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High-Yield Neurologic Disorders for the PANCE

The neurologic system is 7% of the current NCCPA PANCE blueprint (effective Jan 2025), consistently one of the most heavily tested organ systems, with stroke, seizure, headache, and demyelinating/neurodegenerative disease dominating exam items.

Stroke & TIA

  • ◆Ischemic (~87%) vs hemorrhagic — get non-contrast head CT FIRST to exclude bleed before any thrombolytic.
  • ◆IV thrombolysis within 4.5 h of last-known-well: alteplase 0.9 mg/kg OR tenecteplase 0.25 mg/kg (max 25 mg) single bolus — both now Class 1/A in 2024-2026 AHA/ASA guidance, TNK favored for large-vessel occlusion; mechanical thrombectomy up to 24 h for LVO with favorable perfusion/imaging (DAWN/DEFUSE-3).
  • ◆BP threshold: lower to <185/110 before thrombolytics; otherwise permissive hypertension (treat only if >220/120) in ischemic stroke not receiving lytics.
  • ◆TIA = transient deficit without infarction; risk-stratify with ABCD2, start aspirin, and for high-risk TIA (ABCD2 ≥4) or minor stroke (NIHSS ≤3) give short-course DAPT (aspirin + clopidogrel ~21 days) then monotherapy.
  • ◆Atrial fibrillation → anticoagulate (DOAC preferred over warfarin except mechanical valve/moderate-severe mitral stenosis); symptomatic carotid stenosis 70-99% → endarterectomy.
  • ◆Amaurosis fugax = transient monocular vision loss from carotid/retinal emboli; lacunar syndromes (pure motor/sensory) from small-vessel lipohyalinosis in HTN/DM.

Seizures & Status Epilepticus

  • ◆Status epilepticus = ≥5 min continuous or ≥2 seizures without recovery; first-line IV lorazepam 0.1 mg/kg (or IM midazolam 10 mg if no IV access).
  • ◆Second-line: IV levetiracetam, fosphenytoin/phenytoin, or valproate (ESETT: all roughly equivalent); refractory → intubate + continuous infusion (propofol/midazolam).
  • ◆Focal-onset first-line: levetiracetam, lamotrigine; generalized tonic-clonic: valproate (avoid in reproductive-age women — teratogenic), levetiracetam, lamotrigine.
  • ◆Absence (childhood, 3-Hz spike-wave EEG) → ethosuximide first-line; avoid carbamazepine/phenytoin/gabapentin which can worsen absence/myoclonic.
  • ◆New-onset adult seizure: neuroimaging (MRI preferred) + labs (glucose, Na, Ca, tox); provoked causes (hypoglycemia, hyponatremia, alcohol withdrawal) treat the cause rather than start long-term AED.
  • ◆Do not drive; counsel on state reporting laws and medication adherence.

Headache Syndromes

  • ◆Migraine: unilateral, throbbing, photophobia/phonophobia, nausea, ±aura; acute = triptans/NSAIDs (gepants/lasmiditan if triptan-contraindicated); prophylaxis if ≥4 headache days/mo (propranolol, topiramate, amitriptyline, CGRP monoclonal antibodies).
  • ◆Tension-type: bilateral, band-like, non-pulsatile, no nausea; treat with NSAIDs/acetaminophen.
  • ◆Cluster: severe unilateral periorbital pain with ipsilateral lacrimation/rhinorrhea/ptosis/miosis; abort with 100% O2 + subcutaneous sumatriptan; verapamil for prevention.
  • ◆Red flags (SNOOP): thunderclap → SAH (non-contrast CT, then LP for xanthochromia if CT negative), fever+stiff neck → meningitis, papilledema, new headache >50 (giant cell arteritis — check ESR/CRP, start high-dose steroids empirically before temporal artery biopsy), immunocompromised, positional.
  • ◆Idiopathic intracranial hypertension: obese young women, papilledema, high LP opening pressure, normal imaging (rule out venous sinus thrombosis); treat with acetazolamide + weight loss.

Demyelinating, Neurodegenerative & Movement Disorders

  • ◆Multiple sclerosis: relapsing sensory/motor/optic neuritis/INO in young women; MRI periventricular/juxtacortical lesions disseminated in time/space, CSF oligoclonal bands; acute relapse = IV methylprednisolone, disease-modifying therapy long-term.
  • ◆Parkinson disease: resting tremor, cogwheel rigidity, bradykinesia, postural instability; carbidopa-levodopa most effective (dopamine agonists an option in younger patients to delay levodopa).
  • ◆Alzheimer disease: insidious short-term memory loss; cholinesterase inhibitors (donepezil) ± memantine for moderate-severe; anti-amyloid mAbs (lecanemab/donanemab) for early disease at select centers.
  • ◆ALS: mixed upper + lower motor neuron signs, no sensory loss; riluzole modestly extends survival (edaravone an adjunct).
  • ◆Guillain-Barré: ascending symmetric weakness + areflexia post-infection (Campylobacter), albuminocytologic dissociation on CSF; treat IVIG or plasmapheresis — NOT steroids; monitor respiratory status (serial FVC/NIF).
  • ◆Myasthenia gravis: fatigable ptosis/diplopia, anti-AChR (or anti-MuSK) antibodies; pyridostigmine + immunosuppression; crisis → IVIG/plasmapheresis; check chest CT for thymoma.

Peripheral, Cranial Nerve & Neurovascular Emergencies

  • ◆Bell palsy: acute peripheral CN VII palsy affecting the forehead (vs central sparing); treat with prednisone within 72 h (add valacyclovir for severe cases); eye protection/lubrication for incomplete closure.
  • ◆Bacterial meningitis: fever, headache, nuchal rigidity; empiric ceftriaxone + vancomycin (+ ampicillin if >50/immunocompromised/neonate for Listeria) + dexamethasone before/with first antibiotic; do not delay abx for CT/LP.
  • ◆Subarachnoid hemorrhage: 'worst headache of life' thunderclap; non-contrast CT then LP if negative; oral nimodipine to reduce vasospasm-related deficits.
  • ◆Wernicke encephalopathy: confusion + ophthalmoplegia + ataxia in alcoholics/malnourished; give IV thiamine BEFORE glucose.
  • ◆Carpal tunnel (median nerve): nocturnal paresthesia, Phalen/Tinel positive; splinting/steroids, surgical release if severe or with thenar atrophy.
  • ◆Essential tremor: bilateral action/postural tremor improved by alcohol; first-line propranolol or primidone.
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