40.2 Neurology and Rehabilitation Medicine: Stroke and TIA (Localization, Thrombolysis, Thrombectomy, Secondary Prevention), Intracranial Hemorrhage, Seizures and Status Epilepticus, Meningitis and Encephalitis, Tetanus and Rabies, Parkinsonism, Neuromuscular and Degenerative Diseases, Dementia, CNS Tumors, Post-Stroke Rehabilitation and Musculoskeletal Disorders

Why this area matters

Stroke (cerebrovascular disease) is one of the top causes of death in the Philippines, and survivors often need long rehabilitation. Tetanus and rabies still kill people who did not receive wound care or post-exposure prophylaxis. Japanese encephalitis, TB meningitis and neurocysticercosis are seen. The PLE asks you to localize a lesion, choose time-critical treatment and plan rehabilitation.

Stroke and TIA

• Recognition: sudden face drooping, arm weakness, speech difficulty (FAST), plus balance and eye symptoms (BE-FAST). Note the time last known well.
• Localization:
  • middle cerebral artery: contralateral weakness and numbness of the face and arm more than the leg, gaze toward the lesion, aphasia (dominant hemisphere) or neglect (non-dominant);
  • anterior cerebral artery: leg more than arm weakness, urinary incontinence and abulia;
  • posterior cerebral artery: contralateral homonymous hemianopia with macular sparing;
  • lacunar strokes (hypertension, diabetes): pure motor, pure sensory or ataxic hemiparesis without cortical signs;
  • brainstem: crossed signs (ipsilateral cranial nerve palsy with contralateral weakness), vertigo, diplopia and dysphagia;
  • cerebellar: ataxia, vertigo and vomiting, which can cause hydrocephalus.
• Imaging first: non-contrast CT excludes hemorrhage. CT angiography looks for large vessel occlusion. MRI with diffusion is the most sensitive for ischemia.
• Acute ischemic stroke:
  • IV thrombolysis with alteplase 0.9 mg/kg (maximum 90 mg; 10% as a bolus) or tenecteplase 0.25 mg/kg within 4.5 hours of last known well;
  • keep BP below 185/110 before and below 180/105 for 24 hours after thrombolysis;
  • contraindications include hemorrhage, recent major surgery or bleeding, low platelets, therapeutic anticoagulation and glucose below 50 mg/dL (correct glucose first);
  • mechanical thrombectomy for large vessel occlusion within 6 hours, and up to 24 hours with imaging selection;
  • if not thrombolysed, aspirin within 24 to 48 hours; for minor stroke or high-risk TIA, aspirin plus clopidogrel for 21 days;
  • permissive hypertension (do not treat unless above 220/120) in patients not given thrombolysis;
  • swallow screening before oral intake, glucose and temperature control, and DVT prevention with intermittent pneumatic compression.
• TIA: transient symptoms without infarction on imaging. The ABCD2 score estimates early stroke risk. Investigate urgently (imaging, carotid ultrasound, ECG for AF).
• Secondary prevention:
  • antiplatelet therapy, or anticoagulation for AF (DOAC from a few days to 2 weeks depending on stroke size);
  • high-intensity statin;
  • BP control;
  • carotid endarterectomy for symptomatic stenosis of 70% to 99% (and selected 50% to 69%), ideally within 2 weeks;
  • stopping smoking, diabetes control and exercise.
• Intracerebral hemorrhage:
  • from hypertension (basal ganglia, thalamus, pons, cerebellum), cerebral amyloid angiopathy (lobar, elderly), anticoagulants and vascular malformations;
  • lower systolic BP toward about 140 mmHg carefully (avoid large swings), reverse anticoagulation (vitamin K and prothrombin complex concentrate for warfarin; idarucizumab or andexanet for DOACs);
  • surgery for cerebellar hemorrhage over 3 cm or hydrocephalus.
• Aneurysm and AV malformation: subarachnoid hemorrhage presents with a thunderclap headache, and AVMs with hemorrhage or seizures in young people (see neurosurgery).
• Cerebral venous thrombosis: headache, seizures and papilledema in young women (pregnancy, oral contraceptives, dehydration), treated with anticoagulation even with hemorrhage.

