30 types nervous system and spinal cord disease treatment investigation finding differential diagnosis contraindication ICO management OPD prescription

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30 Nervous System & Spinal Cord Diseases

Clinical Reference: Investigations · Findings · Differential Diagnosis · Contraindications · ICU Management · OPD Prescription

1. Ischemic Stroke (Cerebral Infarction)

Investigations: Non-contrast CT brain (immediate), MRI DWI/FLAIR, CT angiography/MR angiography, ECG, echocardiography, CBC, coagulation profile, lipid profile, HbA1c, carotid Doppler.

Findings: CT: hypodense area (after 24–48h); MRI DWI: restricted diffusion (bright DWI, dark ADC); FLAIR: cortical/subcortical signal change. NIHSS score for severity.

Differential Diagnosis: Hemorrhagic stroke, Todd's paralysis (post-ictal), Bell's palsy (facial nerve), hypertensive encephalopathy, demyelinating disease (MS), hypoglycemia, brain tumor.

Contraindications:

tPA: onset >4.5 h, BP >185/110 uncontrolled, recent surgery, INR >1.7, platelets <100,000, recent major stroke, active bleeding
Anticoagulants: large territorial infarct (hemorrhagic transformation risk)
NSAIDs: avoid in acute phase

ICU Management:

Airway: intubate if GCS ≤8 or respiratory failure
BP: allow permissive hypertension up to 220/120 if no thrombolysis; target <180/105 post-tPA
IV alteplase 0.9 mg/kg (max 90 mg) within 4.5 h (10% bolus, remainder over 60 min)
Mechanical thrombectomy if large vessel occlusion within 24 h
Aspirin 300 mg (if no thrombolysis) after CT excludes hemorrhage
DVT prophylaxis, NG feeding if dysphagia, monitor glucose (target 140–180 mg/dL)

OPD Prescription:

Aspirin 75–150 mg/day or Clopidogrel 75 mg/day
Atorvastatin 40–80 mg OD (target LDL <70 mg/dL)
Antihypertensive (amlodipine 5–10 mg or ramipril 5–10 mg)
Anticoagulation if AF: warfarin (INR 2–3) or DOAC (apixaban/rivaroxaban)
Physiotherapy, speech therapy, OT referral

2. Hemorrhagic Stroke (Intracerebral Hemorrhage)

Investigations: Non-contrast CT brain (gold standard), MRI GRE/SWI, CBC, PT/INR, aPTT, LFT, RFT, lipid profile, blood glucose. Angiogram if AVM/aneurysm suspected.

Findings: CT: hyperdense (white) collection; MRI SWI: "blooming" artifact. Hematoma volume = ABC/2 method. Midline shift, herniation signs on CT.

Differential Diagnosis: Ischemic stroke with hemorrhagic transformation, brain tumor with bleeding, venous sinus thrombosis, hypertensive encephalopathy, coagulopathy-related bleed.

Contraindications:

Anticoagulants and antiplatelets: absolute contraindication acutely
tPA: absolute contraindication
Mannitol caution in renal failure; avoid furosemide with hypovolemia
Steroids: NOT indicated (increase mortality in ICH)

ICU Management:

Airway protection, ICP monitoring if GCS ≤8
BP: target SBP <140 mmHg (intensive BP lowering, INTERACT2)
Reverse anticoagulation: Vitamin K + PCC (4-factor) for warfarin; idarucizumab for dabigatran
Surgical evacuation: consider if cerebellar hematoma >3 cm, IVH with hydrocephalus
Seizure prophylaxis (levetiracetam), glucose control, avoid hyperthermia
Ventricular drain (EVD) if obstructive hydrocephalus

OPD Prescription:

Strict BP control: amlodipine 5–10 mg, losartan 50–100 mg
Statin (if atheromatous disease): atorvastatin 20–40 mg
Avoid antiplatelet for ≥4 weeks post-ICH
Lifestyle modification, fall prevention, anticonvulsant if post-ICH seizure (levetiracetam 500–1000 mg BD)

3. Subarachnoid Hemorrhage (SAH)

Investigations: Non-contrast CT brain, LP (xanthochromia if CT negative at >6h), CT angiography, digital subtraction angiography (DSA), ECG (inverted T-waves, QT prolongation), troponin, CBC, coagulation, electrolytes.

Findings: CT: blood in subarachnoid cisterns (star sign), hydrocephalus. LP: xanthochromic CSF, elevated RBC not clearing. Hunt & Hess or WFNS grading.

Differential Diagnosis: Meningitis, migraine (thunderclap), hypertensive emergency, benign thunderclap headache, cervical artery dissection, RCVS.

Contraindications:

Anticoagulants/antiplatelets: avoid acutely pre-repair
Nimodipine IV (use oral; IV associated with hypotension risk)
Lumbar puncture: avoid if raised ICP/CT shows herniation

ICU Management:

Neurosurgical or endovascular repair of aneurysm (coiling preferred, ISAT trial)
Nimodipine 60 mg PO/NG q4h × 21 days (vasospasm prevention)
Maintain euvolemia; avoid hypotension
Treat vasospasm: triple-H therapy (now hypervolemia less favored; maintain euvolemia + induced hypertension)
EVD for hydrocephalus; seizure prophylaxis (short-term levetiracetam)
Statin (simvastatin 40 mg): may reduce vasospasm

OPD Prescription:

Continue nimodipine for 21-day course
Antihypertensive therapy; follow-up DSA at 6 weeks
Neuropsychological rehabilitation; driving advice (no driving ≥6 months)

4. Transient Ischemic Attack (TIA)

Investigations: MRI DWI (may show restricted diffusion), CT/MRI angiography, carotid Doppler, ECG, Holter monitor, echo, CBC, lipid profile, glucose, coagulation.

Findings: DWI may be positive in ~50% of TIA. ABCD2 score (Age, BP, Clinical features, Duration, Diabetes) to stratify 2-day stroke risk.

Differential Diagnosis: Focal seizure, migraine with aura, hypoglycemia, hemiplegic migraine, MS, transient global amnesia, vestibular neuronitis.

Contraindications:

Anticoagulants in patients with peptic ulcer disease (relative CI); avoid dual antiplatelet long-term (increased bleeding)

ICU Management: Rarely needed; admit if high-risk (ABCD2 ≥4, AF, large vessel disease). Urgent evaluation same-day.

OPD Prescription:

Dual antiplatelet for 21 days: Aspirin 75 mg + Clopidogrel 75 mg (POINT trial), then single agent
Atorvastatin 40–80 mg OD
Antihypertensive
Anticoagulate if AF source detected

5. Bacterial Meningitis

Investigations: CBC (leukocytosis, neutrophilia), CRP, procalcitonin, blood cultures × 2, CT brain (pre-LP if papilledema/focal signs/GCS <15), LP: CSF analysis (opening pressure, cells, glucose, protein, Gram stain, culture), CSF meningococcal/pneumococcal PCR.

Findings: CSF: turbid, opening pressure ↑, WBC >1000 cells/μL (neutrophils), protein ↑(>1 g/L), glucose <40 mg/dL (CSF:serum ratio <0.4), positive Gram stain (~70%), positive culture (~80%). Common: Strep. pneumoniae, N. meningitidis, Listeria (elderly/immunocompromised).

Differential Diagnosis: Viral meningitis, tuberculous meningitis, fungal meningitis, brain abscess, SAH, encephalitis, aseptic meningitis, NMDAR encephalitis.

