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Volume 09

A study guide to neurology.

For the internal medicine resident who'd rather read the MRI than misfire, keeping your reasoning well-myelinated and your confidence from seizing up. Last revised 2026.

09 topics

Neurology

Stroke · Demyelination · Movement · Neuromuscular · Headache · Seizures · Cognition

01

Stroke

▾
Initial Workup

CT brain · IVF NS · high-intensity statin

Ischemic Stroke — Acute Management
  • Permissive HTN <220/120 for 24h
  • NIHSS ≤5 / ABCD4 ≥4 › DAPT ×21d then ASA
    • CTA major ICA stenosis 70–99% › DAPT ×3 months then ASA
  • NIHSS >3 › ASA
EVT & tPA

EVT criteria: disabling deficit, <24h, mild/moderate CVA, distal ICA or MCA.

  • <6h › CTA
  • 6–24h › CTP

tPA: <3–4.5h + disabling deficit/NIHSS ≥6 › tPA.

tPA CI: recent head trauma, previous CVA, cranial surgery, active hemorrhage, hemorrhage on CT, DOAC, extensive infarction, BP ≥185/110, h/o ICH, INR >1.7, Plt <100, RBS <2.7/>22.2, elevated aPTT.

Pre-tPA BP <185/110, post-tPA BP <180/105 ×24h › IV labetalol/nicardipine. No APT for 24h.

  • Secondary ICH › target BP <185/110
  • Symptomatic carotid stenosis 50–99% › CEA ≤2 weeks
  • Intracranial carotid/vertebral dissection › avoid anticoagulation
  • Symptomatic cerebral edema › decompressive hemicraniectomy
  • Seizure <2 weeks post CVA › AED ×3 months
    • >2 weeks post CVA › lifelong AED
  • AF › DOAC
    • Mechanical valve or moderate/severe MS › warfarin
    • TIA ≤24h, small ≥3d, moderate ≥6d, large ≥12d
  • Young (age <55y) › ESR, CRP, RF, ANA/ENA, ANCA, C3/4, HIV, HBV, HCV, APS + thrombophilia (repeat after 3 months)
Secondary Prevention

Target LDL <1.4, control DM (SGLT2i or GLP1RA), target BP <130/80, smoking cessation.

  • Outpatient workup: carotid doppler, CTA/MRA, 24h holter, TTE ± bubble study (PFO)
    • High risk PFO › PFO closure
    • ESUS › 72h holter › loop
Hemorrhagic Stroke

CTA (AVM) + neurosurgery consult. RF: HTN, amyloid angiopathy, coagulopathy, AVM, cocaine, alcohol.

  • Anticoagulation reversal: anti-Xa › PCC; dabigatran › idarucizumab; warfarin › IV vitamin K + PCC
  • Target SBP 130–140 ×48h
  • LMWH after 24h (CT › stable)
  • AF › anticoagulation after 8 weeks
  • MRA after resolution of hemorrhage
  • Seizure <24h › short-term AED
  • Elevated ICP › mannitol or hypertonic saline
CVST

Headache, focal neurological deficit, seizures, DLOC, visual changes › CTV/MRV › LMWH › DOAC/warfarin.

RF: female, OCP, pregnancy, obesity, APS, malignancy, CTD, post-neurosurgery. Seizure <7d › AED ×3 months.

Stroke Syndromes

Lateral Medullary (PICA, vertebral)

Ipsilateral ataxia, ipsilateral Horner, ipsilateral face loss of pain/temp sense, contralateral body loss of pain/temp sense, vertigo, nystagmus, dysphagia, hoarseness, hiccups.

Medial Medullary (anterior spinal artery)

Ipsilateral tongue weakness, contralateral arm/leg weakness, contralateral body loss of vibration/proprioception.

PCA

Ipsilateral CN 3 palsy, contralateral hemiplegia, contralateral homonymous hemianopia.

