30 types nervous system and spinal cord disease treatment investigation finding differential diagnosis contraindication ICO management OPD prescription give me a sign and symptom
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Given the budget constraints and the breadth of this request (30 types of nervous system and spinal cord diseases), I'll compile a comprehensive reference from authoritative neurology sources — Adams and Victor's Principles of Neurology, Bradley and Daroff's Neurology in Clinical Practice, and related textbooks — drawing on my integrated medical knowledge.
30 Nervous System & Spinal Cord Diseases
Signs & Symptoms | Investigations | Findings | Differential Diagnosis | Contraindications | ICU Management | OPD Prescription | Treatment
1. ISCHEMIC STROKE (CVA)
| Domain | Details |
|---|---|
| Signs & Symptoms | Sudden hemiplegia/hemiparesis, facial droop, dysphasia/aphasia, hemianopia, neglect, ataxia (FAST criteria) |
| Investigations | Non-contrast CT brain (immediate), MRI DWI (gold standard), CT angiography, ECG, Echo, CBC, INR, lipids, glucose |
| Findings | CT: hypodense area (>6 hrs); MRI DWI: bright signal; perfusion mismatch (penumbra) |
| Differential Dx | Hemorrhagic stroke, Todd's palsy, hypoglycemia, brain tumor, MS relapse, hemiplegic migraine |
| Contraindications | IV tPA contraindicated if: BP >185/110 uncontrolled, recent surgery (<14 days), INR >1.7, platelets <100k, prior ICH |
| ICU Management | BP control (allow permissive HTN <220/120 if no tPA), airway protection, IV tPA (0–4.5 hrs), thrombectomy (0–24 hrs), glucose control, DVT prophylaxis |
| OPD Prescription | Aspirin 75–100 mg OD + Clopidogrel 75 mg OD (dual, 21 days then mono), Atorvastatin 40–80 mg ON, Antihypertensives, rehabilitation |
| Treatment | Thrombolysis (alteplase 0.9 mg/kg IV), mechanical thrombectomy, secondary prevention |
2. HEMORRHAGIC STROKE (ICH)
| Domain | Details |
|---|---|
| Signs & Symptoms | Sudden severe headache ("worst of life"), vomiting, altered consciousness, focal deficits, neck stiffness (if SAH) |
| Investigations | Non-contrast CT (gold standard), MRI, LP (xanthochromia if CT negative), coagulation screen, CTA for aneurysm |
| Findings | CT: hyperdense (white) blood collection; SAH: blood in cisterns; MRI: blood products |
| Differential Dx | Ischemic stroke, hypertensive encephalopathy, meningitis, migraine, brain tumor with bleeding |
| Contraindications | Anticoagulants, tPA, NSAIDs; avoid aggressive BP lowering (SBP <130 if on anticoagulants, else target <140) |
| ICU Management | SBP target <140 mmHg, reverse anticoagulation (Vitamin K, FFP, PCC), ICP monitoring, neurosurgical evacuation if indicated, nimodipine (for SAH vasospasm) |
| OPD Prescription | Nimodipine 60 mg q4h × 21 days (SAH), antiepileptics if seizures (Levetiracetam), manage underlying cause |
| Treatment | Surgical hematoma evacuation, endovascular coiling/clipping (aneurysm), control coagulopathy |
3. SUBARACHNOID HEMORRHAGE (SAH)
| Domain | Details |
|---|---|
| Signs & Symptoms | Thunderclap headache, photophobia, neck stiffness, vomiting, brief LOC, sentinel headache |
| Investigations | Non-contrast CT (within 6 hrs: 98% sensitive), LP (xanthochromia), CTA/DSA for aneurysm |
| Findings | CT: hyperdense blood in basal cisterns/sulci; LP: xanthochromia; DSA: berry aneurysm |
| Differential Dx | ICH, meningitis, migraine, hypertensive crisis, cervical artery dissection |
| Contraindications | LP contraindicated if papilledema or mass lesion; avoid anticoagulants until aneurysm secured |
| ICU Management | Nimodipine 60 mg q4h, euvolemia, BP control (SBP <160 until secured), TCD monitoring for vasospasm, ventricular drainage if hydrocephalus |
| OPD Prescription | Nimodipine, antiepileptics, stool softeners, follow-up angiography |
| Treatment | Surgical clipping or endovascular coiling of aneurysm |
4. MENINGITIS (BACTERIAL)
| Domain | Details |
|---|---|
| Signs & Symptoms | Fever, severe headache, neck stiffness (Kernig's/Brudzinski's sign +ve), photophobia, phonophobia, petechial rash (meningococcal), altered consciousness |
| Investigations | CSF analysis (urgent LP), blood cultures, CBC, CRP, PCT, CT before LP if papilledema/focal signs |
| Findings | CSF: turbid, high pressure; WBC >1000 (neutrophils), protein >1 g/L, glucose <2.2 mmol/L (CSF:serum ratio <0.4); Gram stain/culture |
| Differential Dx | Viral meningitis, encephalitis, subarachnoid hemorrhage, brain abscess, TB meningitis |
| Contraindications | LP contraindicated without prior CT if focal signs, papilledema, GCS <13, seizures |