Contraindications:

LP contraindicated if raised ICP (papilledema, focal deficit, GCS<13): do CT first
Steroids: avoid in Listeria meningitis (relative); avoid delay in antibiotics for steroids

ICU Management:

IV ceftriaxone 2 g BD (add ampicillin if Listeria suspected: elderly, immunocompromised, pregnancy)
Dexamethasone 0.15 mg/kg q6h × 4 days (give 15–20 min before or with 1st antibiotic dose; benefit mainly for Strep. pneumoniae)
Treat septic shock, DIC; ICP management (head elevation 30°, osmotherapy)
Seizure management with lorazepam/levetiracetam
Prophylaxis for contacts: rifampicin or ciprofloxacin (meningococcal)

OPD Prescription (post-discharge):

Complete 10–14-day IV antibiotic course, then oral step-down if stable
Audiological testing (sensorineural hearing loss complication)
Vaccination: meningococcal ACWY, pneumococcal vaccine
Neuropsychological follow-up

6. Viral Encephalitis (HSV Encephalitis)

Investigations: MRI brain (T2/FLAIR: temporal lobe signal change), CSF: lymphocytic pleocytosis, normal-elevated protein, normal glucose, CSF HSV PCR (gold standard), EEG (PLEDS - periodic lateralized epileptiform discharges), LFT, viral serology.

Findings: MRI: bitemporal (temporal + insular) T2/FLAIR signal; hemorrhagic foci on GRE. EEG: PLEDS. CSF: 50–200 WBC (lymphocytes), protein 100–300 mg/dL. HSV PCR sensitivity >96%.

Differential Diagnosis: Bacterial meningitis, autoimmune encephalitis (NMDAR, LGI1), metabolic encephalopathy, drug toxicity, prion disease, cerebral venous thrombosis.

Contraindications:

Do not withhold acyclovir pending PCR confirmation (treat empirically)
Acyclovir: caution in renal failure (dose-adjust); avoid nephrotoxic agents concurrently

ICU Management:

IV acyclovir 10 mg/kg q8h × 14–21 days (renally dose-adjusted)
Seizure management (levetiracetam, phenytoin)
ICP monitoring and management
Supportive care: airway, nutrition, thromboprophylaxis

OPD Prescription:

Complete IV acyclovir course; consider oral valacyclovir 1 g TDS × 3 months (maintenance in severe cases)
Levetiracetam 500–1000 mg BD for seizure prophylaxis
Neuropsychological rehabilitation; driving restriction during seizure freedom period

7. Tuberculous Meningitis (TBM)

Investigations: CSF: lymphocytic pleocytosis (100–500 cells), elevated protein (1–5 g/L), low glucose (CSF:serum <0.5), AFB smear (low sensitivity ~20%), CSF culture (gold standard, 4–6 weeks), CSF MTB PCR, ADA, India ink (exclude cryptococcal), CT/MRI brain (basilar meningeal enhancement, hydrocephalus, vasculitis).

Findings: Meningeal enhancement at base of brain; basal exudate; communicating hydrocephalus; tuberculomas; infarcts (especially perforating arteries).

Differential Diagnosis: Bacterial meningitis, fungal meningitis (cryptococcal), viral meningitis, neurosarcoidosis, carcinomatous meningitis.

Contraindications:

Rifampicin: avoid with many hepatotoxic drugs, major drug interactions (reduces efficacy of many drugs)
Steroids not withheld (reduce mortality per MRC TBM trial)
Avoid single-drug therapy (resistance)

ICU Management:

HRZE (isoniazid + rifampicin + pyrazinamide + ethambutol) × 2 months, then HR × 7–10 months (total 9–12 months)
Dexamethasone 0.4 mg/kg/day tapering over 6–8 weeks (all grades)
EVD or VP shunt for hydrocephalus
Pyridoxine 25–50 mg OD with isoniazid (prevent peripheral neuropathy)

OPD Prescription:

Complete 9–12-month ATT course (DOTS)
Monthly LFT monitoring
Pyridoxine 25 mg OD
Follow-up MRI at 3–6 months
Audiological and neuropsychological assessment

8. Multiple Sclerosis (MS)

Investigations: MRI brain + spine (Gd+): McDonald criteria (dissemination in space and time); CSF: oligoclonal bands (≥2 bands not in serum), IgG index; VEPs (prolonged latency); Neuromyelitis optica IgG (AQP4 Ab) to exclude; VZV, HIV serology.

Findings: MRI: periventricular lesions (Dawson's fingers), juxtacortical, infratentorial, spinal cord lesions; Gd enhancement (active plaques); black holes (T1 hypointensities = chronic damage).

Differential Diagnosis: Neuromyelitis optica spectrum disorder (NMOSD), CNS vasculitis, neurosarcoidosis, Lyme neuroborreliosis, B12 deficiency, ADEM, CNS lymphoma, Susac syndrome.

Contraindications:

Natalizumab: contraindicated if JC virus antibody index >0.9 (PML risk) and prior immunosuppressant use
Fingolimod: contraindicated in significant bradyarrhythmia, AV block, recent MI
Beta-interferons: contraindicated in severe depression, uncontrolled epilepsy
Alemtuzumab: contraindicated in active infection, HIV

ICU Management (Acute Relapse):

IV methylprednisolone 1 g/day × 3–5 days (speeds relapse recovery, doesn't alter long-term disability)
Plasma exchange if refractory to steroids (5 exchanges over 10 days)
Treat concurrent UTI/infection (common relapse trigger)
Manage respiratory failure in cervical cord relapse

OPD Prescription (Disease-Modifying Therapy):

Low-moderate efficacy: Interferon beta-1a (Avonex 30 μg IM weekly), Glatiramer acetate 20 mg SC daily
High efficacy: Natalizumab 300 mg IV q4 weeks; Ocrelizumab 600 mg IV q6 months; Cladribine tablets
Symptomatic: baclofen 10–80 mg/day (spasticity), amantadine 100–200 mg/day (fatigue), oxybutynin 5 mg BD (bladder), gabapentin 300–1800 mg/day (pain)

9. Guillain-Barré Syndrome (GBS)

Investigations: CSF (albumin-cytologic dissociation: elevated protein >45 mg/dL, <10 WBC/μL), nerve conduction studies (NCS: demyelinating vs axonal), anti-ganglioside antibodies (anti-GQ1b in Miller Fisher), stool culture (Campylobacter), spirometry (FVC monitoring).

Findings: NCS: prolonged latencies, reduced conduction velocity, F-wave absence (AIDP); reduced CMAP amplitude (AMAN). Brighton Criteria for diagnosis.

Differential Diagnosis: Myasthenia gravis, botulism, Lyme disease, tick paralysis, acute poliomyelitis, spinal cord compression, critical illness neuropathy, Eaton-Lambert syndrome.

Contraindications:

Steroids: NO benefit (may worsen GBS per Cochrane review)
Do not give IVIG + plasma exchange sequentially (no additive benefit)
Avoid succinylcholine during intubation (hyperkalemia risk due to upregulated ACh receptors)

ICU Management:

Respiratory monitoring: intubate if FVC <20 mL/kg, FVC falling >30% in 24h, PaO2 <70 mmHg, inability to count to 20 in single breath (20/30/40 rule)
IVIG 0.4 g/kg/day × 5 days (2 g/kg total) OR plasma exchange (200–250 mL/kg over 5 sessions)
Autonomic instability: labetalol for hypertension, atropine for bradycardia (avoid long-acting agents)
DVT prophylaxis, pain management (gabapentin, opiates PRN), NG feeding

OPD Prescription:

Physiotherapy (critical for recovery), OT, speech therapy
Gabapentin 300 mg TDS for neuropathic pain
Follow-up NCS at 3 and 6 months; reassess disability (modified Rankin scale)

10. Myasthenia Gravis (MG)

Investigations: Anti-AChR antibodies (~85% of generalized MG), anti-MuSK antibodies (if AChR negative), tensilon (edrophonium) test, repetitive nerve stimulation (decremental response >10%), single-fiber EMG (most sensitive), CT chest (thymoma).