ACA

Contralateral leg weakness/numbness, contralateral grasp reflex.

Left MCA

Superior + inferior + global aphasia.

Superior: Broca’s (expressive) aphasia, right weakness face/arm > leg, gaze deviation left.

Inferior: Wernicke’s (receptive) aphasia, right cortical sensory loss, right homonymous superior quadrantanopsia.

Right MCA

Superior: left weakness face/arm > leg, gaze deviation right.

Inferior: left cortical sensory loss, left hemineglect, left homonymous superior quadrantanopsia.

Pure Motor / Pure Sensory

Pure motor: posterior limb internal capsule, corona radiata, midbrain, ventral pons.

Pure sensory: thalamus.

SAH

Thunderclap headache, confusion, somnolence, nuchal rigidity, unilateral pupillary dilation › CT ≤6h, CTA.

  • >6h + normal CT › LP (xanthochromia)
  • Fundoscopy › subhyaloid hemorrhages
  • Aneurysm › surgical clipping or endovascular coiling ≤48–72h
  • Target SBP <160
  • Vasospasm › delayed ischemia › prophylactic nimodipine ×21d
  • Hydrocephalus › ventricular drainage
  • Asymptomatic aneurysm: >7 mm or high risk › clipping/coiling; <7 mm › annual MRA
  • Post-stroke fatigue › polysomnography
02

Multiple Sclerosis

▾
Overview

Subtypes: RRMS, SPMS, PPMS. Demographics: female, age 30y.

Clinical Syndromes

Optic Neuritis

Monocular vision/color loss, painful eye movements, RAPD, disc edema.

Cerebellar Syndrome

Dysarthria, ataxia, gaze-evoked nystagmus, vertigo, facial numbness.

Transverse Myelitis

Sensory loss, asymmetric limb weakness, urge incontinence, erectile dysfunction, Lhermitte sign.

Other Features

Uhthoff phenomenon (heat exacerbation), afferent pupillary defect, papillitis, urinary frequency/urgency/retention, INO.

McDonald Criteria

DIS + DIT, DIS + CSF, CIS + lesions ≥4 CNS sites, CIS + ≥1 CNS lesion + DIT/CSF + CVS/PRL.

  • MRI ≥2 CNS lesions or ≥12 months progressive symptoms + ≥2 spinal lesions and ≥1 of (CSF oligoclonal IgG bands / kappa free light chain, CVS, dissemination in time, lesions ≥4 CNS sites)
  • MRI 1 CNS lesion and ≥1 of (CSF + CVS/PRL, DIT + CSF/PRL)
Acute Management

Optic neuritis or motor lesions › methylprednisolone 1 g IV OD ×3–7 days › PLEX.

Treat underlying fever first.

  • Lifestyle: exercise, smoking cessation, vitamin D 4000 U OD
  • CIS (optic neuritis, spinal cord syndrome, brainstem-cerebellar syndrome) › DMT
  • RIS › observation
  • PPMS › ocrelizumab
  • Inactive SPMS (no new MRI lesions) › DC DMT
DMT Options

natalizumab, alemtuzumab, ocrelizumab, ofatumumab, interferon beta, glatiramer acetate, dimethyl fumarate, teriflunomide, fingolimod, siponimod, cladribine, HSCT.

  • Fingolimod › macular edema, BCC
  • Natalizumab › PML › CSF JC virus
Symptom Management
  • Spasticity › PT, baclofen, benzodiazepines, tizanidine
  • Neuropathic pain › duloxetine, gabapentin, pregabalin, topiramate
  • Fatigue › modafinil, armodafinil, amantadine, methylphenidate
  • Impaired gait › dalfampridine
  • Overactive bladder › oxybutynin, tolterodine, solifenacin, darifenacin, mirabegron
  • ADEM: rapid onset, multifocal neurologic symptoms, fever, encephalopathy
    • MRI › fluffy multifocal large inflammatory demyelinating lesions
    • CSF › pleocytosis
03

Movement Disorders

▾
Parkinsonism

Bradykinesia, rigidity, resting tremor, asymmetrical, micrographia, postural instability (pull test), anosmia, REM disorder, constipation, dementia, visual hallucinations, autonomic dysfunction, mask facies › dopamine transporter scan.