| ICU Management | IV Ceftriaxone 2g q12h (immediate), Dexamethasone 0.15 mg/kg q6h × 4 days (give before/with first antibiotic), airway management, fluid resuscitation |
| OPD Prescription | Complete antibiotic course; Rifampicin prophylaxis for contacts; vaccines |
| Treatment | IV Ceftriaxone ± Ampicillin (Listeria cover if >50 yrs), steroids |
5. VIRAL ENCEPHALITIS (HSV)
| Domain | Details |
|---|---|
| Signs & Symptoms | Fever, headache, altered consciousness, behavioural changes, temporal lobe features (olfactory hallucinations, amnesia, aphasia), seizures |
| Investigations | MRI brain (T2/FLAIR temporal lobe), LP: CSF PCR for HSV (gold standard), EEG (periodic lateralizing discharges in temporal lobe) |
| Findings | MRI: temporal/frontotemporal T2 hyperintensity; CSF: lymphocytic pleocytosis; EEG: PLEDs |
| Differential Dx | Bacterial meningitis, autoimmune encephalitis (NMDA-R), brain abscess, metabolic encephalopathy, TB |
| Contraindications | Avoid steroids before antiviral treatment unless herpes ruled out; avoid LP if herniation risk |
| ICU Management | IV Aciclovir 10 mg/kg q8h × 14–21 days, seizure control (Levetiracetam), ICP management, ICU monitoring |
| OPD Prescription | Complete aciclovir course, antiepileptics, neuropsychological rehabilitation |
| Treatment | Aciclovir IV; add steroids if autoimmune overlap confirmed |
6. EPILEPSY / SEIZURES
| Domain | Details |
|---|---|
| Signs & Symptoms | Tonic-clonic convulsions, absence episodes, focal motor/sensory features, automatisms, postictal confusion/Todd's palsy |
| Investigations | EEG, MRI brain, blood glucose, electrolytes, AED levels, toxicology screen |
| Findings | EEG: epileptiform discharges; MRI: structural lesion if symptomatic |
| Differential Dx | Syncope, non-epileptic attack disorder (NEAD), TIA, hypoglycemia, movement disorders |
| Contraindications | Carbamazepine in Na channelopathy/absence; Phenytoin IV rapid bolus (cardiac arrhythmia); Valproate in pregnancy (teratogenic); driving restrictions |
| ICU Management | Status epilepticus: Lorazepam 4 mg IV → Phenytoin/Levetiracetam → Phenobarbitone → Propofol/Midazolam infusion (refractory) |
| OPD Prescription | Levetiracetam 500 mg BD, Sodium Valproate 500 mg BD (not in pregnancy), Carbamazepine 200 mg BD, Lamotrigine 25–100 mg BD |
| Treatment | AED monotherapy first, lifestyle advice, surgery (if drug-resistant focal epilepsy) |
7. MULTIPLE SCLEROSIS (MS)
| Domain | Details |
|---|---|
| Signs & Symptoms | Optic neuritis (painful monocular vision loss), INO (diplopia), spastic paraparesis, cerebellar ataxia, sensory symptoms, bladder dysfunction, Lhermitte's sign, Uhthoff's phenomenon (heat-worsened) |
| Investigations | MRI brain/spine (gadolinium), Visual Evoked Potentials, CSF oligoclonal bands, IgG index |
| Findings | MRI: periventricular, juxtacortical, infratentorial, spinal cord plaques (McD criteria); CSF: oligoclonal bands (>2); delayed VEPs |
| Differential Dx | NMO (AQP4/MOG antibodies), CNS vasculitis, B12 deficiency, neurosarcoidosis, brain tumors |
| Contraindications | Live vaccines contraindicated with immunomodulatory therapy; Natalizumab — PML risk (JC virus +ve); avoid beta-interferon in severe depression |
| ICU Management | Acute relapse: Methylprednisolone 1g IV × 3–5 days; respiratory compromise → intubation |
| OPD Prescription | Disease-modifying therapy: Beta-interferon 1a/1b, Glatiramer acetate, Dimethyl fumarate, Natalizumab, Ocrelizumab; Baclofen for spasticity; Oxybutynin for bladder |
| Treatment | DMTs to reduce relapse rate; symptomatic management; physiotherapy |
8. PARKINSON'S DISEASE
| Domain | Details |
|---|---|
| Signs & Symptoms | Resting tremor (pill-rolling), rigidity (lead-pipe/cogwheel), bradykinesia, postural instability, hypomimia, micrographia, festinant gait, anosmia, REM sleep disorder, constipation |
| Investigations | Clinical diagnosis; DaTscan (DAT SPECT) to confirm dopaminergic deficit; MRI to exclude other causes |
| Findings | DaTscan: reduced dopamine transporter uptake; MRI: usually normal; Pathology: Lewy bodies (alpha-synuclein) in substantia nigra |
| Differential Dx | Essential tremor, MSA, PSP, Lewy body dementia, drug-induced parkinsonism (metoclopramide, antipsychotics), NPH, Wilson's disease |
| Contraindications | Metoclopramide, prochlorperazine (dopamine antagonists worsen PD); avoid abrupt withdrawal of levodopa (NMS risk) |
| ICU Management | Continue levodopa enterally; avoid dopamine-blocking antiemetics; if NPO, rotigotine patch |
| OPD Prescription | Levodopa/Carbidopa 100/25 mg TDS (gold standard), Pramipexole 0.125–1 mg TDS, Selegiline 5 mg BD, Entacapone 200 mg with each levodopa dose |
| Treatment | Levodopa remains gold standard; DBS (deep brain stimulation) for advanced cases; physiotherapy, speech therapy |
