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  <head>
    <title>030-02 Time-critical neurology, localisation, and longitudinal decline</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Time-critical neurology, localisation, and decline">
      <outline text="Where, what process, how fast">
        <outline text="Sudden maximal: vascular, haemorrhage, seizure, trauma"/>
        <outline text="Hours to days: inflammation, infection, metabolic, mass"/>
        <outline text="Weeks to months: tumour, immune, compression, degeneration"/>
        <outline text="Precise timeline from last known normal"/>
      </outline>
      <outline text="Acute focal deficit treated as stroke">
        <outline text="Reperfusion benefit decays with time"/>
        <outline text="Posterior: diplopia, dysphagia, truncal ataxia">
          <outline text="Low screening score does not mean benign"/>
        </outline>
        <outline text="Mimics: hypoglycaemia, postictal weakness, aura">
          <outline text="Uncertainty should accelerate imaging"/>
        </outline>
      </outline>
      <outline text="Ischaemic physiology and selection">
        <outline text="Arterial occlusion plus collateral failure"/>
        <outline text="Core: energy failure, cytotoxic oedema, cell death"/>
        <outline text="Penumbra: electrical failure before membrane loss">
          <outline text="Hypotension, hypoxaemia, fever recruit it to core"/>
        </outline>
        <outline text="Recanalisation, collaterals can outlast clock windows"/>
        <outline text="Selection integrates time, imaging, bleeding risk"/>
      </outline>
      <outline text="Imaging and reperfusion">
        <outline text="Non-contrast computed tomography: haemorrhage, mass">
          <outline text="May be normal early in ischaemia"/>
        </outline>
        <outline text="Angiography: large-vessel occlusion, dissection"/>
        <outline text="Thrombolysis after excluding haemorrhage"/>
        <outline text="Thrombectomy removes selected thrombi"/>
        <outline text="Complementary rather than competing"/>
        <outline text="Do not await full certainty once eligible"/>
      </outline>
      <outline text="Care after reperfusion decisions">
        <outline text="Swallow screen before oral intake">
          <outline text="Silent aspiration is common"/>
        </outline>
        <outline text="Secondary prevention follows mechanism">
          <outline text="Antiplatelet for most non-cardioembolic disease"/>
          <outline text="Anticoagulation for appropriate atrial fibrillation"/>
        </outline>
        <outline text="Handover: times, last antithrombotic dose, imaging"/>
        <outline text="Improvement may be transient attack or recanalisation"/>
        <outline text="Unknown mechanism: rhythm and vessel tests by hypothesis"/>
      </outline>
      <outline text="Haemorrhage">
        <outline text="Intracerebral haemorrhage may enlarge early"/>
        <outline text="Deep bleeds: hypertensive small-vessel damage"/>
        <outline text="Lobar bleed in older adult: amyloid angiopathy"/>
        <outline text="Cerebellar bleed compresses brainstem, blocks CSF flow">
          <outline text="May need urgent evacuation"/>
        </outline>
        <outline text="Subarachnoid: maximal within seconds or minutes"/>
        <outline text="Early aneurysm securing limits rebleeding"/>
        <outline text="Nimodipine against delayed cerebral ischaemia"/>
      </outline>
      <outline text="Seizure reconstruction and status">
        <outline text="Reconstruct the event before labelling"/>
        <outline text="Aura reveals focal onset"/>
        <outline text="Tongue injury, postictal confusion: support, not required"/>
        <outline text="Incontinence and post-syncope jerks not specific"/>
        <outline text="Status: failure of seizure termination">
          <outline text="Adequate benzodiazepine dose at five minutes"/>
          <outline text="Then longer-acting drug and search for cause"/>
        </outline>
        <outline text="Unresponsiveness after motor arrest: EEG"/>
        <outline text="First seizure: provoked versus unprovoked">
          <outline text="Trigger does not exclude structural lesion"/>
        </outline>
      </outline>
      <outline text="Raised intracranial pressure">
        <outline text="Pressure deceptively normal while reserve fades">
          <outline text="Then steep rise, tissue shift, herniation"/>
        </outline>
        <outline text="Late: anisocoria, posturing, irregular breathing"/>
        <outline text="Hypotension lowers perfusion from both sides"/>
        <outline text="Head up, neck neutral, avoid hypotonic fluid"/>
        <outline text="Hypertonic saline or mannitol: osmotic gradient">
          <outline text="Volume, sodium, renal, haemodynamic costs"/>
        </outline>
        <outline text="Brief hyperventilation constricts cerebral vessels">
          <outline text="Prolonged use risks ischaemia"/>
        </outline>
        <outline text="Defer lumbar puncture if a gradient could shift tissue"/>
      </outline>
      <outline text="Localising weakness and Guillain-Barre">
        <outline text="Upper motor neuron: tone up, brisk reflexes"/>
        <outline text="Lower motor neuron: wasting, fasciculation"/>
        <outline text="Junction: fluctuating, fatigable, sensation spared"/>
        <outline text="Normal conduction does not exclude small fibre"/>
        <outline text="Guillain-Barre: neurological, autonomic emergency">
          <outline text="Limb strength underestimates respiratory decline"/>
          <outline text="Serial vital capacity, cough, swallowing"/>
          <outline text="Intubate before carbon dioxide rises"/>
        </outline>
        <outline text="Dysautonomia makes vasoactive drugs hazardous"/>
        <outline text="Immunoglobulin or plasma exchange, not combined"/>
      </outline>
      <outline text="Neurodegeneration and longitudinal care">
        <outline text="Diagnose by first, dominant failing network"/>
        <outline text="Lewy bodies: fluctuation, hallucinations, sleep">
          <outline text="Marked antipsychotic sensitivity"/>
        </outline>
        <outline text="Frontotemporal: disinhibition, apathy, empathy loss"/>
        <outline text="Parkinson: bradykinesia plus rigidity or tremor"/>
        <outline text="Motor neuron: upper and lower signs, no sensory">
          <outline text="Respiratory failure without limb decline"/>
        </outline>
        <outline text="Repeat matched measures over time"/>
        <outline text="Stepwise decline: seek infection, drugs, vascular"/>
        <outline text="Discuss wishes while still expressible"/>
      </outline>
    </outline>
  </body>
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