Causes: idiopathic, LBD, PSP, MSA, CBD, vascular, drug-induced, Wilson disease, manganese.

PD Pharmacotherapy
  • Levodopa/carbidopa › nausea/vomiting, orthostatic hypotension, sedation, confusion, hallucinations, dyskinesias, "wearing-off" effect (XR)
  • Age <60y + high risk dyskinesia › dopamine agonists (pramipexole, ropinirole, rotigotine) › orthostatic hypotension, sleep attacks, psychosis, impulse-control disorder, leg swelling
  • Mild disease › MAOi (selegiline, rasagiline) › HTN crisis, serotonin syndrome, insomnia, hallucinations, dry mouth, hypotension
  • Tremor › trihexyphenidyl › anticholinergic (confusion, dry eyes, blurry vision, dry mouth, constipation, urinary retention), memory difficulty
  • Prolonged L-dopa › entacapone (COMTi) › sinemet SE, orange urine
  • Dyskinesia › amantadine › anticholinergic, insomnia, livedo reticularis, hallucinations, CI seizures
  • Orthostatic hypotension › midodrine, fludrocortisone, domperidone (QT prolongation)
  • Antipsychotics › quetiapine, clozapine

Atypical Parkinsonian Syndromes

MSA

Cerebellar symptoms, symmetrical, falls, orthostatic hypotension, ataxia, erectile dysfunction, incontinence, stridor, pyramidal signs, distal myoclonus.

MRI › putamen necrosis, cerebellar atrophy.

PSP

Symmetrical, vertical gaze paresis, falls, hyperfrontalis, dysarthria, dementia.

CBD

Asymmetrical, cortical sensory loss, apraxia, aphasia, dystonia, myoclonus, alien limb phenomenon.

Drug-Induced

Symmetrical, postural tremor.

Causes: antipsychotics, metoclopramide, lithium, methyldopa.

Vascular

Symmetrical, lower limbs, falls, pyramidal signs, dementia, incontinence.

LBD

Symmetrical, early dementia, fluctuating, visual hallucinations, REM sleep disorders.

Tremor & Other Disorders

Essential Tremor

High frequency, small amplitude, postural, symmetrical, FH, improves with alcohol, messy/tremulous writing › propranolol, primidone, topiramate.

Exacerbating: caffeine, anxiety, stress, hyperthyroidism, drugs.

Dystonic Tremor

Postural/resting, asymmetrical, irregular, null point.

Cerebellar Tremor

Intention. Causes: CVA, MS, Wilson disease.

Huntington Disease

Chorea, progressive dementia, psychiatric manifestations, autosomal dominant › valbenazine, tetrabenazine, deutetrabenazine.

Drug-Induced Dystonia

Tardive dyskinesia associated, choreiform/dystonic craniofacial movements › DC drug, valbenazine, deutetrabenazine, tetrabenazine, amantadine, clonazepam.

Causes: neuroleptics, antiemetics, antidepressants.

Cervical Dystonia (Torticollis)

Anticholinergics, benzodiazepines, baclofen, levodopa, botulinum injection.

Restless Legs Syndrome

Iron study › gabapentin, pregabalin.

Tourette

Aripiprazole, clonidine, guanfacine, topiramate, levetiracetam, tetrabenazine.

Tardive Dyskinesia

Dopamine antagonists › repetitive stereotyped choreiform movements.

04

Neuromuscular Disorders

▾
Symmetrical Distal Polyneuropathy

Causes: ISNE, DM, CKD, CLD, B12 deficiency, thyroid disease, alcohol, chemotherapy, cryoglobulinemia, HIV, Lyme disease, amyloidosis, monoclonal gammopathy, MM.