Findings: Anti-AChR Ab ≥0.4 nmol/L; repetitive stimulation: >10% decrement; SFEMG: increased jitter; CT: thymoma in 10–15%, thymic hyperplasia in 70%.

Differential Diagnosis: Lambert-Eaton syndrome, GBS, botulism, MS, mitochondrial myopathy, motor neuron disease, orbital pseudotumor, ptosis from other causes.

Contraindications:

Drugs that worsen MG: aminoglycosides, fluoroquinolones, macrolides, beta-blockers, procainamide, chloroquine, IV magnesium, neuromuscular blockers (prolonged effect)
Succinylcholine: unpredictable response
Overtreatment with pyridostigmine → cholinergic crisis

ICU Management (Myasthenic Crisis):

Mechanical ventilation if FVC <15 mL/kg or impending respiratory failure
IVIG 2 g/kg over 2–5 days OR plasma exchange (5 sessions) — act within 24h
Withhold pyridostigmine during crisis (may worsen secretions)
Treat precipitating infection, avoid offending drugs
Resume pyridostigmine when extubated

OPD Prescription:

Pyridostigmine 30–60 mg TDS–6×/day (acetylcholinesterase inhibitor)
Prednisolone 0.5–1 mg/kg/day (taper slowly; monitor for initial worsening)
Steroid-sparing: azathioprine 2–3 mg/kg/day; mycophenolate mofetil 1–2 g/day
Thymectomy for generalized MG <60 years (MGTX trial)

11. Parkinson's Disease

Investigations: Clinical diagnosis. DaT-SPECT/dopamine transporter scan (DaTscan) to distinguish from essential tremor; MRI brain to exclude Parkinson-plus syndromes; autonomic function tests; smell test (hyposmia, early marker).

Findings: DaTscan: asymmetric reduction in striatal dopamine transporter. MRI: "hummingbird sign" (midbrain atrophy) in PSP; "hot cross bun" in MSA. No specific blood test.

Differential Diagnosis: Essential tremor, drug-induced parkinsonism (antipsychotics, metoclopramide), PSP, MSA, DLB, vascular parkinsonism, Wilson's disease (young onset).

Contraindications:

Levodopa: contraindicated with non-selective MAO inhibitors (hypertensive crisis), active psychosis (use with caution), NMS
Dopamine agonists: avoid in cardiac valve disease (ergot-derived: cabergoline); impulse control disorder risk
Antipsychotics (especially haloperidol): worsen parkinsonism; only clozapine/quetiapine if psychosis needed
Metoclopramide, prochlorperazine: contraindicated (block dopamine)

ICU Management:

Continue dopaminergic medications via NG tube (do NOT abruptly stop — risk of NMS/akinetic crisis)
NMS: discontinue dopamine antagonists, dantrolene 1–2.5 mg/kg QID, bromocriptine, supportive care
Deep brain stimulation (DBS) perioperative management: coordinate with neurosurgery

OPD Prescription:

Levodopa-carbidopa (25/100) TDS (gold standard for motor symptoms)
Dopamine agonists (pramipexole 0.5–1.5 mg TDS, ropinirole 2–8 mg TDS) — first-line in young patients
MAO-B inhibitors: rasagiline 1 mg OD, selegiline 5 mg BD (neuroprotective, mild symptomatic)
COMT inhibitors: entacapone 200 mg with each levodopa dose (for wearing-off)
Constipation: lactulose; orthostatic hypotension: fludrocortisone; sialorrhea: botulinum toxin

12. Epilepsy

Investigations: EEG (ictal/interictal), MRI brain (gold standard structural imaging), serum AED levels, CBC, LFT, RFT, glucose, electrolytes, prolactin (elevated post-generalized seizure), ECG, neuropsychological assessment.

Findings: EEG: focal spikes/sharp waves (focal epilepsy), generalized 3 Hz spike-wave (absence), hypsarrhythmia (infantile spasms). MRI: hippocampal sclerosis, cortical dysplasia, tumors, vascular malformations.

Differential Diagnosis: Syncope (vasovagal), psychogenic non-epileptic seizures (PNES), cardiac arrhythmia, TIA, metabolic (hypoglycemia, hyponatremia), sleep disorders, movement disorders.

Contraindications:

Carbamazepine/oxcarbazepine: contraindicated in absence epilepsy and JME (worsens)
Valproate: avoid in pregnancy (teratogenic — neural tube defects), liver disease, mitochondrial disease
Phenytoin: avoid in porphyria, sinus bradycardia, heart block; teratogenic
Lamotrigine: start low and titrate slowly (Stevens-Johnson syndrome risk especially with valproate)
AED withdrawal: never abrupt (seizure threshold drops acutely)

ICU Management (Status Epilepticus):

Phase 1 (0–5 min): IV lorazepam 0.1 mg/kg (max 4 mg) × 2 doses; if no IV: IM midazolam 10 mg or buccal midazolam
Phase 2 (5–30 min): IV levetiracetam 60 mg/kg (max 4.5 g) OR valproate 40 mg/kg OR fosphenytoin 20 mg PE/kg
Phase 3 (>30 min, refractory): intubation, general anesthesia — propofol, midazolam infusion, thiopental
Treat underlying cause: glucose for hypoglycemia, thiamine for Wernicke's, antibiotics for meningitis

OPD Prescription (by epilepsy type):

Focal epilepsy: carbamazepine 400–1200 mg/day BD; lamotrigine 100–400 mg/day; levetiracetam 500–3000 mg/day
Generalized tonic-clonic: valproate 600–2000 mg/day (not in women of childbearing age); lamotrigine; levetiracetam
Absence: valproate or ethosuximide 500–1500 mg/day
JME: valproate (males), levetiracetam (females)
Seizure-free for 2 years → consider AED withdrawal (taper over 6 months)

13. Alzheimer's Disease (AD)

Investigations: MMSE/MoCA cognitive assessment, MRI brain (medial temporal lobe/hippocampal atrophy, parietal atrophy), CSF biomarkers (Aβ42 ↓, total tau ↑, phospho-tau ↑), amyloid PET/FDG-PET, genetic testing (APOE ε4), CBC, TSH, B12, folate, LFT, syphilis serology (to exclude reversible dementia).

Findings: MRI: hippocampal and entorhinal atrophy; global atrophy. PET: hypometabolism in parietotemporal cortices. CSF: low Aβ42 (<550 pg/mL), elevated p-tau (>80 pg/mL).

Differential Diagnosis: Vascular dementia, Lewy body dementia (DLB), frontotemporal dementia (FTD), normal pressure hydrocephalus (NPH), hypothyroidism, B12 deficiency, depression (pseudodementia), chronic subdural hematoma.

