Overview
This lecture covers common neurological red flags, their assessment, and practical steps for general practitioners regarding recognition, referral, and immediate management.
Neurological Red Flags Overview
- Neurological issues account for 1:10 GP consults and 10% of emergency admissions (excluding stroke).
- Red flags can indicate both common (migraine) and rare (Guillain-Barre) conditions.
- Recognizing and acting on red flags can significantly affect patient outcomes.
Key Principles in Neurology
- Neurology applies general diagnostic principles; many disorders are treatable.
- Important symptoms include symmetry, stereotypy, and number of affected areas.
- Onset timing helps differentiate causes (instant: vascular/trauma; minutes-hours: infection/migraine; days-weeks: neoplasia; months: degenerative).
Rapid Assessment Techniques
- 1-minute neuro exam: fundoscopy, cranial nerve assessment, limb power and coordination, standing/walking tests.
Headache Red Flags
- Sudden "worst ever" headache: suspect subarachnoid haemorrhage (SAH).
- Headaches with vomiting, photophobia, neck stiffness, or in patients >50 require urgent assessment.
- Raised intracranial pressure: early morning headache, vomiting, vision changes.
- Infection symptoms or temporal arteritis signs (jaw claudication) also require urgent referral.
Migraine and Cluster Headache
- Migraines are episodic with systemic symptoms, often in those with family history.
- Red flags: late onset or change in character.
- Treatments: lifestyle, acute/preventive drugs, supplements, acupuncture, Botox.
- Cluster headaches: severe, with autonomic features; treat with prednisolone and verapamil after ECG.
Transient Loss of Consciousness (TLoC)
- TIA rarely causes TLoC; most causes are cardiovascular.
- ECG, cardiac history, and exam are key.
- Red flags: abnormal ECG, exertional TLoC, heart murmur, family history of sudden cardiac death.
Weakness
- Distinguish between weakness, numbness, and heaviness.
- Assess onset (hyperacute, acute, sub-acute, chronic), pattern (cranial, mono-, hemi-, para-).
- Red flags: cranial nerve involvement, pain, wasting, post-infectious onset.
Altered Sensation
- Types: numbness, tingling, pain, allodynia.
- Patterns: glove/stocking, dermatomal, patchy.
- Red flags: weakness, rapid progression, sensory level, rash, past relapses.
Dizziness / Unsteadiness
- Clarify if true vertigo or lightheadedness.
- Assess for cardiac causes or multifactorial origins (proprioceptive, cerebellar).
Transient Ischaemic Attack (TIA)
- Presents as sudden, brief episode (usually <1hr), not associated with LOC.
- Urgent investigation and treatment (aspirin 300mg stat, clopidogrel after).
Tremor
- Tremor types: rest, action, postural; consider distractibility and gait changes.
- Red flags: systemic/metabolic symptoms, psychiatric features, gait/bradykinesia, rapid progression.
- Parkinson's: progressive, asymmetric, resting tremor, bradykinesia, instability.
Memory Problems
- Common; consider anxiety, depression, head injury.
- Red flags: functional decline, disorientation, personality change, rapid/progressive onset, hallucinations.
Key Terms & Definitions
- Subarachnoid Haemorrhage (SAH) — Sudden bleeding in the space around the brain; presents with a sudden severe headache.
- TIA (Transient Ischaemic Attack) — Temporary blockage of blood flow to the brain causing neurological symptoms that resolve.
- Migraine — Recurrent headache with systemic symptoms; can have aura or be acephalgic.
- Cluster Headache — Severe, unilateral headache with autonomic symptoms.
- Allodynia — Pain from stimuli that don't normally provoke pain.
- Bradykinesia — Slowness of movement, characteristic of Parkinson’s disease.
Action Items / Next Steps
- Refer urgently for suspected SAH, temporal arteritis, or raised intracranial pressure.
- Complete 1-minute neuro exams where appropriate.
- Start aspirin for suspected TIA; arrange rapid specialist review.
- Advise patients with TLoC not to drive until cleared.
- Consult NICE guidance and local protocols for referrals and management.