Seizures and epilepsy

• Classification:
  • focal seizures, with or without impaired awareness, which may spread to bilateral tonic-clonic seizures;
  • generalized seizures: tonic-clonic, absence (3 Hz spike-and-wave in children), myoclonic and atonic.
• First seizure: check glucose, sodium, calcium and magnesium, toxins and alcohol withdrawal, and look for infection. Brain imaging (MRI preferred) and EEG follow.
• Epilepsy is diagnosed after 2 unprovoked seizures more than 24 hours apart, or 1 seizure with a high recurrence risk (60% or more), or an epilepsy syndrome.
• Treatment:
  • levetiracetam, lamotrigine, carbamazepine (focal) or valproate (generalized) chosen by seizure type and patient;
  • avoid valproate in women who could become pregnant (neural tube defects and lower IQ in children); lamotrigine and levetiracetam are preferred, with folic acid;
  • counsel about driving, swimming and heights.
• Status epilepticus (a seizure lasting 5 minutes or more, or repeated seizures without recovery):
  • airway, oxygen, glucose (give thiamine before glucose in malnourished or alcoholic patients);
  • first line: IV lorazepam, IV diazepam, or IM midazolam 10 mg if there is no IV access;
  • second line (at about 20 minutes): IV levetiracetam, fosphenytoin or valproate;
  • refractory status: intubation and anesthetic infusions (midazolam, propofol);
  • eclampsia is treated with magnesium sulfate.

CNS infections

• Bacterial meningitis:
  • fever, headache, neck stiffness and altered mental status; petechial rash suggests meningococcus;
  • CT before LP only with focal deficits, papilledema, new seizures, severe impairment of consciousness or immunosuppression, but blood cultures and antibiotics must not wait;
  • empiric treatment: ceftriaxone 2 g every 12 hours plus vancomycin, adding ampicillin for Listeria if over 50, pregnant or immunocompromised;
  • dexamethasone 0.15 mg/kg every 6 hours for 4 days, started with or just before the first antibiotic dose (benefit mainly in pneumococcal meningitis);
  • chemoprophylaxis for close contacts of meningococcal disease with rifampicin, ciprofloxacin or ceftriaxone.
• TB meningitis: subacute headache, fever, cranial nerve palsies (VI), hydrocephalus and basal enhancement. Treated with 2HRZE/10HR plus dexamethasone.
• HSV encephalitis: fever, confusion, behavior change and seizures, with temporal lobe changes on MRI and EEG. Start IV acyclovir immediately.
• Japanese encephalitis: mosquito-borne (Culex, rice fields and pigs), with encephalitis and parkinsonian features. Supportive care; prevented by vaccination.
• Neurocysticercosis: the most common cause of acquired epilepsy in endemic areas, from ingesting Taenia solium eggs.
• Tetanus:
  • trismus (lockjaw), risus sardonicus, neck and back rigidity (opisthotonus) and painful spasms with full consciousness, after a wound or in neonates via the umbilical stump;
  • treatment: human tetanus immune globulin, wound debridement, metronidazole, benzodiazepines and magnesium for spasms, a quiet dark room, airway protection and treatment of autonomic instability;
  • tetanus does not give immunity, so vaccinate after recovery;
  • wound prophylaxis: tetanus toxoid if the last dose was more than 10 years ago (more than 5 years for dirty wounds), and TIG for dirty wounds if fewer than 3 doses or the history is unknown.
• Rabies:
  • prodrome of fever and pain or tingling at the bite site, then furious rabies (agitation, hydrophobia, aerophobia, hypersalivation) or paralytic rabies (ascending weakness, mimicking Guillain-Barré);
  • almost always fatal once symptoms appear, so care is palliative with sedation in a quiet room, and staff use standard precautions;
  • prevention by prompt wound washing and post-exposure prophylaxis under the National Rabies Prevention and Control Program (see microbiology).