Contraindications:

Anticholinergic drugs: worsened cognitive function (avoid oxybutynin, diphenhydramine, TCAs)
Benzodiazepines: avoid (paradoxical agitation, sedation, fall risk)
Antipsychotics: use cautiously only for BPSD; increased stroke/death risk in dementia patients (black box warning)

ICU Management (Behavioral Crisis/Delirium on Background AD):

Treat underlying cause (infection, metabolic, medication)
Low-dose haloperidol 0.5–1 mg if severe agitation (short course)
Maintain hydration, nutrition; reorient; calm environment

OPD Prescription:

AChEI: donepezil 5–10 mg OD (first-line all stages); rivastigmine 3–6 mg BD or 9.5 mg patch; galantamine 8–24 mg/day
Moderate-severe: add memantine 5–20 mg OD (NMDA antagonist)
Lecanemab/donanemab (anti-amyloid mAb): for early/MCI stage (monitor for ARIA on MRI)
Manage comorbidities; caregiver education; legal planning (power of attorney)

14. Motor Neuron Disease (ALS/MND)

Investigations: EMG/NCS (fasciculations, fibrillations, widespread denervation with normal sensory NCS), MRI brain+spine (exclude mimic, UMN changes), genetic testing (SOD1, C9orf72 expansion, FUS, TARDBP), PFTs (FVC, sniff nasal inspiratory pressure — respiratory monitoring), speech assessment, LFT (riluzole baseline).

Findings: EMG: widespread denervation (fasciculations, positive sharp waves, reduced interference pattern) in ≥3 regions with normal sensory conduction — El Escorial/Awaji criteria. MRI: corticospinal tract signal change in brain.

Differential Diagnosis: Kennedy disease (SBMA — X-linked, gynecomastia), multifocal motor neuropathy (MMN — treatable!), cervical myelopathy + peripheral neuropathy, PLS, PMA, inclusion body myositis, Lambert-Eaton.

Contraindications:

Riluzole: contraindicated in liver disease (ALT >5× ULN), CYP1A2 inducers reduce efficacy
NIV/mechanical ventilation: patient preference; discuss ADRT
Opioids: use carefully to manage breathlessness (not contraindicated if for comfort)

ICU Management:

Respiratory failure: NIV (BiPAP) if FVC <50% or symptomatic (lengthens survival, improves QoL per NICE)
Invasive ventilation: only if patient has made an informed decision; otherwise comfort care
Sialorrhea: glycopyrronium, botulinum toxin to parotids
Nutrition: PEG/RIG tube if dysphagia and FVC >50% (below 50%, RIG safer)

OPD Prescription:

Riluzole 50 mg BD (glutamate antagonist; extends survival ~3 months)
Edaravone 60 mg IV daily × 14 days each 28-day cycle (Japan/US, selected patients)
Tofersen (SOD1-ALS): antisense oligonucleotide injection intrathecal
Baclofen/tizanidine (spasticity), dextromethorphan/quinidine (pseudobulbar affect), melatonin/mirtazapine (insomnia)

15. Spinal Cord Compression (Myelopathy)

Investigations: Urgent MRI spine (gold standard), plain X-ray (spondylosis, fracture), CT myelogram if MRI contraindicated, bone scan/PET if malignant compression, bone biopsy, PSA/CA-125/tumor markers (malignant cause), CBC, ESR, CRP.

Findings: MRI: cord compression with or without signal change (T2 hyperintensity = myelomalacia = worse prognosis); disc herniation, spondylotic bar, epidural mass. ASIA impairment scale for severity.

Differential Diagnosis: Transverse myelitis, MS (plaques), ALS, syringomyelia, intramedullary tumor, B12 deficiency myelopathy, HIV vacuolar myelopathy.

Contraindications:

High-dose steroids in traumatic cord injury: controversial (NASCIS III study); avoid unless within 8 h
Anticoagulation in epidural hematoma causing compression: must reverse urgently before surgery
MRI incompatible devices: use CT myelogram

ICU Management:

Traumatic: ABCDE; C-spine immobilization; mean arterial pressure >85 mmHg (spinal cord perfusion); avoid hypoxia/hypotension
Surgical decompression urgently (<6–24 h for best outcome)
Malignant cord compression: dexamethasone 16 mg loading then 4–8 mg QID; urgent radiotherapy or surgical decompression within 24 h
Urinary catheterization (neurogenic bladder); bowel care

OPD Prescription:

Post-decompression physiotherapy and rehabilitation
Neurogenic bladder: oxybutynin 5–10 mg TDS; intermittent self-catheterization
Neuropathic pain: pregabalin 75–300 mg BD, amitriptyline 25–75 mg OD
Spasticity: baclofen 10–80 mg/day, tizanidine 4–36 mg/day
Bisphosphonates if on steroids (osteoporosis prophylaxis)

16. Transverse Myelitis (TM)

Investigations: MRI spine with gadolinium (T2 signal spanning ≥2 vertebral segments = longitudinally extensive TM → NMOSD), CSF (lymphocytic pleocytosis, elevated protein), AQP4-IgG and MOG-IgG antibodies, VEP, HIV, NMO panel, autoimmune screen (ANA, ANCA, anti-dsDNA), Lyme serology, viral PCR.

Findings: MRI: central T2 cord signal change (MS = eccentric, <2 segments; NMOSD = central, ≥3 segments); Gd enhancement in active lesion.

Differential Diagnosis: MS, NMOSD, ADEM, spinal cord compression, ischemia (anterior spinal artery), paraneoplastic myelopathy, vascular malformation (DAVF).

Contraindications:

Natalizumab/fingolimod: NOT for NMOSD (may precipitate severe relapses)
High-dose steroids: standard first-line; avoid if infectious TM not excluded

ICU Management:

IV methylprednisolone 1 g/day × 3–5 days
If refractory or severe (NMOSD): plasma exchange 5 sessions + IVIG
Catheterization for retention; pressure sore prevention; DVT prophylaxis

OPD Prescription (NMOSD maintenance):

Azathioprine 2–3 mg/kg/day + prednisolone 5–10 mg OD (maintenance)
Eculizumab (AQP4+), inebilizumab, satralizumab — approved for NMOSD
MOG-IgG positive: high-dose steroids + mycophenolate
Physiotherapy, bladder management

17. Cervical Spondylotic Myelopathy (CSM)

Investigations: MRI cervical spine (cord compression, signal change), CT cervical spine (bony anatomy, osteophytes), plain X-ray (spondylosis, disc height loss, instability), EMG/NCS (coexistent radiculopathy), SSEP (spinal cord function assessment).

Findings: MRI: multilevel disc-osteophyte complexes, cord flattening, T2 hyperintensity (myelomalacia), T1 hypointensity (poor prognosis). CT: ossification of posterior longitudinal ligament (OPLL), spinal canal stenosis.

Differential Diagnosis: ALS (UMN+LMN = no sensory), MS, subacute combined degeneration (B12 deficiency), spinal cord tumor, normal pressure hydrocephalus (gait), peripheral neuropathy.

Contraindications:

High-dose steroids: not indicated routinely for degenerative CSM
Manipulation of cervical spine: ABSOLUTELY contraindicated in myelopathy (risk of acute quadriplegia)

ICU Management:

Post-surgical (anterior cervical discectomy and fusion / laminectomy): airway monitoring (anterior approach — hematoma compresses airway), neurological checks, neck immobilization.

OPD Prescription:

Mild: physiotherapy, NSAIDs (ibuprofen 400 mg TDS with food) short-term
Neuropathic pain: gabapentin 300 mg TDS, pregabalin 75 mg BD
Surgical referral if progressive myelopathy (decompression prevents deterioration)
B12 supplementation if coexistent deficiency; cervical collar (limited evidence)

18. Peripheral Neuropathy (Diabetic Polyneuropathy)

Investigations: HbA1c, fasting glucose, CBC, LFT, RFT, TSH, B12, folate, serum protein electrophoresis (SPEP), anti-MAG Ab, anti-ganglioside Ab, NCS (sensorimotor or motor or sensory), nerve biopsy (if systemic vasculitis suspected), skin punch biopsy (small fiber neuropathy).

