neostigmine 2. immunosuppression (prednisolone, azathioprine) 3. thymectomy 4. monoclonal antibodies - rituximab eculizumab *for myasthenia crisis- NIV, immunomodulatory therapies, IV immunoglobulins, plasma exchange.

Question 18

Lambert-Eaton Myasthenic Syndrome management

Answer 18

*any underlying small cell lung cancer? amifampridine- allows more Ach to be released into NNMJ by blocking K+ channels in presynaptic cells to prolong depolarisation Immunosuppressants (prednisolone, azathioprine) IV immunoglobulins Plasmapheresis

Question 19

Gullian-barre syndrome

Answer 19

IV immunoglobulin plasma exchange supporitve care VTE prophylaxis

Question 20

Sinusitis

Answer 20

resolves 2-3 weeks nasal irrigation with saline steroid nasal spray

Question 21

Trigeminal neuralgia - management

Answer 21

Carbamezepine Gabapentin Amitryptine Surgery to decompress or intentionally damage the trigeminal nerve. (glycerol rhizolysis)

Question 22

Migraines acute management prophylaxis

Answer 22

acute management: paracetemol triptans- sumatriptan 50mg as the migraine starts NSAIDS- ibuprofen, naproxen antiemetics (metoclopramide) prophylaxis: propanolol topiramate amitryptiline acupuncture riboflavin

Question 23

Cluster headaches - acute - prophylaxis

Answer 23

acute: triptans (sumatriptan 6mg injected subcutaneously) high flow 100% o2 given for 15-20 mins prophylaxis: verapamil lithium prednisolone corticosteroids