Movement, neuromuscular and degenerative disorders

• Parkinson disease:
  • bradykinesia plus rest tremor ("pill-rolling") or rigidity, often asymmetric, with shuffling gait, masked face and micrographia;
  • loss of dopaminergic neurons in the substantia nigra;
  • treated with levodopa-carbidopa (most effective), dopamine agonists and MAO-B inhibitors;
  • drug-induced parkinsonism (haloperidol, metoclopramide) is symmetric and improves after stopping the drug.
• X-linked dystonia-parkinsonism ("Lubag"):
  • an inherited neurodegenerative disease found almost only in Filipinos, especially men with maternal roots in Panay Island (Capiz);
  • begins in adulthood with dystonia, later replaced by parkinsonism;
  • deep brain stimulation helps severe dystonia.
• Myasthenia gravis:
  • fatigable weakness of eye muscles (ptosis, diplopia), bulbar and limb muscles, worse at the end of the day;
  • acetylcholine receptor antibodies, repetitive nerve stimulation (decrement), and CT of the chest for thymoma;
  • treated with pyridostigmine, steroids and immunosuppressants, and thymectomy;
  • myasthenic crisis (respiratory failure): intubation, IVIG or plasma exchange. Avoid aminoglycosides, fluoroquinolones and magnesium.
• Guillain-Barré syndrome:
  • ascending symmetric weakness with areflexia days to weeks after diarrhea (Campylobacter) or respiratory infection;
  • CSF protein high with normal cells (albuminocytologic dissociation) and demyelination on nerve conduction studies;
  • treated with IVIG or plasma exchange (not steroids);
  • monitor FVC and autonomic function; intubate if FVC falls below 20 mL/kg or with bulbar weakness.
• Amyotrophic lateral sclerosis: upper and lower motor neuron signs together (fasciculations, atrophy, spasticity, brisk reflexes) with normal sensation. Treated with riluzole and supportive care.
• Multiple sclerosis: episodes separated in time and space (optic neuritis, internuclear ophthalmoplegia, sensory symptoms), with periventricular MRI lesions and CSF oligoclonal bands. Relapses are treated with high-dose IV methylprednisolone, with disease-modifying drugs for prevention.

Dementia and delirium

• Dementia: acquired decline in memory and other cognitive domains that impairs daily function.
  • Alzheimer disease: the most common; early short-term memory loss, then language, visuospatial and executive problems. Treated with cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine for moderate to severe disease.
  • Vascular dementia: stepwise decline with stroke risk factors.
  • Dementia with Lewy bodies: visual hallucinations, fluctuating cognition and parkinsonism, with severe sensitivity to antipsychotics.
  • Frontotemporal dementia: early personality and behavior change or language problems in people in their 50s and 60s.
• Reversible causes to exclude:
  • vitamin B12 deficiency, hypothyroidism, neurosyphilis and HIV;
  • normal pressure hydrocephalus (gait apraxia, urinary incontinence and dementia: "wet, wobbly and wacky"), which may improve with a shunt;
  • chronic subdural hematoma, depression ("pseudodementia") and drugs (anticholinergics, sedatives).
• Delirium: an acute, fluctuating disturbance of attention and awareness from infection, drugs, metabolic disturbances, urinary retention or pain, common in elderly inpatients. Treat the cause, reorient the patient, and use antipsychotics only for severe agitation.
• CNS tumors: progressive deficits, seizures, raised ICP and personality change; metastases are the most common in adults (see neurosurgery).

Rehabilitation medicine

• Post-stroke rehabilitation:
  • starts once the patient is stable, ideally within days, with a multidisciplinary team (physiatrist, physical, occupational and speech therapists, nurses and family);
  • very early, intensive mobilization in the first 24 hours is not recommended;
  • dysphagia screening prevents aspiration pneumonia;
  • prevent complications: DVT, pressure injuries (turning every 2 hours), shoulder subluxation and pain (support the arm), spasticity (stretching, splints, botulinum toxin), contractures, falls and post-stroke depression;
  • function is measured with the modified Rankin Scale and the Barthel Index;
  • goals include walking with aids, activities of daily living, communication and return to the community.
• Musculoskeletal disorders:
  • acute low back pain: most cases resolve within 6 weeks. Advise patients to stay active (bed rest delays recovery), with heat, NSAIDs and physiotherapy. Red flags (cancer history, fever, weight loss, saddle anesthesia, urinary retention, progressive weakness, trauma in osteoporosis) need imaging;
  • knee osteoarthritis: quadriceps strengthening, weight loss, walking aids and activity modification;
  • carpal tunnel syndrome: numbness of the thumb, index and middle fingers at night, a positive Phalen and Tinel test; treated with a wrist splint, steroid injection or surgical release;
  • de Quervain tenosynovitis: a positive Finkelstein test, common in new mothers;
  • adhesive capsulitis (frozen shoulder): painful loss of active and passive rotation, linked to diabetes, treated with physiotherapy and injection;
  • rotator cuff tendinopathy: painful arc and weakness on abduction;
  • plantar fasciitis: heel pain with the first steps in the morning;
  • assistive devices: canes are held in the hand opposite the affected leg.