Findings: NCS: symmetric sensorimotor polyneuropathy — reduced sural SNAP amplitude, prolonged latencies, slow CV (length-dependent); distal denervation on EMG.

Differential Diagnosis: B12 deficiency, hypothyroid, CIDP, vasculitic neuropathy, Charcot-Marie-Tooth, alcoholic neuropathy, toxic neuropathy (chemotherapy — paclitaxel, vincristine), amyloid neuropathy, POEMS.

Contraindications:

Metformin in severe neuropathy with B12 deficiency: increases B12 malabsorption (monitor B12)
Tricyclic antidepressants: avoid in cardiac arrhythmia, recent MI, glaucoma, urinary retention
Gabapentinoids in renal failure: dose-reduce

ICU Management: Rarely ICU-specific unless diabetic ketoacidosis or severe autonomic neuropathy causing hemodynamic instability (hypotension, arrhythmia).

OPD Prescription:

Tight glycemic control (HbA1c target <7%)
Neuropathic pain first-line: pregabalin 75–300 mg BD, duloxetine 30–60 mg OD, amitriptyline 10–75 mg OD
Second-line: gabapentin 300–1200 mg TDS, tramadol (with caution)
B12 1000 μg IM monthly × 3 months then 3-monthly (if deficient)
Foot care education, podiatry referral

19. Bell's Palsy (Idiopathic Facial Palsy)

Investigations: Clinical diagnosis. MRI with Gd (if atypical — bilateral, recurrent, no improvement at 3 months): exclude Ramsay Hunt, parotid tumor, stroke. If bilateral: Lyme serology, sarcoidosis (ACE, chest X-ray), HIV, diabetes screen.

Findings: Lower motor neuron facial palsy (all facial muscles, including forehead): House-Brackmann grading. Exclude UMN (forehead sparing = stroke). Ramsay Hunt: ipsilateral vesicles in ear (herpes zoster).

Differential Diagnosis: Stroke (spares forehead), Ramsay Hunt syndrome, Lyme disease, sarcoidosis, parotid tumor, Melkersson-Rosenthal syndrome, cholesteatoma, post-mastoidectomy.

Contraindications:

Antivirals alone without steroids: not recommended (NNT too high for antivirals alone)
Steroids contraindicated if: uncontrolled diabetes (relative — monitor glucose), active TB, peptic ulcer disease

ICU Management: Not typically ICU. Manage if associated with severe encephalitis (Ramsay Hunt with CNS involvement).

OPD Prescription (within 72 hours of onset):

Prednisolone 50 mg OD × 10 days (CORBELL trial: significantly improves outcomes)
Aciclovir 400 mg 5×/day × 7 days + prednisolone (Ramsay Hunt or suspected viral; modest additional benefit)
Eye care: artificial tears (lubricating eye drops QID), lubricating eye ointment at night, tape eyelid shut, eye patch
Physiotherapy (facial nerve rehabilitation)
Review at 3 months; if no recovery: EMG, consider surgical decompression

20. Trigeminal Neuralgia (TN)

Investigations: MRI brain + trigeminal nerve (FIESTA/CISS sequence): neurovascular compression at root entry zone; exclude MS, tumor (CPA, cavernoma), aneurysm. LP if demyelination suspected.

Findings: MRI CISS: artery (usually SCA) indenting trigeminal root. In MS: plaque at trigeminal nucleus. No abnormal blood tests expected.

Differential Diagnosis: Dental pain, SUNCT/SUNA, cluster headache, postherpetic neuralgia, glossopharyngeal neuralgia, atypical facial pain, TMJ disorders.

Contraindications:

Carbamazepine: avoid in HLA-B*1502 carriers (Asian populations) — severe cutaneous reactions (SJS/TEN); avoid with MAO inhibitors; monitor CBC (aplastic anemia, agranulocytosis risk)
Gabapentin dose adjustment in renal failure
Oxcarbazepine: hyponatremia — monitor sodium, especially in elderly

ICU Management: Not typically ICU. Acute severe pain crisis: IV lidocaine 1–5 mg/kg infusion (specialist setting) or IV phenytoin.

OPD Prescription:

First-line: carbamazepine 100–400 mg BD (titrate slowly; target 800–1200 mg/day)
Alternative: oxcarbazepine 300–900 mg BD; gabapentin 300 mg TDS–1800 mg/day; pregabalin 75–300 mg BD
Second-line: baclofen 10–80 mg/day (especially MS-TN)
Surgical: microvascular decompression (MVD) — best long-term outcome if neurovascular conflict confirmed; gamma knife radiosurgery; balloon compression; glycerol injection

21. Migraine

Investigations: Clinical diagnosis (ICHD-3 criteria). Brain MRI if: new headache pattern, focal neurology, thunderclap onset, postural headache, papilledema. CBC, metabolic panel to exclude secondary causes.

Findings: Usually normal MRI. May show white matter changes (migraine with aura — increased risk small vessel disease). ICHD-3: ≥5 attacks, 4–72 h, 2 of 4 features (unilateral, pulsating, moderate-severe, aggravated by movement) + 1 of: nausea/vomiting or photophobia/phonophobia.

Differential Diagnosis: Tension-type headache, cluster headache, sinusitis, SAH (thunderclap onset), idiopathic intracranial hypertension, cervicogenic headache, giant cell arteritis (>50 years), brain tumor.

Contraindications:

Triptans: contraindicated in basilar artery/hemiplegic migraine, IHD, uncontrolled hypertension, within 24 h of ergotamine
Ergotamines: contraindicated in peripheral vascular disease, coronary disease, pregnancy, hypertension
NSAIDs and triptans: risk of medication overuse headache (MOH) if >10–15 days/month
Beta-blockers (prophylaxis): avoid in asthma, COPD, heart block, depression
Valproate: absolutely avoid in pregnancy (teratogenic)

ICU Management: Rarely ICU. Status migrainosus (>72 h): IV hydration, IV prochlorperazine 12.5 mg or metoclopramide 10 mg, IV sumatriptan or dihydroergotamine, IV dexamethasone 4–8 mg.

OPD Prescription:

Acute: paracetamol 1 g + metoclopramide 10 mg; triptans (sumatriptan 50–100 mg PO, rizatriptan 10 mg); CGRP antagonists (ubrogepant, rimegepant)
Prophylaxis (≥4 days/month): propranolol 40–120 mg BD; topiramate 25–100 mg OD; amitriptyline 10–75 mg OD; CGRP mAb: erenumab 70–140 mg SC monthly, fremanezumab, galcanezumab

22. Idiopathic Intracranial Hypertension (IIH / Pseudotumor Cerebri)

Investigations: MRI brain (empty sella, optic nerve sheath distension, transverse sinus stenosis, flattening of posterior globe), LP (opening pressure >25 cmCSF, normal CSF composition), fundoscopy (papilledema), perimetry (visual field defects), BMI, ophthalmology referral.

Findings: Raised ICP on LP (>25 cmCSF). MRI: empty sella, enlarged optic nerve sheaths, bilateral transverse sinus stenosis. Visual fields: enlargement of blind spot, arcuate defects.

Differential Diagnosis: Cerebral venous sinus thrombosis (CVST), meningitis, hydrocephalus, brain tumor, medication-induced (tetracyclines, vitamin A, steroids withdrawal, oral contraceptives).

Contraindications:

Tetracyclines (including doxycycline): can precipitate or worsen IIH — avoid in IIH patients
Vitamin A/retinoids (isotretinoin): contraindicated
Excessive vitamin A supplementation: contraindicated

ICU Management: Fulminant IIH with severe visual loss: urgent serial therapeutic LP (30–40 mL) or neurosurgical shunt (LP shunt or VP shunt) or optic nerve sheath fenestration within 24–48 h.

