NEUROLOGY SMLE

REVIEW
Elaf Faisal
Internal medicine resident
Alnoor specialist hospital - Makkah
|| .. Headache .. ||
Initial step to diagnose headache is to take full history and examination

Migraine:- Unilateral pulsatile or throbbing pain, preceded by

flashing light or zigzag lines (aura), photophobia

Cluster headache:- Pain over one eye, lasting for minutes to

hours, associated with lacrimation, rhinorrhea and flushing of
the forehead, lasts several weeks a few times a year

Tension headache:- Episodic or chronic, bilateral over the

occiput, frontal or temporal, band-like or tightness in nature
Infection (meningitis, encephalitis or brain abscess):-
Generalized headache associated with photophobia with a stiff
neck is typically for meningitis

Intracerebral bleeding (subdural haematoma, subarachnoid or

intracerebral haemorrhage):- Sudden severe onset, initially
localized but becomes generalized, associated with neck stiffness
Temporal arteritis:- Persistent unilateral over the temporal
area, associated with blurred vision, diplopia, jaw claudication
or jaw pain during eating which can lead to loss of weight

Acute sinusitis:- Associated with pain or fullness behind the

eyes or over the cheeks or forehead

Cervical spondylosis:- Pain over the occiput, associated with

neck stiffness
Raised intracranial pressure (brain tumor or idiopathic intracranial
HTN):- Generalized, worse in morning and with coughing,
associated with drowsiness and vomiting, history of using OCPs in
obese woman (idiopathic intracranial hypertension)

Medication overuse headache:- History of using of analgesia

especially codeine and opiate for 10-15 days per month

Trigeminal neuralgia:- Brief paroxysms of unilateral lancinating

pain in the V2 or V3 distribution of the trigeminal nerve, triggered
by light touch of the affected area, Carbamazepine is the treatment
POUND mnemonic to diagnose Migraine …
Pulsatile quality
One day duration ( between 4 and 72 hours)
Unilateral in location
Nausea or vomiting
Disabling intensity (patient goes to bed)

Management of migraine:-
Acute mild to moderate >> Aspirin or NSAIDs
Acute moderate to severe or poor response to NSAIDs >> Triptan
Migraine associated with vomiting >> nasal or SC Triptan

N.B: Triptan are contraindication in CAD, cerebrovascular

disease, brainstem aura and hemiplegic migraine
Choose migraine prophylaxis when ..
- Migraine do not respond to therapy
- Headache occur >= 10 days per month
- Using acute migraine medication is >= 8 days per month
- Disabling headache >= 4 days per month

Migraine prophylaxis:- Beta blocker (Metoprolol, Propranolol,

Timolol), Amitriptyline, Topiramate, Valproic acid and
Venlafaxine
Most important headache management you should know …

Acute Prophylaxis
Migraine Mild to moderate = NSAIDs Beta blocker
Moderate to severe = Triptan
Cluster headache 100% Oxygen Calcium channel
blocker (Verapamil)
Tension headache NSAIDs TCA (Amitriptyline)

Subarachnoid hemorrhage:- urgent neurosurgery referral

Trigeminal neuralgia:- Carbamazepine
Temporal arteritis:- High dose steroid (don’t wait for biopsy!)
|| .. Stroke .. ||
What do you need to know about stroke management?
CT BRAIN is mandatory and it is the most important step in any patient presented with
neurological deficit
It will differentiate between Ischemic stroke vs Hemorrhagic stroke

Management:-
Hemorrhagic stroke >> Neurosurgery referral
Ischemic stroke >> within window period (4.5 hours) or no?
Out of the window >> Dual antiplatelet (Aspirin and Clopidogrel)
Within window >> thrombolytic if no contraindication and hold Antiplatelet in 1st 24 hours

N.B: Remember to differentiate acute stroke from transient ischemic attack (TIA)
TIA is defined by the absence of infarction on neuroimaging, independent of symptoms
duration, which typically lasts from 5 to 60 minutes

N.B: Rule out atrial fibrillation as the most common cause of cryptogenic stroke
|| .. Guillain Barre syndrome .. ||
Guillain Barre syndrome …
Acute ascending areflexic paralysis and paresthesia (distal to proximal)
with history of URTI or GI infection (Campylobacter jeujeni) multiple
weeks ago

Diagnosis:-
Clinically, CSF sample may showed high protein and normal cell count

Treatment:-
IVIG or plasma exchange

Prognosis is excellent with full recovery in most of the patient

|| .. Myasthenia gravis .. ||
Myasthenia gravis in 1 slide ...
Autoimmune antibody against Acetylcholine receptor which result in impaired neuromuscular
transmission