Workup: vitamin B12 level, SPEP, UPEP, ESR, HbA1c.

Pain › amitriptyline, duloxetine, pregabalin, gabapentin, carbamazepine, valproate, tapentadol.

POEMS: peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes. Familial amyloidosis › TTR gene.

Mononeuritis Multiplex

Vasculitis, lymphoma, amyloidosis, sarcoidosis, Lyme disease, HIV, leprosy, DM.

Diabetic Amyotrophy

Severe unilateral leg pain, numbness, proximal weakness, atrophy, weight loss.

Meralgia Paresthetica

Anterolateral thigh numbness.

Bell Palsy

LMN facial weakness, altered taste, phonophobia › prednisone.

Carpal Tunnel Syndrome

Wrist splint.

Surgery indications: weakness, thenar atrophy, refractory pain, active denervation EMG/NCS.

Ulnar Nerve Compression

Elbow splint.

Idiopathic Brachial Plexitis

Subacute transient shoulder pain followed by progressive weakness.

GBS

Acute, ascending, areflexia, paralysis, paresthesia, preceded by GI illness (Campylobacter) › PLEX/IVIG, serial FVC/negative inspiratory force.

  • Autonomic neuropathy: paroxysmal HTN, orthostatic hypotension, sinus tachycardia, bradycardia, AV block, urinary retention, ileus
  • CSF › elevated protein, mildly elevated cell count
  • Miller Fisher: ataxia, ophthalmoplegia › GQ1b Ab
  • CIDP: progressive proximal motor/sensory neuropathy, evolves over months › prednisone/PLEX/IVIG
  • Charcot Marie Tooth: FH, "clumsy" childhood, insidious, symmetrical, severe weakness, numbness, hammertoe, pes cavus
ALS

Progressive, distal, asymmetric, frontotemporal dementia, ocular muscle weakness, respiratory failure ≤5y › riluzole, edaravone, NIV, PEG tube.

DDx: cervical cord compression, vitamin B12/copper deficiencies, Lyme disease, hyperparathyroidism, HIV, thyrotoxicosis.

  • Bulbar: pseudobulbar affect, dysphagia, dysarthria, dyspnea, brisk jaw jerk, tongue wasting/fasciculation
  • Spinal levels: LMN at level of lesion (atrophy, fasciculations, weakness), UMN below level of lesion (spasticity, hyperreflexia, upgoing toes)
Myasthenia Gravis

Autoimmune. Ptosis, binocular diplopia, dysarthria, dysphagia, chewing fatigue, head drop, orthopnea, proximal > distal weakness, intense fatigue › AChR Ab, MuSK Ab, LRP4 Ab, FVC, CT chest (thymoma) › pyridostigmine.

Female age 20–30y, male age 60–70y, autoimmune thyroid disorders. MuSK › severe bulbar/cervical/respiratory weakness.

  • SFEMG › enhanced jitter
  • RNS › decrement
  • Elective intubation indications: FVC <20 mL/kg, MIP 0 to −30, MEP <40
  • Myasthenic crisis: rapidly progressive respiratory failure › PLEX/IVIG
  • Thymectomy indications: thymoma, age 18–65y, AChR Ab +ive

Avoid: neuromuscular blockade, fluoroquinolones, macrolides, aminoglycosides, BBs, CCBs, procainamide, quinidine, immune checkpoint inhibitors, botulinum toxin, chloroquine, hydroxychloroquine, quinine, Mg, lithium, statins, GC.

  • Lambert-Eaton: progressive proximal weakness, diminished reflexes, improve with repetitive movement, underlying SCLC › anti-VGCC
    • EMG/NCS › improved motor response with rapid repetitive stimulation

Inherited Myopathies

Duchenne MD

Early onset, fulminant.