OPD Prescription:

Acetazolamide 250 mg–1 g BD (carbonic anhydrase inhibitor; check sulfa allergy)
Topiramate 25–50 mg BD (alternative + weight loss benefit)
Weight loss program (10% body weight → 50% reduction in ICP)
Furosemide 40 mg OD as adjunct
Serial visual field monitoring (3-monthly)

23. Normal Pressure Hydrocephalus (NPH)

Investigations: MRI brain (Evans index >0.3, Sylvian fissure widening, tight high convexities, DESH pattern), CT brain, LP (large volume CSF tap test — 40–50 mL removal → gait improvement = shunt-responsive), Gait analysis, cognitive testing (MoCA), urodynamic study.

Findings: MRI: ventriculomegaly out of proportion to cortical atrophy; "tight" high parietal sulci; periventricular white matter changes. CSF: normal pressure and composition (by definition). Tap test: >20% improvement in gait = shunt responsive.

Differential Diagnosis: Alzheimer's disease (no gait), PD (no incontinence initially), vascular dementia, degenerative ataxia, spinal stenosis (gait), obstructive hydrocephalus.

Contraindications:

Shunting in patients with MRI not consistent with NPH: low likelihood of benefit with surgical risk
Acetazolamide: occasionally tried but no strong evidence; not standard
Anticoagulants: manage perioperatively for shunt insertion

ICU Management: Post-shunt: monitor for subdural hematoma (over-drainage), infection, malfunction; neurological checks.

OPD Prescription:

VP shunt or LP shunt (adjustable pressure shunt preferred)
Manage co-morbidities; falls prevention; bladder training
Regular shunt pressure checks (if programmable shunt), MRI (non-MRI compatible shunts: avoid)

24. Cerebral Venous Sinus Thrombosis (CVST)

Investigations: MRI brain + MRV (gold standard: absent flow void in sinus, T1 hyperintense thrombus), CT venogram, D-dimer (elevated), CBC (polycythemia, thrombocytopenia), coagulation (factor V Leiden, prothrombin mutation, protein C/S/antithrombin deficiency), anticardiolipin Ab, lupus anticoagulant, homocysteine, OCP use history.

Findings: MRI: "cord sign" (T1 bright thrombus in sinus), venous infarcts (often hemorrhagic, cross arterial territories), sulcal effacement. MRV: absent sinus flow. CT: "dense triangle sign" (superior sagittal sinus).

Differential Diagnosis: Bacterial meningitis, IIH, hypertensive encephalopathy, SAH, stroke, brain abscess.

Contraindications:

Anticoagulation: NOT contraindicated even if hemorrhagic venous infarct present (continue LMWH/UFH per ESO guidelines)
Avoid dehydration; avoid OCP postpartum (common precipitant)
Thrombolytics: reserved for deteriorating patients despite anticoagulation (specialist decision only)

ICU Management:

IV heparin (UFH) or LMWH full-dose anticoagulation immediately
ICP management if severe (head elevation, osmotherapy, EVD for hydrocephalus)
Seizure management (levetiracetam)
Endovascular thrombectomy/thrombolysis if deteriorating (last resort)

OPD Prescription:

Warfarin (INR 2–3) for 3–12 months depending on provoked/unprovoked
DOAC (dabigatran equivalent in RE-SPECT CVT trial)
Treat underlying cause (OCP discontinuation, thrombophilia workup)
Neurologist follow-up MRV at 3–6 months

25. Brain Abscess

Investigations: MRI brain with contrast (ring enhancement + restricted diffusion in DWI — distinguishes from tumor), CT with contrast, blood cultures × 2, CBC (leukocytosis), CRP, ESR, chest X-ray (source: lung abscess, TB), echo (endocarditis), dental X-ray, ENT assessment (sinusitis, mastoiditis), HIV, immunosuppression screen.

Findings: CT/MRI: ring-enhancing lesion with surrounding edema; DWI restricted diffusion (pyogenic abscess — bright DWI, dark ADC) vs. tumor (no diffusion restriction). MR spectroscopy: amino acids (leucine, isoleucine, valine), succinate, acetate peaks in abscess.

Differential Diagnosis: Glioblastoma (GBM), metastasis, lymphoma (CNS), tumefactive MS, subacute infarct, toxoplasmosis (immunocompromised), neurocysticercosis.

Contraindications:

LP: ABSOLUTE CONTRAINDICATION (raised ICP, herniation risk)
Steroids: use only for life-threatening edema (reduce antibiotic penetration); taper rapidly
Delay in surgery: worsens outcome in abscess >2.5 cm or deteriorating

ICU Management:

Surgical drainage (stereotactic aspiration or open craniotomy)
IV antibiotics 4–6 weeks: ceftriaxone 2 g BD + metronidazole 500 mg TDS (± vancomycin if MRSA/post-surgical)
Dexamethasone only if life-threatening herniation; taper quickly
Seizure prophylaxis (levetiracetam), ICP management

OPD Prescription:

Oral antibiotics to complete course guided by culture/sensitivity
Levetiracetam 500–1000 mg BD (seizure prophylaxis for ≥3 months)
Treat source (dental, ENT, cardiac)
Follow-up MRI at 4–6 weeks to assess resolution

26. Neuromyelitis Optica Spectrum Disorder (NMOSD)

Investigations: AQP4-IgG (serum ELISA: sensitivity ~73%, specificity >99%), MOG-IgG (if AQP4 negative), MRI brain + spine (longitudinally extensive TM ≥3 segments; area postrema lesion; periaqueductal GM lesion; optic nerve enhancement), VEP, CSF analysis, NMO panel.

Findings: MRI spine: central T2 hyperintensity ≥3 vertebral segments (vs MS <2 segments, eccentric). MRI brain: area postrema lesion (intractable hiccups/vomiting), hypothalamic, periaqueductal lesions.

Differential Diagnosis: MS, ADEM, MOG-antibody disease, acute transverse myelitis (idiopathic), paraneoplastic myelopathy, lupus myelitis, spinal cord compression.

Contraindications:

MS disease-modifying therapies (natalizumab, fingolimod, IFN-beta): absolutely contraindicated in NMOSD AQP4+ (exacerbate disease)
Alemtuzumab: may worsen NMOSD

ICU Management:

Acute attack: IV methylprednisolone 1 g/day × 5 days
Plasma exchange 5 sessions if incomplete steroid response (severe attacks)
Respiratory support if high cervical cord involvement

OPD Prescription (Maintenance — attack prevention):

AQP4+: eculizumab (complement C5 inhibitor) — FDA approved, most effective; inebilizumab (CD19 depleter); satralizumab (IL-6R inhibitor)
Alternative: azathioprine 2–3 mg/kg/day + oral prednisolone (low cost option)
Mycophenolate mofetil 1.5–3 g/day
MOG-IgG+: high-dose steroids; IVIG for attack prevention; rituximab

27. Huntington's Disease

Investigations: Genetic testing: HTT CAG repeat expansion (≥36 repeats diagnostic; ≥40 = full penetrance); MRI brain (caudate nucleus atrophy, "boxer's brain," dilated lateral ventricles); neuropsychological testing; FDG-PET (caudate/putamen hypometabolism); pre-symptomatic genetic counseling before testing.

Findings: MRI: caudate nucleus atrophy (butterfly sign with dilated lateral ventricles), putaminal atrophy. Genetic: CAG ≥36; higher repeat length = earlier onset.

