RCP-SoPW 2019 – Acute neurology cases most likely to be picked up at district hospitals

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by Rachel Pugh

Neurological cases make up around 20% of acute hospital admissions (not including stroke), but most of them are treated by general physicians in non-specialist units, so these clinicians need highly developed awareness of what to look out for in cases presenting in Accident and Emergency (A&E).

In her talk given at the joint conference in Cardiff of the Royal College of Physicians/Society of Physicians in Wales, Dr Ann Johnson, drew a sharp contrast between the popular picture of neurology dominated by innovative treatments for multiple sclerosis (MS) and medicinal uses of cannabis for epilepsy, and the reality which is dominated by acute stroke, first seizure clinics and rapid-access MS clinics.

Although neurology covers headache, seizures and weakness, Johnson focused on headaches and underlined the need for consistent and practical principles to assess patients arriving at district general hospitals, only 28% of which have access to magnetic resonance imaging (MRI) scans 24/7.

Basic principles covering all three conditions are:

*  Locate the problem above or below the neck and in the upper or lower motor neuron

*  Observe whether symptoms/signs respect the anatomy

*  Establish whether the disease evolution fits the patient story.

Headaches divide into primary disorders (such as migraine) and secondary headaches (possibly attributable to hypertension, raised intracranial pressure, sudden severe headache, cerebral vein/sinus thrombosis or intracranial hypertension).

Migraines can present in A&E and need to be examined to rule out stroke, subarachnoid haemorrhage or meningitis. Imaging plus testing of cerebrospinal fluid (CSF) will be advised. Testing should be done for meningitis/encephalitis, looking out for a fever, neck stiffness, nausea and vomiting, altered consciousness, seizures and focal signs. Management of migraine is focused on advising sleep and rest, provision relief of pain and vomiting. Temazepam should be prescribed in acute cases.

Cerebral vein and sinus thrombosis also feature headaches alongside intracranial pressure, nausea and vomiting, papilloedema, false localising of VIth nerve. Computed tomography (CT) imaging and Cerebrospinal fluid (CSF) with opening pressure and computed tomographic venography (CTV) is advised. Consideration should be given to carrying out the ova cysts and parasites test (OCP), checking for dehydration, ulcerative colitis and Crohns, and for secondary brain infection as part of a systemic process.

Brain tumours are the biggest worry to patients with headaches even though a general practitioner (GP) survey has shown the one-year risk of malignant brain tumour to be 0.045%. Also, tumours rarely cause a headache until they reach a significant size. Signs to look out for are new onset headaches, seizures, papilledema and immune compromise.

Another form of headache GPs may encounter in A&E is carotid dissection, characterised by headache, neck pain and Horner’s Syndrome (a relatively rare disorder resulting in a constricted pupil, drooping of the upper eyelid, absence of sweating of the face, and sinking of the eyeball into the bony cavity that protects the eye.