9. ALZHEIMER'S DISEASE
| Domain | Details |
|---|---|
| Signs & Symptoms | Progressive episodic memory loss, visuospatial difficulty, executive dysfunction, apraxia, aphasia, personality change, behavioural symptoms |
| Investigations | MMSE/MoCA, CT/MRI (hippocampal atrophy), PET amyloid scan, CSF (Aβ42↓, tau/p-tau↑), ApoE genotyping |
| Findings | MRI: medial temporal/hippocampal atrophy; PET: amyloid/tau deposition; CSF: characteristic biomarker pattern |
| Differential Dx | Vascular dementia, Lewy body dementia, FTD, normal pressure hydrocephalus, hypothyroidism, B12 deficiency, depression |
| Contraindications | Anticholinergics (worsen cognition); benzodiazepines (↑fall risk, worsen cognition); Donepezil — bradycardia in sick sinus syndrome |
| ICU Management | Delirium superimposed on dementia management; avoid sedatives; treat underlying cause |
| OPD Prescription | Donepezil 5–10 mg OD (AChEI), Rivastigmine 1.5–6 mg BD, Galantamine 8–24 mg OD, Memantine 5–20 mg OD (moderate-severe), Lecanemab/Donanemab (anti-amyloid mAbs, new) |
| Treatment | Symptomatic only (most); anti-amyloid therapy emerging; caregiver support, occupational therapy |
10. GUILLAIN-BARRÉ SYNDROME (GBS)
| Domain | Details |
|---|---|
| Signs & Symptoms | Ascending flaccid paralysis (distal to proximal), areflexia, back/limb pain, autonomic dysfunction (labile BP, arrhythmia), respiratory failure, cranial nerve palsies (facial diplegia) |
| Investigations | LP: CSF (albuminocytological dissociation), nerve conduction studies (NCS), anti-ganglioside antibodies (anti-GQ1b in MFS), pulmonary function (FVC monitoring) |
| Findings | CSF: high protein (>0.45 g/L) with normal WBC; NCS: demyelinating or axonal pattern |
| Differential Dx | Myasthenia gravis, botulism, diphtheria, transverse myelitis, spinal cord compression, critical illness polyneuropathy |
| Contraindications | Steroids (not beneficial, may worsen); avoid succinylcholine (hyperkalemia); caution with IV fluids (autonomic instability) |
| ICU Management | Respiratory monitoring (FVC — intubate if <20 ml/kg or 20-30-40 rule), IVIG 0.4 g/kg/day × 5 days OR plasma exchange (5 exchanges), autonomic management, DVT prophylaxis |
| OPD Prescription | Analgesia (gabapentin/pregabalin for neuropathic pain), physiotherapy, bladder/bowel care |
| Treatment | IVIG or plasmapheresis (equivalent efficacy); supportive care; rehab |
11. MYASTHENIA GRAVIS (MG)
| Domain | Details |
|---|---|
| Signs & Symptoms | Fatigable ptosis, diplopia, dysarthria, dysphagia, proximal limb weakness, respiratory failure (myasthenic crisis); symptoms worsen with activity |
| Investigations | Anti-AChR antibodies (85%), anti-MuSK antibodies (10%), Tensilon (edrophonium) test, repetitive nerve stimulation (decremental response), SFEMG, CT chest (thymoma) |
| Findings | Decremental EMG response; positive antibodies; thymoma on CT in 10–15% |
| Differential Dx | Lambert-Eaton syndrome (proximal > ocular, facilitating on RNS), GBS, botulism, ocular myopathies, stroke |
| Contraindications | Avoid drugs that worsen MG: aminoglycosides, fluoroquinolones, beta-blockers, neuromuscular blockers, Mg²⁺; avoid succinylcholine |
| ICU Management | Myasthenic crisis: IVIG 2 g/kg over 5 days OR plasmapheresis; intubation/ventilation if FVC falling; stop/taper anticholinesterases during crisis |
| OPD Prescription | Pyridostigmine 30–60 mg TDS–QDS, Prednisolone 1 mg/kg (start low, increase slowly), Azathioprine 2–3 mg/kg OD, Mycophenolate mofetil 1–1.5 g BD, Eculizumab (refractory) |
| Treatment | Anticholinesterases (symptomatic), immunosuppression, thymectomy (generalized MG, thymoma) |
12. MOTOR NEURONE DISEASE (MND/ALS)
| Domain | Details |
|---|---|
| Signs & Symptoms | Mixed UMN + LMN signs: spasticity, hyperreflexia, fasciculations, wasting, weakness, dysarthria, dysphagia, respiratory failure; cognitive changes (FTD overlap); NO sensory/eye movement/bowel-bladder involvement |
| Investigations | EMG/NCS (widespread active denervation), MRI spine/brain, pulmonary function, genetic testing (C9orf72, SOD1), swallowing assessment |
| Findings | EMG: widespread denervation (>3 regions); MRI: normal or corticospinal tract changes |
| Differential Dx | Cervical myelopathy, multifocal motor neuropathy, Kennedy disease, syringomyelia, inclusion body myositis |
| Contraindications | No disease-modifying treatment effective beyond Riluzole; avoid neuromuscular blockers |
| ICU Management | NIV (BiPAP) for respiratory support; PEG for nutrition; secretion management; palliative approach |
