1. Neurology Dr Chris Derry Consultant Neurologist
Department of Clinical Neurosciences
WGH, Edinburgh

2. Outline What is neurology? What is a neurologist?
Elements of neurological diagnosis
History
Examination
Demonstration
Signs/ videos
Laboratory tests
Final diagnosis

3. 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)

4. 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

5. 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

6. Why are patients referred to a Neurologist?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

7. Example… 32 year old female. Background of migraine
Persistent daily headache for 1/12
Worsening headache, presented to A&E
Admitted, MRI
Does she have MS?

8. Making a neurological diagnosis
Where is the problem?
CNS (brain/ spinal cord)
Nerves
Muscle
What is the nature of the problem?
‘vascular’
‘inflammatory’
‘infection’
‘neoplastic’ etc..
3. What is the definitive diagnosis?

9. How are those stages reached?
History
80% of diagnostic information
Particularly useful for localisation and mechanism
Examination
Can confirm localisation
Investigations
Can help with pathological/ definitive diagnosis

10. 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

11. 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

12. 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!

13. 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

14. 1. Cranial nerves ‘Head’ functions (including special senses) Smell
Sight
Facial sensation
Facial movements
Taste
Hearing
Tongue movements
Swallowing

15. Cranial nerve II (optic nerve)

16. Cranial nerves II, IV, VI

17. Cranial nerves II, IV, VI

18. Cranial nerve VII

19. Cranial nerve XII

20. 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

21. Some “Spot” diagnoses
Parkinson’s Disease
Huntingdon’s Chorea

22. Investigations

23. CT (computed tomography)

24. CT (computed tomography)

25. 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

26. MRI

27. Nuclear medicine

28. Lumbar puncture

29. Electroencephalography (EEG)

30. Case 32 year old female. Background of migraine
Persistent daily headache for 1/12
Worsening headache, presented to A&E
Admitted, MRI
Does she have MS?

31. 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…