Neurology

NeurologyDr Chris Derry

Consultant NeurologistDepartment of Clinical

NeurosciencesWGH, Edinburgh

Outline• What is neurology?• What is a neurologist?• Elements of neurological diagnosis

– History– Examination

• Demonstration• Signs/ videos

– Laboratory tests– Final diagnosis

What is Neurology?• The medical specialty concerned with the

diagnosis, investigation and management of disorders of the nervous system.

• Clinical neurosciences vs basic neurosciences

• Nervous system– Central Nervous System (CNS)– Peripheral Nervous System (PNS)– Autonomic nervous system (ANS)

What does a neurologist do?• Diagnostics of nervous system disease

– Traditional role

• Management of acute neurological conditions– Status epilepticus, encephalitis, acute stroke etc

• Management of chronic neurological diseases– Epilepsy, parkinsons disease, multiple sclerosis

• Research

Other nervous system specialists…

• Neurosurgeon– Surgical treatment of neurological disease. Open and

stereotactic procedures

• Neuroradiologist– Neuroimaging. Interventional neuroradiology

• Neurophysiologist– EEG, NCV/EMG, evoked potentials

• Neuropathologist– Biopsy analysis, autopsy

• Psychiatrist– Mental illness

Why are patients referred to aNeurologist?

• GP– Neurological symptoms worrying patient/ doctor – headache/ numbness/ weakness

• Other specialists– Neurological complications of other diseases– Confusing clinical pictures

– Many tests not definitive– Some invasive/expensive

Example…• 32 year old female.• Background of

migraine

• Persistent daily headache for 1/12

• Worsening headache, presented to A&E

• Admitted, MRIDoes she have MS?

Making a neurological diagnosis

1. Where is the problem?• CNS (brain/ spinal cord)• Nerves• Muscle

2. What is the nature of the problem?• ‘vascular’• ‘inflammatory’• ‘infection’• ‘neoplastic’ etc..

3. What is the definitive diagnosis?

How are those stages reached?

1. History• 80% of diagnostic information• Particularly useful for localisation and

mechanism

2. Examination• Can confirm localisation

3. Investigations• Can help with pathological/ definitive diagnosis

The neurological history• Presenting complaint

– Headache, blackouts, dizziness, weakness, sensory symptoms, memory difficulties etc etc etc

– Evolution of symptoms– Acute, subacute, chronic– Episodic, persistent

– Systematic review– Additional neurological symptoms. ?Focal,

multifocal or systemic disorder

The neurological history• Previous medical history

– Earlier neurological symptoms, including symptoms seemingly unconnected

• Family history– Many neurological disorders have a genetic basis

• Social history– Consequences for job, family, driving, hobbies, sport,

recreation– Smoking, alcohol– Drug history

Neurological examination• After the history, you usually have a fair idea of:

– Where the lesion is – Type of lesion

– And you may also know the final diagnosis…

• Examination serves several purposes– Confirm localisation/ hypothesis testing

• e.g Spinal cord vs peripheral nerve– Screening for unsuspected abnormalities– Closely observe patient behaviours– Reassure patient– Think!

Neurological examination• Cognition (Addenbrooke’s Cognitive Examination)• Cranial nerves• Limbs

– Inspection (wasting etc)– Tone– Power– Co-ordination– Reflexes– Sensation

• Romberg’s/ Unterberger’s/ Hallpike’s• Gait

1. Cranial nerves

– ‘Head’ functions (including special senses)

• Smell• Sight• Facial sensation• Facial movements• Taste• Hearing• Tongue movements• Swallowing

Cranial nerve II (optic nerve)

Cranial nerves II, IV, VI

Cranial nerves II, IV, VI

Cranial nerve VII

Cranial nerve XII

Limb Examination• UPPER LOWER

EXTREMITIES• Neck movement and

strength• Motor function• Muscle bulk• Tone• Power• Reflexes• Co-ordination• Sensory examination

• AXIAL EXAMINATION

• Shoulder girdle muscles

• Curvature• Rise from supine• Abdominal reflexes

• Unterberger’s• Romberg’s • Hallpike’s

Some “Spot” diagnoses

• Parkinson’s Disease• Huntingdon’s Chorea

Investigations

CT (computed tomography)

CT (computed tomography)

Magnetic Resonance (MR) imaging

• Similar looking machinery to CT– No radiation source– Works via powerful magnets

• Very high definition of anatomy – eg white matter v grey

• Better than CT for detecting most brain pathology, particularly small/subtle abnormalities

MRI

Nuclear medicine

Lumbar puncture

Electroencephalography (EEG)

Case• 32 year old female.• Background of

migraine

• Persistent daily headache for 1/12

• Worsening headache, presented to A&E

• Admitted, MRIDoes she have MS?

Assessment• Full history

– Remote neurological episodes (even minor)– Family history

• Examination findings suggestive of previous neurological events

• Consider investigations– repeating MRI– lumbar puncture

• Uncertainty may persist…