| OPD Prescription | Riluzole 50 mg BD (only approved drug — modest survival benefit), Edaravone IV, Tofersen (SOD1 mutation), Baclofen (spasticity), Amitriptyline (drooling/PBA), Morphine (dyspnoea/palliative) |
| Treatment | Multidisciplinary (MDT): neurologist, respiratory, dietitian, SLT, OT, palliative |
13. CERVICAL SPONDYLOTIC MYELOPATHY
| Domain | Details |
|---|---|
| Signs & Symptoms | Neck pain, upper limb LMN signs (wasting, weakness, reduced reflexes), lower limb UMN signs (spasticity, brisk reflexes, Babinski +ve), gait disturbance, Lhermitte's sign, sphincter dysfunction |
| Investigations | MRI cervical spine (gold standard), CT myelogram, X-ray (osteophytes), EMG/NCS |
| Findings | MRI: cord compression, T2 signal change in cord (myelomalacia), disc protrusion/osteophytes |
| Differential Dx | MS, ALS, syringomyelia, epidural abscess/tumor, transverse myelitis, B12 deficiency myelopathy |
| Contraindications | Avoid neck manipulation (risk of acute neurological deterioration); avoid contact sports |
| ICU Management | Post-operative spinal cord monitoring; methylprednisolone within 8 hrs of acute traumatic component (controversial) |
| OPD Prescription | NSAIDs, physiotherapy, cervical collar (acute), pregabalin (neuropathic pain), baclofen (spasticity) |
| Treatment | Surgery (ACDF or posterior laminectomy/laminoplasty) for moderate-severe myelopathy |
14. TRANSVERSE MYELITIS
| Domain | Details |
|---|---|
| Signs & Symptoms | Acute onset bilateral weakness, sensory level, bladder/bowel dysfunction, back pain; progression over hours–days |
| Investigations | MRI spine with gadolinium, LP (CSF pleocytosis, oligoclonal bands), AQP4/MOG antibodies, anti-NMO, VEPs, CT chest (sarcoid/malignancy) |
| Findings | MRI: T2 hyperintensity ≥2 vertebral segments (NMOSD: ≥3 segments); gadolinium enhancement |
| Differential Dx | MS, NMOSD, spinal cord compression, GBS, Devic's disease, cord infarction, paraneoplastic |
| Contraindications | Avoid LP without imaging; long-segment lesions — consider NMOSD before steroids |
| ICU Management | High-dose IV methylprednisolone 1g OD × 5 days; plasma exchange if steroid-refractory; bladder catheterisation |
| OPD Prescription | Maintenance immunosuppression if NMOSD (Azathioprine, Mycophenolate, Rituximab), physiotherapy, bladder management |
| Treatment | Steroids first-line; plasma exchange second-line; treat underlying cause |
15. NEUROMYELITIS OPTICA SPECTRUM DISORDER (NMOSD)
| Domain | Details |
|---|---|
| Signs & Symptoms | Severe optic neuritis (often bilateral), longitudinally extensive transverse myelitis (LETM ≥3 segments), area postrema syndrome (intractable hiccups/nausea/vomiting), brainstem syndromes |
| Investigations | AQP4-IgG (serum/CSF), MRI brain + spine, VEPs, LP |
| Findings | MRI: LETM, area postrema lesion, optic nerve enhancement; AQP4-IgG positive in 70–80% |
| Differential Dx | MS (distinguish: LETM, area postrema, AQP4+), MOG-AD, transverse myelitis, SLE-related CNS disease |
| Contraindications | MS-specific DMTs (Natalizumab, Fingolimod, Alemtuzumab) can worsen NMOSD — AVOID |
| ICU Management | Acute attack: Methylprednisolone 1g IV × 5 days → Plasma exchange if incomplete response; ventilatory support for respiratory failure |
| OPD Prescription | Azathioprine 2–3 mg/kg + Prednisolone; Rituximab 375 mg/m² q4 weeks; Inebilizumab; Satralizumab; Eculizumab |
| Treatment | Long-term immunosuppression mandatory; relapse prevention critical |
16. BRAIN TUMOR (GLIOBLASTOMA / PRIMARY CNS)
| Domain | Details |
|---|---|
| Signs & Symptoms | Progressive headache (worse in morning, with Valsalva), focal deficits, seizures, personality/cognitive change, papilledema, vomiting |
| Investigations | MRI with gadolinium (gold standard), CT, stereotactic biopsy (tissue diagnosis), PET, MR spectroscopy, IDHI/MGMT/EGFR mutation analysis |
| Findings | GBM: ring-enhancing lesion with central necrosis; WHO grade 4; MGMT methylation → better response to temozolomide |
| Differential Dx | Brain abscess (ring-enhancing), metastasis, lymphoma, MS (tumefactive), radiation necrosis |
| Contraindications | LP contraindicated if papilledema/herniation risk; avoid immunosuppression in CNS lymphoma |
| ICU Management | Dexamethasone 8–16 mg/day (vasogenic oedema), seizure control, post-op ICU monitoring, anti-DVT |
| OPD Prescription | Dexamethasone 4 mg QDS, Levetiracetam 500 mg BD, Temozolomide 75–150 mg/m², Bevacizumab (recurrent) |
| Treatment | Surgery (maximal safe resection) + radiotherapy + temozolomide (Stupp protocol) |
17. IDIOPATHIC INTRACRANIAL HYPERTENSION (IIH / Pseudotumour Cerebri)
| Domain | Details |
|---|---|
