Neurology

•  

  Emergency

  If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

  Adult

  Stroke/transient ischaemic attack (TIA)

  • Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
  • New acute symptoms

  Progressive loss of neurological function

  • Acute onset severe:
    
    • ataxia
    • vertigo
    • visual loss
  • Acute severe exacerbation of known MS

  Seizures/epilepsy

  • Status epilepticus/epilepsy with concerning features:
    
    • first seizure
    • focal deficit post-ictally
    • seizure associated with recent trauma
    • persistent severe headache > 1 hour post-ictally
    • seizure with fever

  Headache/migraine

  • Headache with concerning features:
    
    • sudden onset/thunderclap headache
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • first severe headache age > 50 years
    • severe headache associated with recent head trauma
    • recent onset headaches in young obese females
    • headaches with papilledema
    • >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected

  Movement disorders

  • Ocular

  Other referrals to emergency
  

  • Altered level of consciousness
  • Bilateral limb weakness with or without bladder and/or bowel dysfunction
  • Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
  • Delirium/sudden onset confusion with or without fever

  Paediatric

  Seizures/epilepsy

  • New onset seizures that require emergency care/advice
  • Status epilepticus (convulsive or non-convulsive)
  • Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
  • New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
  • Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
  • High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
  • Neonate / infant (<12-month-old) with epileptic seizure onset

  Headaches/migraine

  • Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
  • Headaches that wake at night or headaches immediately on wakening
  • New severe headaches
  • Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
  • Focal neurological features
  • Associated with significant persisting change of personality or cognitive ability or deterioration in school performance

  Functional neurological symptoms

  • The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition

  Movement disorder

  • Abrupt onset or deterioration of a movement disorder
  • Acute onset of ataxia / chorea
  • Impairment of function i.e. walking, attend school

  Hypotonic infant

  • Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
  • Feeding difficulties with weight loss

  Gait abnormality, isolated motor delay or focal weakness

  • Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
  • Acute onset focal weakness (suspected stroke – call 000)
  • Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
  • Feeding or swallowing difficulties
  • Acute foot drop or acute onset focal neuropathy

  Stroke

  • Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)

  Other neurological conditions

  • Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
  • Acute encephalopathy, acute confusional state, altered level of consciousness
•  

  CPC in scope Not an exhaustive list

  Please note this is not an exhaustive list of all conditions for outpatient services and does not exclude consideration for referral unless specifically stipulated in the CPC out of scope section.

  • Fetal conditions with neurological risk PAEDIATRIC
  • Functional neurological symptoms PAEDIATRIC
  • Gait abnormality, isolated motor delay or focal weakness PAEDIATRIC
  • Headaches/migraine PAEDIATRIC
  • Headaches/migraine ADULT
  • Hypotonic infant PAEDIATRIC
  • Movement disorders PAEDIATRIC
  • Movement disorders including Parkinson’s disease (PD), dystonia and essential tremor ADULT
  • Other neurological conditions PAEDIATRIC
  • Peripheral neuropathy ADULT
  • Progressive loss of neurological function, including multiple sclerosis (MS), motor neurone disease (MND), myasthenia gravis and other neuromuscular disorders ADULT
  • Seizures/epilepsy ADULT
  • Seizures/epilepsy PAEDIATRIC
  • Stroke PAEDIATRIC
  • Stroke/transient ischaemic attack (TIA) ADULT
•  

  CPC out of scope

  The following are not routinely provided in a public Neurology service.

  Adult

  • Mild or tension headache
  • Untreated headache/migraine
  • Dementia without prior assessment by physician or geriatrician
  • Syncope (consider cardiology)
  • Fibromyalgia/chronic fatigue syndrome
  • Lyme disease
  • Head injury including concussion (consider neurosurgery)
  • See specific Spine CPC
  • Chronic unexplained pain/ pain syndrome
  • Back and Neck Pain including radicular pain
  • Whiplash injuries

  Paediatric

  • The following are not routinely provided in a public Paediatric Neurology service.
  • Simple febrile seizures in a developmentally normal child with no risk factors for epilepsy (e.g. no known brain abnormality)
  • New onset epileptic seizures in a developmentally normal child > 2 years of age (unless specific criteria for
  • Neurology referral – see Epilepsy/Seizures CPC's)
  • Syncope with stiffening/twitching during the syncopal event (convulsive syncope)
  • Head injury including concussion (consider neurosurgery and rehabilitation services)
  • Tics and Tourette syndrome
  • ADHD
  • Autism spectrum disorders, unless concern for epileptic encephalopathy or regression
  • Mild global developmental delay
  • Headache (unless specific criteria for Neurology referral – see Headache/Migraine CPC's)
  • Toe walking without fixed foot deformity,
  • Cerebral palsy (Paediatrician and Rehabilitation services can refer to Neurology for support with aetiological diagnosis if required)
  • Stereotypic movements (primary or complex motor stereotypies) – differentiating from epilepsy in a young child can be supported by Neurologist review of videos
  • Dizziness and vertigo (unless paroxysmal in nature and concern for an epileptic basis)
  • Idiopathic intracranial hypertension (unless specific criteria for Neurology referral – see Headache/Migraine CPC's)
  • Functional neurological symptom disorder (unless specific criteria for Neurology referral – see Functional Neurological Symptoms CPC's)
  • Bell's palsy
  • Erb's/Klumpke's palsy
  • Horner's syndrome
  • Arterio-venous malformation, Vein of Galen malformations, Arterio-Venous fistulas and aneurysms (consider neurosurgery)
  • Haematological disorders with no previous stroke but concern regarding increased risk of stroke (consider Haematology referral)
  • Incidental findings on MRI brain scans considered of no clinical significance for the patient now or into the future, specifically static T2/FLAIR hyperintensities in white matter ('unidentified bright objects') and pineal cysts. Approximately 18% of MRIs in healthy volunteers show incidental findings, of these 15/18% required no referral. Of incidental findings that require referral, the majority are neurosurgical conditions (tumor, arachnoid cyst, vascular abnormalities such as cavernous angioma). Progressive demyelinating disorders (multiple sclerosis) are rare in childhood, if this condition is considered, call the on-call Neurology service (after transfer of images to Queensland Health PACS system so they are available for case discussion)