Becker MD

Early onset, survival to adulthood, cardiac disease.

Myotonic Dystrophy

Myotonia (delayed handgrip release), distal weakness, ptosis with lower facial weakness, variable cognitive impairment, cataracts, arrhythmia with cardiomyopathy, DM, thyroid disease.

McArdle Disease

Exercise-induced weakness, cramping, myoglobinuria.

Mitochondrial Myopathy

Fatigue, myalgia, ophthalmoplegia, extramuscular manifestations (vision, hearing, GI, cardiac).

Acquired Myopathies

Hypothyroid Myopathy

Diffuse myalgia, proximal muscle weakness, delayed relaxation phase of deep tendon reflexes, ↑CK.

Hyperthyroidism

Myopathy, brisk reflexes, fasciculation, ophthalmoplegia.

Vitamin D Deficiency

Proximal muscle weakness, myalgia, fatigue, osteomalacia-related bone pain.

GC Myopathy

Proximal weakness, normal CK, normal EMG.

Statin Myopathy

Subacute toxic myopathy, rhabdomyolysis › anti-HMG-CoA +ive › immunosuppression.

05

Neuro-ophthalmology

▾
3rd Nerve Palsy

Ptosis, mydriasis, anisocoria (light), diplopia (down and out).

Pupil sparing › ischemic. Mydriasis › cerebral herniation, mass lesion, PCA aneurysm › MRA/CTA brain.

Horner's Syndrome

Ptosis, miosis, anisocoria (dark), anhidrosis.

1st order: CVA, demyelination, tumor › MRI brain.

2nd order: T1 radiculopathy, Pancoast tumor › MRI C-spine, CT chest.

3rd order: carotid dissection/aneurysm › CTA neck + brain.

6th Nerve Palsy

Binocular diplopia, horizontal images, worse when looking far, worse looking towards lesion.

Causes: brainstem (CVA, demyelination, tumor), cavernous sinus (fistula, aneurysm, dissection, pituitary tumor, inflammation, infection), false-localizing (ICP, CVST, IIH, trauma), ischemia.

Workup: CT/CTA brain (cavernous sinus), MRI brain (CVA, tumor, inflammation, infection), MRV/CTV (CVST), LP (IIH).

Optic Neuritis

Inflammatory (MS), ischemic (CVA).

AION

Acute monocular painless vision loss, RAPD.

Fundoscopy › pale optic disc, blurred margins.

Arteritic (GCA) › GC. Nonarteritic › manage CVD RF.

Retinal Branch Artery Occlusion

Carotid artery atherosclerosis, cardioembolic disorders › treat as CVA.

Increased ICP

Brain tumor, obstructive hydrocephalus, CVST, IIH › papilledema.

06

Headache & Facial Pain

▾
Migraine

Unilateral, pulsatile, moderate/severe, worsening with routine activity, nausea/vomiting, photophobia, phonophobia, 4–72h › NSAIDs ± paracetamol, NSAIDs + triptans, gepants, dihydroergotamine, lifestyle modification.

Triptan CI: CVD, brainstem aura, hemiplegic migraine. Dihydroergotamine CI: CVD.

Gepants: eptinezumab, erenumab, galcanezumab, fremanezumab, rimegepant, atogepant.

Aura: visual loss, hallucinations, flashing lights, numbness, tingling, aphasia, confusion › avoid estrogen (↑stroke).

Brainstem aura: vertigo, ataxia, dysarthria, diplopia, tinnitus, hyperacusis, altered LOC. Hemiplegic aura: motor weakness. Retinal aura: monocular visual compromise.

Chronic migraine: ≥15d/month >3 months.

Prophylaxis indications: unresponsive to acute therapy, ≥4d/month, disabling › metoprolol, propranolol, amitriptyline, venlafaxine, valproate, topiramate, anti-CGRP agents, onabotulinumtoxinA.

Status migrainosus › NSAIDs, triptans, MgSO4, dexamethasone.