Signs and symptoms:- Diplopia, ptosis (but pupil is normal), dysphagia, SOB, normal sensation and deep
tendon reflex

3 tests you have to do for MG:- EMG, TSH (autoimmune thyroid disorders), CT chest (to detect thymoma)

Management:- Pyridostigmine
Myasthenic crisis and refractory disease is treated by Plasmapheresis or IVIG

N.B: Medication may trigger myasthenic crisis:- quinolone, aminoglycoside, beta blocker, Mg, CCB

Lambert-eaton syndrome:- mimic MG but weakness improved with activity + diminished tendon reflex
Diagnosed by Anti-voltage calcium channel antibody, always search for hidden malignancy (SCLC)
|| .. Multiple sclerosis .. ||
Multiple sclerosis …
Demyelination disease

Think in MS as a spot diagnosis in young age with multiple neurological

symptoms in different part of the body at a different time

Diagnosis:- MRI brain and spine (McDonald criteria)

CSF analysis if done will show Oligoclonal band IgG

Treatment:–
Acute exacerbation à IV Methylprednisolone
After resolution of attack you may gibe Interferon Beta (caution with liver
disease or depression) or Glatiramer
|| .. Meningitis .. ||
Meningitis …
Symptoms:- fever, neck stiffness, photophobia, altered mental status
Signs:- +ve Kerning sign, +ve Brudzinski sign

Precaution:- Droplet (discontinue isolation after 24 hours of antibiotic)

Diagnosis:- lumbar puncture (CT head to be done before if there is signs of increased
intracranial pressure such as papilledema, focal neurologic deficit, altered mental status, new
onset seizure, previous CNS lesion or immunocompromised patient to avoid risk of
herniation)

Most common organism:- Streptococcus pneumpnie

Think of listeria monocytogenus in extreme age, pregnant, immunocompromised and diabetic
N.B: affection of temporal area on imaging is a hint to diagnose HSV
Etiology of meningitis Glucose Protein Predominant cell
Bacterial Low Normal or increased Neutrophil
Viral Normal Normal Lymphocyte
TB Low Normal or increased Lymphocyte

Cryptococcus Low Normal or increased Lymphocyte

Management of meningitis ..
Bacterial:- IV Ceftriaxone + IV Vancomycin + IV Dexamethasone
+ IV Ampicillin only in extreme age (to cover listeria)

N.B: post neurosurgical or hospital acquired meningitis >> IV Vancomycin + IV Ceftazidime

or Cefepime or Meropenem (for pseudomonas aeruginosa)

Viral:- supportive (IV antibiotic is initiated until bacterial cause is excluded)

Viral encephalitis:- IV acyclovir

Prophylaxis to contacted people:- Single dose Ciprofloxacin or 2 doses of Rifampicin

N.B: Ciprofloxacin is contraindicated in age < 18
Ceftriaxone may be used as a prophylaxis also

Lat complication of meningitis in general is Hearing loss

|| .. Epilepsy .. ||
Most common cause of seizure attack in epilepsy:- low AED level
Sleep deprivation is other cause

N.B: do not forget hypoglycemia as a cause of seizure attack

Absence seizure à Ethosuximide

Generalized epilepsy --> Na valproate (but other can be used)
Safe in pregnancy --> Levetiracetam

N.B: note that some drugs can decrease seizure threshold such as
Bupropion and fluoroquinolone
|| .. Cranial nerve injuries .. ||
Treatment:- Steroid
|| .. Parkinson disease .. ||
Parkinson disease ..
Degeneration of dopaminergic neuron in substantia nigra in midbrain

Clinical diagnosis, at least 2 of the following to diagnose:- bradykinesia, cogwheel

rigidity, resting tremor (asymmetric at onset), postural reflex abnormality (falling)

Important to memorize medication induced parkinsonism (symmetrical at onset):-

Metoclopramide, Haloperidol and Methyldopa

N.B: Early dementia within the first year of the appearance of parkinsonism is a hall mark
of dementia with lewy body!

Treatment:- Levodopa with Carbidopa

|| .. Dementia.. ||
Vitamin B12 deficiency mimic dementia
|| .. Miscellaneous .. ||
Amyotrophic lateral sclerosis ..
Combination of upper motor neuron sign (hyperreflexia, spasticity, and
extensor plantar response) with lower motor neuron signs (atrophy and
fasciculation), sensory deficit are absent

Can be associated with difficulty speaking and swallowing

Very poor prognosis