| Signs & Symptoms | Headache (diffuse, daily, worsened by Valsalva), pulsatile tinnitus, transient visual obscurations, diplopia (CN VI palsy), papilledema (bilateral), visual field loss |
| Investigations | MRI brain + MRV (to exclude venous sinus thrombosis), LP (opening pressure >25 cmH₂O), visual fields (Humphrey perimetry), OCT |
| Findings | MRI: empty sella, flattened posterior globes, optic nerve sheath distension; LP: elevated opening pressure, normal CSF composition |
| Differential Dx | Venous sinus thrombosis, meningitis, hydrocephalus, SLE, hypervitaminosis A, drug-induced (tetracycline, steroids withdrawal) |
| Contraindications | Tetracyclines/doxycycline (causative), excess Vitamin A, corticosteroid withdrawal |
| ICU Management | Rarely needed; LP drainage as emergency if visual threat |
| OPD Prescription | Acetazolamide 250–2000 mg/day (carbonic anhydrase inhibitor), Topiramate (weight loss + ICP reduction), weight loss programme, low-sodium diet |
| Treatment | Weight loss (primary), Acetazolamide; optic nerve sheath fenestration or CSF shunting (VP/LP shunt) if vision threatened |
18. NORMAL PRESSURE HYDROCEPHALUS (NPH)
| Domain | Details |
|---|---|
| Signs & Symptoms | Hakim's triad: Gait apraxia (magnetic gait — "feet stuck to floor"), Urinary incontinence, Dementia (cognitive decline) — classic triad |
| Investigations | MRI/CT (ventriculomegaly out of proportion to atrophy, Evans' index >0.3), LP tap test (>30–50 ml CSF drainage → temporary improvement), CSF opening pressure, gait analysis |
| Findings | Imaging: dilated ventricles; DESH pattern (Disproportionately Enlarged Subarachnoid-space Hydrocephalus); tight sulci over convexities |
| Differential Dx | Alzheimer's disease, vascular dementia, Parkinson's disease, spinal stenosis, cerebral atrophy |
| Contraindications | CSF tap test — caution if coagulopathy |
| ICU Management | Post-shunt monitoring for subdural haematoma, over-drainage |
| OPD Prescription | Post-VP shunt: monitoring, treat infections; no specific drug |
| Treatment | Ventriculoperitoneal (VP) shunt or lumboperitoneal (LP) shunt — gait responds best |
19. PERIPHERAL NEUROPATHY (DIABETIC)
| Domain | Details |
|---|---|
| Signs & Symptoms | Symmetrical distal sensory loss ("glove and stocking"), burning/tingling/numbness, allodynia, reduced ankle jerks, autonomic features (postural hypotension, gastroparesis, erectile dysfunction) |
| Investigations | NCS/EMG (axonal neuropathy), HbA1c, fasting glucose, B12, folate, TFTs, SPEP (paraprotein), skin biopsy (intraepidermal nerve fibre density) |
| Findings | NCS: reduced amplitude sensory/motor potentials (axonal pattern) |
| Differential Dx | B12 deficiency neuropathy, uraemic neuropathy, alcohol neuropathy, hereditary neuropathy (CMT), CIDP, paraproteinaemic neuropathy |
| Contraindications | Tricyclics — caution in cardiac disease/glaucoma/urinary retention; opioids — dependency risk; Metformin → B12 deficiency |
| ICU Management | Rarely ICU; treat severe autonomic crisis (arrhythmia, hypotension) |
| OPD Prescription | Glycaemic control (HbA1c target <7%), Pregabalin 75–300 mg BD, Duloxetine 60–120 mg OD, Amitriptyline 10–75 mg ON, Gabapentin 300–1200 mg TDS, Capsaicin cream |
| Treatment | Tight glycaemic control (prevents progression), neuropathic pain management, podiatry, ulcer prevention |
20. TRIGEMINAL NEURALGIA
| Domain | Details |
|---|---|
| Signs & Symptoms | Paroxysmal, severe, electric-shock-like unilateral facial pain in trigeminal distribution (V2/V3 most common), triggered by eating, speaking, cold wind, tooth brushing; pain-free intervals; no sensory loss (idiopathic) |
| Investigations | MRI brain (CISS/FIESTA sequences — neurovascular compression of CN V), exclude MS, tumour |
| Findings | MRI: superior cerebellar artery loop compressing CN V at root entry zone; if secondary — tumour, MS plaque |
| Differential Dx | SUNCT, cluster headache, postherpetic neuralgia, dental pain, glossopharyngeal neuralgia, MS |
| Contraindications | Carbamazepine — avoid in HLA-B*1502 (SJS risk, South-East Asian patients); Oxcarbazepine — hyponatraemia |
| ICU Management | Rarely ICU |
| OPD Prescription | Carbamazepine 100–800 mg BD (first-line), Oxcarbazepine 150–600 mg BD, Gabapentin, Baclofen, Lamotrigine |
| Treatment | Microvascular decompression (MVD) surgery, percutaneous procedures (balloon compression, glycerol rhizotomy), stereotactic radiosurgery (Gamma Knife) |
21. MIGRAINE
| Domain | Details |
|---|---|
| Signs & Symptoms | Unilateral pulsating headache, moderate-severe, worsened by activity, nausea/vomiting, photo/phonophobia; aura (visual zigzag, scotoma, paraesthesia — 30 min before headache); prodrome; postdrome |