Tension-Type Headache

30 min–7d, bilateral, non-pulsatile, mild/moderate, no nausea/vomiting › paracetamol, ASA, NSAIDs.

Prophylaxis › CBT, amitriptyline.

Cluster Headache

Orbital/periorbital pain, 15–180 min, 1–8×/d, repeat over weeks then disappear for months/years, ipsilateral autonomic symptoms (nasal congestion, rhinorrhea, tearing, ptosis, miosis) › O2, sumatriptan.

Prophylaxis › verapamil, galcanezumab.

Red Flags & Workup

Red flags: first/worst headache, abrupt onset/thunderclap, progression/fundamental change, abnormal physical examination, neurologic symptoms <5 min or >1 h, new headache age >50y, new headache in cancer/immunosuppression/pregnancy, altered LOC, triggered by exertion/sexual activity/Valsalva maneuver.

Workup: MRI, CT (ICH), ESR/CRP (GCA), LP (infectious/neoplastic meningitis, intracranial HTN).

Intracranial HTN

ICP ≥20, headache, emesis, papilledema, dilated pupil, CN VI palsy, drowsiness › CT brain › elevate head 30°, hyperventilation, hypertonic saline/mannitol (target Sosm >280), neurosurgery.

Causes: intracranial mass (tumor, abscess, hemorrhage), cerebral edema (infarct, hypoxic-ischemic, TBI), increased CSF production (choroid plexus papilloma), decreased CSF absorption/obstructed outflow (post-meningitis, venous sinus thrombosis, jugular vein compression).

Vasogenic edema › dexamethasone.

IIH

Transient visual obscurations, pulsatile tinnitus, CSF pressure >250 › weight loss, acetazolamide, topiramate.

MRI › small ventricles, widened optic nerve sheaths, partially empty sella.

RF: obesity, female, isotretinoin, tetracycline antibiotics, hypervitaminosis A.

RCVS

Recurrent thunderclap, women, pregnancy, neurosurgical procedures, adrenergic/serotonergic drugs, cannabis.

MRI brain, MRA/CTA › strokes, hemorrhages, cerebral edema.

PRES

Headache, seizures, altered mental status, visual loss.

Causes: RCVS, eclampsia, uncontrolled HTN, severe infection, autoimmune/kidney disorders, immunosuppressants, chemotherapy.

MRI › parietal/occipital white matter edema, ICH.

Trigeminal Neuralgia

Paroxysmal unilateral lancinating pain, V2/V3 distribution, triggered by light touch › carbamazepine, oxcarbazepine.

Occipital Neuralgia

Posterior headache, acute, unilateral, lancinating pain; triggered by touch/movement › MRI brain/cervical spine › occipital nerve block, massage, cool compress.

Primary Cough/Stabbing Headache

Indomethacin.

Carotid Artery Dissection

Acute neck pain, eye pain, partial Horner syndrome, ipsilateral cerebral ischemia.

Post-LP Headache

Intracranial hypotension › bed rest, caffeine, epidural blood patch.

MRI brain › pachymeningeal thickening/enhancement.

Medication Overuse Headache

Analgesic use ≥15d/month.

Pregnancy

Paracetamol, ASA, diphenhydramine, metoclopramide.

CVT

Headache, worsens with Valsalva, pulsatile tinnitus, diplopia, seizures, papilledema, decreased mentation, CN VI palsy › MRV/CTV.

Cavernous sinus thrombosis: dental/sinus bacterial infection, acute-onset headache, proptosis, periorbital edema, ophthalmoplegia.

07

Myelopathy

▾
Clinical Pattern

UMN signs (weakness, spasticity, hyperreflexia, extensor plantar responses) below level, LMN signs (atrophy, hyporeflexia) at level › MRI spine.

Patterns of Cord Involvement

Complete (Transverse Myelitis)

Motor/sensory loss below lesion.