Differential Diagnosis: Wilson's disease (KF rings, ceruloplasmin), chorea gravidarum, Sydenham's chorea, Huntington disease-like syndromes (HDL1–4), dentatorubral-pallidoluysian atrophy (DRPLA), neuroacanthocytosis, benign hereditary chorea.

Contraindications:

Tetrabenazine/valbenazine: contraindicated in depression (worsens), suicidal ideation, Parkinson's features; avoid with MAO inhibitors
Dopamine antagonists (haloperidol for chorea): risk of tardive dyskinesia with prolonged use
Genetic testing in minors: generally deferred (ethical issues)

ICU Management: Rarely ICU unless severe aspiration pneumonia (dysphagia), chorea-related trauma, severe psychiatric crisis. Manage chorea acutely with benzodiazepines (clonazepam 0.5 mg IV).

OPD Prescription:

Chorea: tetrabenazine 12.5–50 mg TDS; deutetrabenazine 6–48 mg/day (better tolerated); valbenazine
Dystonia: baclofen, botulinum toxin
Psychiatric: SSRI (fluoxetine/sertraline — depression), quetiapine (psychosis/sleep)
Cognitive: rivastigmine (limited evidence)
Multidisciplinary: speech therapy (dysphagia), dietitian, social work, genetic counseling

28. Wilson's Disease (Hepatolenticular Degeneration)

Investigations: Serum ceruloplasmin (<0.2 g/L), serum copper (total), 24-hour urine copper (>100 μg/24h), slit-lamp examination (Kayser-Fleischer rings), LFT, coagulation, MRI brain (T2 hyperintensity in putamen, caudate, thalamus, pons — "face of giant panda"), liver biopsy (quantitative copper >250 μg/g dry weight), ATPB7 gene mutation analysis.

Findings: MRI brain: bilateral putaminal/thalamic T2 hyperintensity; "face of giant panda" sign (midbrain); "face of miniature panda" (pontine). KF rings on slit-lamp. Liver: steatosis → cirrhosis. Coombs-negative hemolytic anemia.

Differential Diagnosis: Young-onset Parkinson's disease, Huntington's disease, juvenile HD, OAT (organic acidurias), manganese toxicity, Hallervorden-Spatz (PKAN), autoimmune hepatitis, viral hepatitis.

Contraindications:

Zinc + penicillamine simultaneously: do not co-administer (zinc reduces penicillamine absorption)
Penicillamine: contraindicated in penicillin hypersensitivity (10% cross-reactivity), optic neuritis, lupus, severe renal impairment; neurological worsening risk initially
Abrupt discontinuation of chelation therapy: can cause catastrophic hepatic decompensation

ICU Management (Acute Liver Failure / Fulminant Wilson's):

Urgently list for liver transplantation (Wilson's Index / King's Criteria)
Plasmapheresis/albumin dialysis to reduce copper load preoperatively
Treat coagulopathy (FFP, vitamin K), cerebral edema management, hepatic encephalopathy management (lactulose, rifaximin)

OPD Prescription:

Chelation: penicillamine 500–750 mg BD (titrate to urine copper); pyridoxine 25 mg OD (prevent B6 deficiency)
Alternative: trientine 750 mg BD–TDS (better tolerated, less side effects than penicillamine)
Maintenance: zinc acetate 50 mg TDS (blocks GI copper absorption; used for pre-symptomatic or maintenance after chelation)
Low-copper diet (avoid: liver, shellfish, nuts, mushrooms, chocolate)
Monitoring: 24-h urine copper, LFT, CBC q6-monthly; slit-lamp q1 yearly

29. Spinal Muscular Atrophy (SMA)

Investigations: SMN1 gene deletion (homozygous deletion/conversion of exon 7 = diagnostic), SMN2 copy number (predicts severity, guides therapy selection), EMG/NCS (fibrillation, positive sharp waves, fasciculations, normal sensory), muscle biopsy (grouped atrophy), CK (normal or mildly elevated), PFT (FVC monitoring), swallowing assessment.

Findings: EMG: denervation changes; NCS: normal sensory, reduced CMAP. SMN1 deletion confirms diagnosis. SMN2 copies: 2 = SMA type I–II; 3–4 = type III–IV.

Differential Diagnosis: GBS (acute onset, sensory involvement, CSF dissociation), LEMS, spinal cord injury, congenital myopathy, Pompe disease (GAA deficiency), Werdnig-Hoffmann disease (type I SMA is Werdnig-Hoffmann).

Contraindications:

Nusinersen intrathecal: avoid in active infection, severe spinal deformity limiting LP access; monitor for communicating hydrocephalus
Gene therapy (onasemnogene abeparvovec/Zolgensma): weight limit <21 kg; anti-AAV9 antibody titer high = excluded; hepatotoxicity monitoring required; ONLY for infants ≤2 years
Risdiplam: not studied in SMA0/type I on permanent ventilation safely

ICU Management:

Respiratory failure: NIV (BiPAP) first; invasive ventilation per family/patient wishes
Nutritional support: NG/PEG tube for SMA type I/II with poor suck/swallow
Prevent respiratory infections: vaccination (influenza, pneumococcal), prompt antibiotic treatment

OPD Prescription:

Nusinersen (Spinraza): intrathecal injections — 4 loading doses (days 1, 14, 28, 63), then q4 months maintenance
Risdiplam (Evrysdi): 0.2–0.25 mg/kg/day PO (splice modifier; for type II/III adults/children)
Onasemnogene abeparvovec (Zolgensma): IV single-dose gene replacement; for infants ≤2 years with confirmed diagnosis
Physiotherapy, assistive technology, respiratory equipment, genetic counseling

30. Neurocysticercosis (NCC)

Investigations: MRI brain (most sensitive: scolex within cyst = pathognomonic "hole with dot" sign), CT brain (calcifications in chronic stage), serology (EITB: sensitivity 80–100% for multiple lesions, less for single), CSF (lymphocytic pleocytosis, elevated protein, eosinophilia, EITB in CSF), CBC (eosinophilia, peripheral), stool O&P (for intestinal taeniasis), ophthalmic examination (ocular NCC).

Findings: MRI: 4 stages — vesicular (live cyst, clear fluid, scolex visible), colloidal vesicular (cyst wall enhancement, perilesional edema), granular nodular (small ring-enhancing nodule), nodular calcified (Ca2+ spot, no edema). CT: calcifications (end-stage).

Differential Diagnosis: Brain abscess, glioma, meningioma, TB tuberculoma, CNS lymphoma, hydatid cyst (Echinococcus), CNS toxoplasmosis (immunocompromised), DNET.