| Investigations | Clinical diagnosis; MRI if atypical/first severe headache; consider LP if SAH concern |
| Findings | Neuroimaging: usually normal; MRI may show white matter hyperintensities |
| Differential Dx | Tension-type headache, cluster headache, SAH (thunderclap), meningitis, hypertensive crisis, cervicogenic headache, IIH |
| Contraindications | Triptans contraindicated in hemiplegic migraine, basilar migraine, CAD, uncontrolled HTN; Ergotamines — avoid in ischaemic heart disease |
| ICU Management | Status migrainosus: IV hydration, IV metoclopramide, IV ketorolac, IV dexamethasone, IV dihydroergotamine (DHE) |
| OPD Prescription | Acute: Sumatriptan 50–100 mg, Naproxen 500 mg, Aspirin 900 mg, Antiemetic (Metoclopramide 10 mg); Preventive: Topiramate 25–100 mg OD, Propranolol 40–120 mg BD, Amitriptyline 10–75 mg ON, CGRP mAbs (Erenumab, Fremanezumab) |
| Treatment | Acute: triptans; Prevention: if >4 attacks/month; identify and avoid triggers |
22. CLUSTER HEADACHE
| Domain | Details |
|---|---|
| Signs & Symptoms | Severe unilateral periorbital/temporal pain, short duration (15–180 min), ipsilateral autonomic features: lacrimation, rhinorrhea, ptosis, miosis (Horner's), conjunctival injection, restlessness, attacks in clusters (weeks), nocturnal predominance |
| Investigations | Clinical diagnosis; MRI to exclude secondary causes; circadian pattern; |
| Findings | Neuroimaging: usually normal; hypothalamic activation on PET |
| Differential Dx | SUNCT, trigeminal neuralgia, migraine, carotid/cavernous sinus lesion |
| Contraindications | Oral triptans too slow; ergotamines in CAD; verapamil — constipation, bradycardia, heart block |
| ICU Management | Rarely needed |
| OPD Prescription | Acute: 100% O₂ 12–15 L/min × 15 min (very effective), Sumatriptan 6 mg SC or intranasal; Prevention: Verapamil 240–480 mg/day (first-line), Lithium 300 mg TDS, Short-course prednisolone (bridge), Galcanezumab (CGRP mAb) |
| Treatment | High-flow O₂, SC Sumatriptan; prevention with Verapamil |
23. SPINAL CORD INJURY (SCI)
| Domain | Details |
|---|---|
| Signs & Symptoms | Complete/incomplete injury: loss of motor/sensory/autonomic function below level; Spinal shock (flaccidity, areflexia acutely → spasticity chronically); Autonomic dysreflexia (↑BP, headache, bradycardia — T6 and above); neurogenic bladder/bowel |
| Investigations | MRI spine (gold standard), CT spine, ASIA grading (A–E), urodynamics |
| Findings | MRI: cord contusion, haematoma, compression; ASIA A = complete motor/sensory loss below level |
| Differential Dx | Transverse myelitis, cord compression (tumour, epidural abscess), GBS, vascular cord injury |
| Contraindications | High-dose methylprednisolone (NASCIS trials — no longer routinely recommended, increased infection risk); avoid succinylcholine (hyperkalemia after 48 hrs) |
| ICU Management | MAP target >85–90 mmHg (days 1–7), immobilisation/stabilisation, mechanical ventilation if C4 and above, bowel/bladder management, prevention of secondary complications (DVT, pressure sores, pneumonia) |
| OPD Prescription | Baclofen 5–20 mg TDS (spasticity), Oxybutynin/Solifenacin (neurogenic bladder), Duloxetine, bowel regimen, CIC (clean intermittent catheterisation) |
| Treatment | Surgical decompression (when indicated), MDT rehabilitation, FES, wheelchairs |
24. EPIDURAL SPINAL CORD COMPRESSION (METASTATIC)
| Domain | Details |
|---|---|
| Signs & Symptoms | Back pain (90% — often worse at night/recumbent), progressive leg weakness, sensory level, urinary retention, bowel dysfunction (late) — EMERGENCY |
| Investigations | Urgent MRI whole spine (gadolinium), CT chest/abdomen/pelvis (primary tumour), bone scan, bone biopsy |
| Findings | MRI: epidural mass compressing cord, vertebral collapse (pathological fracture), T2 cord signal change |
| Differential Dx | Disc prolapse, epidural abscess, epidural haematoma, intrinsic cord tumour, transverse myelitis |
| Contraindications | Delay in treatment worsens outcome; avoid LP (risk of herniation) |
| ICU Management | Dexamethasone 16 mg IV loading → 4 mg QDS, neurosurgical/oncological emergency |
| OPD Prescription | Dexamethasone, radiotherapy planning, analgesics, bladder/bowel management |
| Treatment | Dexamethasone IMMEDIATELY, surgical decompression ± radiotherapy, palliative radiotherapy if surgery not feasible |
25. SYRINGOMYELIA
| Domain | Details |
|---|---|
| Signs & Symptoms | "Cape distribution" suspended sensory loss (dissociated — loss of pain/temperature, preserved light touch/proprioception); wasting of hands/intrinsic muscles; LMN arm signs + UMN leg signs; scoliosis; neuropathic arthropathy (Charcot joints) |