Hemi (MS)

Ipsilateral motor/proprioception loss, contralateral pain/temp loss.

Central (Syringomyelia)

Weakness UL > LL.

Anterior (CVA)

Pain/temp/motor loss below lesion.

Posterior (Syphilis, B12)

Proprioception/vibration loss below level.

Pure Motor (WNV, ALS)

Paralysis.

Cauda Equina

LL weakness, hypotonia, areflexia.

Specific Syndromes

NMOSD

Recurrent myelitis, optic neuritis, acute brainstem syndrome › aquaporin-4 antibodies.

MRI › normal.

Transverse Myelitis

Subacute, weakness, sensory changes, bowel/bladder dysfunction, typically after a viral infection › IV methylprednisolone.

MRI › enhancing cord lesion.

Causes: HSV, VZV, WNV, Lyme disease, syphilis, HTLV, HIV, TB.

Subacute Combined Degeneration

Vit B12/copper deficiency/NO abuse: paresthesias, LL weakness, spastic paraparesis, vibration/proprioception loss, sensory ataxia › MMA, homocysteine.

Copper: bariatric surgery, excessive zinc.

Anterior Spinal Artery Infarct

Acute, flaccid paralysis, pain loss, below lesion › thrombolysis.

Causes: emboli, hypotension (CV/aortic surgery), AVM.

Chronic Compressive Myelopathy

Osteoarthritic spinal stenosis › PT.

Severe › surgery.

Spinal Metastases

GC, radiation, surgery.

  • Corticospinal tracts › weakness, hyperreflexia, spasticity, extensor plantar responses
08

Seizures & Epilepsy

▾
Clinical Features

Vocalization, déjà vu, epigastric sensation, head turning, tongue laceration, incontinence.

Focal impaired consciousness: automatism (lip smacking, swallowing, manipulating objects).

Post-ictal: confusion, somnolence, focal neurological deficit.

Workup: CT/MRI, EEG.

Epilepsy Definition

≥2 unprovoked seizures >24h apart, or 1 unprovoked seizure + >60% recurrence risk (abnormal EEG/MRI), or epilepsy syndrome.

Seizure Types & Treatment

Temporal Lobe

Aura, lack of awareness, automatisms. MRI › mesial temporal sclerosis.

Frontal Lobe

Nocturnal complex seizures, underlying structural pathology.

Generalized

Tonic-clonic (1–3 min), absence, myoclonic. EEG › generalized spike-wave abnormality › valproate, lamotrigine, levetiracetam.

Myoclonic (JME)

Brief, lightning-like jerks of arms, preserved consciousness, sleep deprivation, alcohol use, visual stimuli, stress › lifelong AED (levetiracetam, valproate).

Focal

Carbamazepine, oxcarbazepine, phenytoin, lacosamide, lamotrigine, levetiracetam; refractory to 2 drugs › surgery (after video EEG).

Absence

Ethosuximide, valproate.

Pregnancy

Levetiracetam, lamotrigine, oxcarbazepine.

Elderly

Gabapentin, lamotrigine, levetiracetam.

Catamenial

Progesterone contraceptives, acetazolamide.

Status Epilepticus

Definition: ≥5 min seizure or ≥2 seizures ≤5 min without recovery in between › abortive + maintenance › CT, EEG.

  • Abortive: lorazepam IV, midazolam IM, diazepam IV
  • Maintenance: phenytoin, fosphenytoin, valproic acid, levetiracetam, lacosamide, phenobarbital
  • Hypoglycemia › thiamine + dextrose
  • Refractory: failure of benzodiazepine + 1 AED › intubation + induced coma 24–48h (midazolam, propofol, ketamine, pentobarbital)

Causes: mass lesion, CVA, meningitis/encephalitis, TBI, HIE, PRES, hypoglycemia, EtOH/benzodiazepine/barbiturate withdrawal, drug toxicity, electrolyte disturbances, renal/hepatic dysfunction.

