Neurology
Stroke and TIA
Intravenous thrombolysis is licensed within 4.5 hours of onset and mechanical thrombectomy for large vessel occlusion within 6 hours (selected patients up to 24 hours). Immediate CT excludes haemorrhage; check glucose before thrombolysis. Lower blood pressure only above 185/110 before thrombolysis or above 220/120 otherwise. After TIA, arrange urgent carotid imaging and start dual antiplatelet therapy for 21 days in high-risk patients.
Headache and seizures
Red flags: thunderclap onset (subarachnoid haemorrhage - CT is highly sensitive within 6 hours, otherwise lumbar puncture for xanthochromia after 12 hours), fever with neck stiffness, papilloedema, new headache over age 50, and postural headache. Status epilepticus is treated with a benzodiazepine followed by levetiracetam or phenytoin; check glucose, sodium, calcium and pregnancy (eclampsia responds to magnesium).
Neuromuscular and movement disorders
Distinguish upper from lower motor neuron signs. Guillain-Barré syndrome causes ascending areflexic weakness and is treated with IVIG or plasma exchange; myasthenia gives fatigable ptosis with anti-acetylcholine receptor antibodies and can present in crisis. Multiple sclerosis requires dissemination in time and space, with oligoclonal bands in CSF.
Traps: attributing a first seizure to epilepsy without checking glucose or sodium; missing subarachnoid haemorrhage because the CT was done late; forgetting that a normal CT does not exclude posterior circulation infarction.
Rule of thumb: time is brain - document the exact time of onset, and never let a CT request delay calling the stroke team.