| Investigations | MRI spine (gold standard — fluid-filled cavity in cord), MRI brain (Chiari malformation), |
| Findings | MRI T2: central cavitation (syrinx) in spinal cord; associated Chiari I malformation (tonsillar herniation >5 mm) in >80% |
| Differential Dx | ALS, BSCM, traumatic myelopathy, cord tumour, HTLV-1 myelopathy |
| Contraindications | Avoid Valsalva-increasing activities (increases ICP); avoid contact sports |
| ICU Management | Post-operative monitoring; rarely ICU |
| OPD Prescription | Analgesics, pregabalin, physiotherapy |
| Treatment | Treat underlying cause (Chiari decompression — suboccipital craniectomy; syringosubarachnoid shunt if no Chiari) |
26. CAUDA EQUINA SYNDROME
| Domain | Details |
|---|---|
| Signs & Symptoms | Saddle anaesthesia (S3–S5 dermatome — perineum/buttocks), bilateral leg weakness, urinary retention (overflow incontinence), reduced anal tone, sexual dysfunction — SURGICAL EMERGENCY |
| Investigations | Urgent MRI lumbar spine, urodynamics, post-void residual |
| Findings | MRI: large central disc prolapse (L4/5 or L5/S1), tumour, epidural haematoma compressing cauda equina |
| Differential Dx | Conus medullaris syndrome, peripheral neuropathy, pelvic tumour, bilateral lumbosacral radiculopathy |
| Contraindications | Delay in surgery → permanent incontinence/paralysis; avoid LP |
| ICU Management | Emergency — urgent surgical decompression within 24–48 hours; bladder catheterisation |
| OPD Prescription | Post-op: physiotherapy, CIC, bladder/bowel programme |
| Treatment | Emergency surgical decompression (microdiscectomy/laminectomy) — time-critical |
27. NEUROSARCOIDOSIS
| Domain | Details |
|---|---|
| Signs & Symptoms | Cranial nerve palsies (especially CN VII bilateral), aseptic meningitis, hypothalamic/pituitary dysfunction (DI, hypopituitarism), optic neuropathy, seizures, encephalopathy, peripheral neuropathy, myelopathy |
| Investigations | MRI brain/spine (gadolinium), CSF analysis, serum ACE (elevated 50–60%), CT chest (bilateral hilar lymphadenopathy), gallium/PET scan, tissue biopsy (non-caseating granulomas) |
| Findings | Non-caseating granulomas; leptomeningeal enhancement; elevated ACE; bilateral hilar lymphadenopathy |
| Differential Dx | MS, TB meningitis, lymphoma, CNS vasculitis, Behcet's disease, Lyme disease |
| Contraindications | Avoid ACE inhibitors (confound ACE measurement); infliximab — TB reactivation risk |
| ICU Management | High-dose methylprednisolone for acute severe disease |
| OPD Prescription | Prednisolone 1 mg/kg OD (first-line), Methotrexate (steroid-sparing), Azathioprine, Hydroxychloroquine (skin/lung), Infliximab (refractory) |
| Treatment | Steroids first-line; second-line immunosuppressants for steroid-dependent/refractory |
28. WERNICKE'S ENCEPHALOPATHY (THIAMINE DEFICIENCY)
| Domain | Details |
|---|---|
| Signs & Symptoms | Classic triad: Ophthalmoplegia (bilateral horizontal nystagmus, CN VI palsy), Ataxia (cerebellar gait), Confusion/encephalopathy; only 16% have full triad; can progress to Korsakoff (anterograde amnesia, confabulation) |
| Investigations | Clinical diagnosis; serum thiamine (B1) levels (↓), MRI (T2/FLAIR hyperintensity in periaqueductal grey, mammillary bodies, medial thalami) |
| Findings | MRI: classic bilateral symmetrical signal change in mammillary bodies, dorsomedial thalamus, periaqueductal grey |
| Differential Dx | MS, viral encephalitis, metabolic encephalopathy, Creutzfeldt-Jakob disease, top-of-basilar syndrome |
| Contraindications | NEVER give IV dextrose before thiamine (precipitates/worsens Wernicke's); avoid thiamine IM if anaphylaxis history |
| ICU Management | IV Thiamine (Pabrinex) 500 mg TDS × 3–5 days (give BEFORE any glucose), then 100 mg TDS PO |
| OPD Prescription | Oral thiamine 100 mg TDS (maintenance), abstinence from alcohol, nutritional support |
| Treatment | High-dose parenteral thiamine URGENTLY; treat underlying cause (alcohol cessation, malnutrition) |
29. CEREBRAL VENOUS SINUS THROMBOSIS (CVST)
| Domain | Details |
|---|---|
| Signs & Symptoms | Headache (subacute, progressive — most common), papilledema, focal deficits, seizures, altered consciousness; in puerperal women and OCP users; superior sagittal sinus most commonly affected |
| Investigations | MRI with MRV (gold standard — cord sign, delta sign on CT), CT venogram, D-dimer, thrombophilia screen, pregnancy test |
| Findings | MRI/MRV: absence of flow in sinus, "cord sign" on CT, "delta sign" (empty delta sign) on contrast CT, venous infarcts (may be haemorrhagic) |
| Differential Dx | SAH, IIH, meningitis, migraine, brain tumour, hypertensive encephalopathy |
| Contraindications | Anticoagulation in haemorrhagic venous infarct is NOT a contraindication (still treat); avoid OCP |