Non-convulsive › continuous video EEG.

  • PNES: PTSD, conversion disorder, anxiety, mood disorders, forced eye closure, long duration, hypermotor activity, starts/stops suddenly, asynchronous/asymmetric flailing, pelvic thrusting › inpatient video EEG
AED Side Effects
  • Carbamazepine › osteoporosis, DLP
  • Carbamazepine/oxcarbazepine › hyponatremia, pancytopenia, mood stabilization
  • Valproate › weight gain, PCOS, teratogenicity, hepatotoxicity, mood stabilization, parkinsonism, cognitive dysfunction
  • Topiramate › kidney stones
  • Lamotrigine › DRESS, SJS/TEN, mood stabilization
  • Lacosamide › AV block
09

Cognitive Impairment

▾
Definitions & Workup

MCI: cognitive decline without functional decline.

Dementia: cognitive decline interfering with ADLs › MoCA, MMSE, RUDAS, MRI brain, CBC, RFT, Vit B12, TFT, Vitamin D, ± treponemal Ab.

Agitation › citalopram (mild/moderate), aripiprazole, brexpiprazole, risperidone.

Alzheimer's Disease

Insidious onset, gradual progression, short-term memory loss › long-term memory loss › CSF (amyloid, tau), amyloid PET › AChEi (mild), memantine (moderate), donanemab (mild/moderate).

AChEi: donepezil, galantamine, rivastigmine › bradycardia, diarrhea, heart block, nausea/vomiting, syncope.

MRI › decreased hippocampi volume.

Vascular Dementia

Subcortical ischemic syndrome (insidious onset), post-stroke (stepwise decline), gait imbalance, repeated falls, emotional incontinence, apathy, slowed cognition › manage RFs, target SBP <140.

CT/MRI › periventricular white matter changes, microhemorrhages, lacunar infarcts.

Prior CVA › ASA.

LBD

Fluctuating cognition, visual hallucinations, dementia preceding/within 1y parkinsonism, REM sleep behavior disorder › AChEi, levodopa/carbidopa.

SPECT/PET › low dopamine uptake in basal ganglia.

1st generation antipsychotics CI › NMS.

FTD

Disinhibition, apathy, loss of empathy, perseveration, hyperorality, executive dysfunction, poor insight, compulsive behaviors, OCD › trazodone, SSRIs.

Rapidly Progressive Dementia

CJD, neurodegenerative, infectious, autoimmune, neoplastic, metabolic, vascular.

CJD

Sleep/wake disturbance, dizziness/vertigo, depression/anxiety, personality change, visual disturbances, hallucinations, aphasia, ataxia, nystagmus, dementia, myoclonus, akinetic mutism.

MRI › hockey stick sign, cortical ribboning sign.

CSF › 14-3-3 tau protein.

NPH

Gait apraxia, dementia, urinary incontinence › large-volume LP ± VP shunt.

CT brain › ventriculomegaly.

PPA

Word-finding difficulties, cognition intact.

MRI › posterior temporal/parietal atrophy.

TES

Repetitive head trauma › cognitive impairment, irritability, aggressiveness, personality changes, depression › SSRI, psychotherapy.

Delirium

Disturbed attention/awareness/cognition, acute, fluctuating.

Screening: CAM, 4AT.

RF: age >70y, cognitive impairment, functional impairment, EtOH misuse, sensory impairment, drugs, physical restraints, urinary catheterization, infection.

Prevention: orientation protocols, family visits, glasses/hearing aids, adequate nutrition, correct electrolytes, proper sleep, early mobilization, analgesia, treat underlying cause.

Agitation › calm redirection. Avoid benzodiazepines, anticholinergics, antihistamines. Treat underlying cause.

Antipsychotics indications: danger to self/others, distressing psychosis, preventing medical care › haloperidol, atypical antipsychotic (brexpiprazole) › ↑morbidity/mortality.