Contraindications:

Antiparasitic (albendazole/praziquantel) WITHOUT steroids: risk of severe inflammatory response / edema / status epilepticus (always cover with dexamethasone)
Antiparasitic therapy in: ocular NCC (risk of inflammatory ocular damage — treat ocular first surgically), spinal NCC (controversial), calcified/dead cysts (not beneficial)
Praziquantel + rifampicin, carbamazepine, phenytoin: major drug interactions (CYP450 induction reduces praziquantel levels significantly)

ICU Management:

Acute hydrocephalus: EVD or VP shunt; ventricular NCC may need endoscopic removal
Status epilepticus: standard management (lorazepam → levetiracetam)
Massive edema: dexamethasone 4–8 mg QID
Antiparasitic + steroid cover: start dexamethasone 24–48 h before antiparasitic

OPD Prescription:

Antiparasitic: albendazole 7.5 mg/kg BD (max 400 mg BD) × 10–28 days (preferred over praziquantel for brain parenchymal NCC; better CSF penetration)
Combined therapy for multiple cysts: albendazole + praziquantel 50 mg/kg/day in 3 divided doses × 14 days
Dexamethasone 6–8 mg/day (reduce inflammation during antiparasitic course) OR prednisolone 1 mg/kg/day
Antiepileptics: carbamazepine 200–400 mg BD or levetiracetam 500–1000 mg BD (continue until calcification/cure confirmed × 1–2 years minimum)
Repeat MRI at 3–6 months; albendazole + steroid cycles for recalcitrant multi-lesion disease

Summary Reference Table

#	Disease	Key Investigation	First-Line ICU Treatment	Key OPD Drug	Critical Contraindication
1	Ischemic Stroke	MRI DWI	IV alteplase / thrombectomy	Aspirin + statin	tPA if >4.5h or hemorrhage
2	ICH	CT brain	BP <140 mmHg, reverse AC	Antihypertensive	Anticoagulants, steroids
3	SAH	CT + LP (xanthochromia)	Nimodipine + aneurysm repair	Nimodipine 60mg q4h	Anticoagulation pre-repair
4	TIA	MRI DWI, ECG, Holter	Admit if high risk	Dual antiplatelet × 21d	Long-term dual antiplatelet
5	Bacterial Meningitis	CSF culture, PCR	Ceftriaxone + Dexa	Vaccination	LP if raised ICP
6	HSV Encephalitis	CSF HSV PCR, MRI	IV Acyclovir 10mg/kg q8h	Valacyclovir maintenance	Withhold acyclovir for PCR
7	TBM	CSF AFB, PCR, ADA	HRZE + dexamethasone	ATT 9–12 months	Monotherapy
8	MS	MRI (Dawson's fingers), OCBs	IV methylprednisolone 1g/d × 5	Natalizumab/ocrelizumab	JC+ natalizumab
9	GBS	CSF protein↑ + NCS	IVIG 2g/kg or PEX	Gabapentin (pain)	Steroids
10	Myasthenia Gravis	Anti-AChR Ab, SFEMG	IVIG or PEX, intubate if FVC<15	Pyridostigmine 60 mg TDS	Aminoglycosides, beta-blockers
11	Parkinson's Disease	DaTscan, MRI	Continue levodopa via NG	Levodopa-carbidopa	Metoclopramide, haloperidol
12	Epilepsy	EEG, MRI brain	Lorazepam → levetiracetam → anesthesia	AED per epilepsy type	Carbamazepine in absence/JME
13	Alzheimer's Disease	MRI, CSF biomarkers, PET	Treat delirium precipitant	Donepezil + memantine	Anticholinergics, benzo
14	MND/ALS	EMG, SOD1 gene	NIV (BiPAP) if FVC<50%	Riluzole 50mg BD	Stopping levodopa abruptly
15	Cord Compression	MRI spine	Dexamethasone + urgent decompression	Gabapentinoids	Cervical manipulation in myelopathy
16	Transverse Myelitis	MRI spine, AQP4-IgG	IV methylprednisolone	Azathioprine (NMOSD)	Natalizumab in NMOSD
17	Cervical Spondylosis	MRI cervical, SSEP	Post-surgical airway monitoring	Pregabalin + surgical referral	Cervical manipulation
18	Diabetic Neuropathy	NCS, HbA1c	Autonomic instability support	Pregabalin/duloxetine	Metformin → B12 depletion
19	Bell's Palsy	MRI if atypical	Steroids (if encephalitis rare)	Prednisolone 50mg × 10d	Steroids alone in Ramsay Hunt
20	Trigeminal Neuralgia	MRI CISS/FIESTA	IV lidocaine (acute crisis)	Carbamazepine 100–400 mg BD	Carbamazepine in HLA-B*1502+
21	Migraine	Clinical, MRI if atypical	IV prochlorperazine, IV DHE	Sumatriptan/triptans	Triptans in IHD, basilar migraine
22	IIH	MRI + LP opening pressure	Therapeutic LP, shunt if acute	Acetazolamide 250–1000 mg BD	Tetracyclines, retinoids
23	NPH	MRI + tap test	Post-shunt monitoring	VP shunt	Shunt without confirmed NPH
24	CVST	MRI + MRV	LMWH anticoagulation	Warfarin/DOAC 3–12 months	Withholding anticoagulation
25	Brain Abscess	MRI DWI ring-enhancing	Ceftriaxone + metro + drainage	Levetiracetam + oral antibiotics	LP (absolute CI)
26	NMOSD	AQP4-IgG, MRI spine	IVMP + plasma exchange	Eculizumab/azathioprine	Natalizumab, fingolimod, IFN-β
27	Huntington's Disease	HTT CAG repeat, MRI	Clonazepam (acute chorea)	Tetrabenazine/deutetrabenazine	Tetrabenazine in depression/suicide
28	Wilson's Disease	Ceruloplasmin + KF rings	Liver transplant listing (fulminant)	Penicillamine or trientine + zinc	Simultaneous zinc + penicillamine
29	SMA	SMN1 deletion, EMG	NIV/PEG feeding	Nusinersen/risdiplam/Zolgensma	Zolgensma if >21 kg or anti-AAV+
30	Neurocysticercosis	MRI (scolex), EITB serology	Dexamethasone + antiparasitic	Albendazole + antiepileptic	Antiparasitic without steroids

Sources: Bradley and Daroff's Neurology in Clinical Practice | Adams and Victor's Principles of Neurology, 12th Ed | Harrison's Principles of Internal Medicine 22E | Plum and Posner's Diagnosis and Treatment of Stupor and Coma | Rosen's Emergency Medicine | NICE/ESO/AHA Clinical GuidelinesHere is the complete clinical reference for all 30 nervous system and spinal cord diseases, each covering all six domains you requested. A quick orientation:

Structure for each disease:

Investigations — which tests to order and why
Findings — what those tests show
Differential Diagnosis — conditions to consider and distinguish
Contraindications — drugs, procedures, and interventions to avoid
ICU Management — acute/critical care protocols
OPD Prescription — long-term outpatient treatment with specific drugs and doses

Diseases covered (1–30):

Ischemic Stroke | 2. Intracerebral Hemorrhage | 3. Subarachnoid Hemorrhage | 4. TIA | 5. Bacterial Meningitis | 6. HSV Encephalitis | 7. TB Meningitis | 8. Multiple Sclerosis | 9. Guillain-Barré Syndrome | 10. Myasthenia Gravis | 11. Parkinson's Disease | 12. Epilepsy | 13. Alzheimer's Disease | 14. MND/ALS | 15. Spinal Cord Compression | 16. Transverse Myelitis | 17. Cervical Spondylotic Myelopathy | 18. Diabetic Neuropathy | 19. Bell's Palsy | 20. Trigeminal Neuralgia | 21. Migraine | 22. IIH | 23. Normal Pressure Hydrocephalus | 24. Cerebral Venous Sinus Thrombosis | 25. Brain Abscess | 26. NMOSD | 27. Huntington's Disease | 28. Wilson's Disease | 29. Spinal Muscular Atrophy | 30. Neurocysticercosis

Key points to note:

The summary table at the end gives a rapid one-line reference for all 30 diseases — useful for quick revision or bedside reference
Contraindications are clinically critical — e.g., steroids worsen GBS; natalizumab/fingolimod are absolutely contraindicated in NMOSD; tPA has strict exclusion criteria; LP is absolutely contraindicated in brain abscess
ICU protocols follow current AHA/ESO/NICE guidelines (alteplase dosing, status epilepticus ladder, ventilation thresholds in GBS/MG/SMA)
OPD prescriptions include specific drug names, doses, and frequencies

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