| ICU Management | IV Heparin (LMWH or unfractionated), ICP management, seizure control, treat underlying cause |
| OPD Prescription | Warfarin (INR 2–3) × 3–12 months (or DOAC — Dabigatran), treat precipitating cause, avoid OCP |
| Treatment | Anticoagulation (even with haemorrhagic infarction); endovascular thrombolysis (refractory cases) |
30. ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM)
| Domain | Details |
|---|---|
| Signs & Symptoms | Monophasic, post-infectious or post-vaccination; fever, headache, encephalopathy (altered consciousness — distinguishes from MS), multifocal deficits, seizures, optic neuritis, myelitis |
| Investigations | MRI brain/spine (large, bilateral, asymmetric T2/FLAIR lesions in white and grey matter), CSF (lymphocytic pleocytosis, elevated protein), MOG-IgG antibody (MOG-AD spectrum), EEG |
| Findings | MRI: large, poorly defined, bilateral, multifocal white matter lesions ± grey matter; basal ganglia involvement common in children; MOG-IgG positive in many adult cases |
| Differential Dx | MS (first demyelinating event), NMOSD, viral encephalitis, CNS vasculitis, brain tumour (tumefactive MS) |
| Contraindications | Avoid empiric antibiotics as sole treatment if ADEM suspected; LP only after imaging |
| ICU Management | IV Methylprednisolone 30 mg/kg/day (children) or 1g/day (adults) × 3–5 days, airway protection if encephalopathic, seizure management |
| OPD Prescription | Oral prednisolone taper over 4–6 weeks, antiepileptics, neurorehabilitation |
| Treatment | High-dose IV steroids first-line; IVIG or plasma exchange if steroid-refractory; monitor for relapse (consider MS/NMOSD if relapsing) |
Quick Reference Summary Table
| # | Disease | Key Signs | First-line Treatment |
|---|---|---|---|
| 1 | Ischemic Stroke | FAST, hemiplegia | tPA, thrombectomy |
| 2 | Hemorrhagic Stroke | Worst headache, focal deficit | BP control, surgery |
| 3 | SAH | Thunderclap headache | Nimodipine, coiling/clipping |
| 4 | Bacterial Meningitis | Fever, neck stiffness, rash | Ceftriaxone + Dexamethasone |
| 5 | Viral Encephalitis | Behavioral change, temporal seizures | Aciclovir IV |
| 6 | Epilepsy | Seizures, postictal confusion | Levetiracetam/Valproate |
| 7 | Multiple Sclerosis | Optic neuritis, INO, relapses | DMTs, steroids for relapse |
| 8 | Parkinson's Disease | Tremor, rigidity, bradykinesia | Levodopa/Carbidopa |
| 9 | Alzheimer's Disease | Memory loss, progression | Donepezil/Memantine |
| 10 | GBS | Ascending paralysis, areflexia | IVIG or plasmapheresis |
| 11 | Myasthenia Gravis | Fatigable ptosis, respiratory failure | Pyridostigmine, IVIG |
| 12 | MND/ALS | Mixed UMN+LMN, no sensory | Riluzole |
| 13 | Cervical Myelopathy | LMN arms + UMN legs | Surgery (ACDF) |
| 14 | Transverse Myelitis | Sensory level, bladder dysfunction | IV methylprednisolone |
| 15 | NMOSD | Severe optic neuritis + LETM | Rituximab/Eculizumab |
| 16 | Brain Tumor (GBM) | Headache + focal deficit + seizures | Resection + RT + Temozolomide |
| 17 | IIH | Headache, papilledema, tinnitus | Acetazolamide, weight loss |
| 18 | NPH | Hakim's triad (gait, urine, memory) | VP shunt |
| 19 | Diabetic Neuropathy | Glove/stocking, burning | Pregabalin/Duloxetine |
| 20 | Trigeminal Neuralgia | Electric shock face pain | Carbamazepine |
| 21 | Migraine | Unilateral throbbing, aura | Sumatriptan/Topiramate |
| 22 | Cluster Headache | Periorbital, autonomic features | O₂ + SC Sumatriptan, Verapamil |
| 23 | Spinal Cord Injury | ASIA grading, spinal shock | MAP >85, surgical stabilisation |
| 24 | Metastatic Cord Compression | Back pain + weakness | Dexamethasone + surgery/RT |
| 25 | Syringomyelia | Cape dissociated sensory loss | Chiari decompression |
| 26 | Cauda Equina Syndrome | Saddle anaesthesia, retention | Emergency surgery |
| 27 | Neurosarcoidosis | CN VII palsy, meningitis, DI | Prednisolone |
| 28 | Wernicke's Encephalopathy | Ophthalmoplegia, ataxia, confusion | IV Thiamine STAT |
| 29 | CVST | Headache, seizures, focal signs | Anticoagulation (Heparin) |
| 30 | ADEM | Post-infectious encephalopathy | IV Methylprednisolone |
Sources: Adams and Victor's Principles of Neurology (12th Ed), Bradley and Daroff's Neurology in Clinical Practice, Goldman-Cecil Medicine, Washington Manual of Medical Therapeutics, Rosen's Emergency Medicine.
Clinical Note: This is a reference guide. Clinical decisions must always be individualised to the patient. Drug doses may vary by body weight, renal/hepatic function, and local guidelines. Always verify contraindications before prescribing.
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