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Master Neurology
for MRCP Part 1

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HIGH YIELD NOTES ~5 min read

Core Concepts

Neurology focuses on diseases of the central (brain, spinal cord) and peripheral (nerves, muscles, neuromuscular junction) nervous systems. Key to diagnosis is anatomical localisation of lesions and understanding the pathophysiological process. Common presentations include weakness, sensory disturbances, abnormal movements, headaches, seizures, and cognitive impairment. The cranial nerves, sensory tracts (spinothalamic, posterior column), and motor tracts (corticospinal) are fundamental for localisation.

Clinical Presentation

Stroke/TIA: Acute onset focal neurological deficit (e.g., hemiparesis, dysphasia, visual field loss). TIA symptoms resolve within 24 hours.
Seizures: Transient disturbance of brain function due to abnormal electrical activity. Can be generalised (e.g., tonic-clonic, absence) or focal (with or without impaired awareness).
Multiple Sclerosis (MS): Relapsing-remitting episodes of neurological dysfunction (e.g., optic neuritis, sensory symptoms, weakness, ataxia), separated in time and space.
Parkinson's Disease: Bradykinesia, rigidity (cogwheel), resting tremor (pill-rolling), postural instability.
Myasthenia Gravis: Fluctuating fatigable weakness, worse with exertion, better with rest. Affects ocular muscles (ptosis, diplopia), bulbar muscles (dysphagia, dysarthria), and limbs.
Guillain-Barré Syndrome (GBS): Rapidly progressive, ascending flaccid paralysis with areflexia, often preceded by infection. Risk of respiratory failure.
Motor Neuron Disease (MND/ALS): Progressive weakness with signs of both upper (spasticity, brisk reflexes) and lower (fasciculations, wasting) motor neuron involvement, typically without sensory loss.
Headaches:
- Migraine: Unilateral, pulsatile, moderate-severe, photophobia/phonophobia, aura.
- Tension: Bilateral, band-like, mild-moderate, no severe associated symptoms.
- Cluster: Unilateral, excruciating periorbital pain, associated with ipsilateral autonomic features (lacrimation, ptosis, rhinorrhoea).
Dementia: Progressive decline in memory and other cognitive functions (e.g., language, executive function, visuospatial skills) severe enough to interfere with daily life.

Diagnosis (Gold Standard)

Stroke: Immediate CT brain to rule out haemorrhage. MRI brain (DWI sequence) for acute ischemia. Carotid Doppler for TIA/ischemic stroke workup.
Seizures: Clinical diagnosis, EEG (epileptiform activity), MRI brain to exclude structural lesions.
MS: MRI brain and spinal cord (dissemination in space and time per McDonald criteria), CSF oligoclonal bands.
Parkinson's Disease: Clinical diagnosis based on UK Brain Bank criteria. DAT scan can aid differentiation from essential tremor.
Myasthenia Gravis: Acetylcholine receptor antibodies (most common), MuSK antibodies. EMG (decremental response to repetitive nerve stimulation).
GBS: Clinical criteria, CSF (albumino-cytological dissociation), NCS/EMG (demyelinating features).
MND: Clinical diagnosis (El Escorial criteria), EMG (denervation/reinnervation).
Headaches: Clinical (International Headache Society criteria). MRI for red flags.
Dementia: Clinical history, cognitive screening (MMSE, MoCA), MRI brain (atrophy, vascular changes, rule out reversible causes).

Management (First Line)

Ischemic Stroke: IV thrombolysis (alteplase within 4.5h), mechanical thrombectomy (within 6-24h for large vessel occlusion). Antiplatelets (aspirin), statins, blood pressure control, rehabilitation.
Haemorrhagic Stroke: Blood pressure control, neurosurgical consultation for evacuation in selected cases.
Acute Seizures: IV lorazepam/diazepam. Status epilepticus: IV benzodiazepines, then phenytoin/levetiracetam/valproate. Long-term Seizure: Antiepileptic drugs (e.g., lamotrigine, levetiracetam, carbamazepine, valproate) based on seizure type and patient factors. Parkinson's Disease: Levodopa (most effective), dopamine agonists (e.g., ropinirole), MAO-B inhibitors (e.g., rasagiline). MS Relapse: High-dose IV corticosteroids (methylprednisolone). Disease-modifying therapies (DMTs) for long-term management (e.g., interferon-beta, glatiramer acetate, natalizumab, ocrelizumab). Myasthenia Gravis: Pyridostigmine (symptomatic). Immunosuppression (steroids, azathioprine). Crisis: IVIG or plasmapheresis. GBS: IVIG or plasmapheresis. Supportive care, including respiratory support. MND: Riluzole (slows progression). Symptomatic management (e.g., baclofen for spasticity, non-invasive ventilation). Migraine: Acute: NSAIDs, triptans. Prophylaxis: Beta-blockers (propranolol), topiramate, amitriptyline. Cluster Headache: Acute: High-flow oxygen, sumatriptan SC. Prophylaxis: Verapamil. Alzheimer's Dementia: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-moderate. Memantine for moderate-severe.

Exam Red Flags

Thunderclap headache: Sudden, severe headache reaching maximal intensity in seconds. Consider Subarachnoid Haemorrhage (SAH) – urgent CT head.
Headache with papilloedema: Raised intracranial pressure (e.g., brain tumour, idiopathic intracranial hypertension, cerebral venous thrombosis).
Fever, headache, neck stiffness, photophobia: Meningitis/Encephalitis – urgent LP after CT head (if indicated).
New-onset focal neurological deficit (acute): Stroke/TIA.
Acute painful vision loss in elderly with jaw claudication: Giant Cell Arteritis – urgent ESR/CRP and steroid treatment.
New onset seizure in adult: Rule out structural causes (e.g., tumour, stroke) with MRI brain.
Progressive weakness with respiratory compromise: Myasthenic crisis, GBS, MND – requires urgent airway assessment.
Unexplained gait disturbance, urinary incontinence, dementia: Normal Pressure Hydrocephalus.

Sample Practice Questions

Question 1

A 28-year-old male presents with a 2-week history of progressive ascending weakness, starting in his feet and now affecting his hands, accompanied by tingling sensations. He reports having a 'flu-like illness' a month ago. On examination, he has symmetrical flaccid paralysis of all four limbs, absent deep tendon reflexes, and reduced sensation in a 'glove-and-stocking' distribution. His vital capacity is decreasing. What is the most likely finding on cerebrospinal fluid (CSF) analysis?

A) Normal protein, elevated white blood cells (pleocytosis).

B) Elevated protein, normal white blood cells (albumino-cytological dissociation).

C) Low glucose, elevated protein, elevated white blood cells.

D) Oligoclonal bands present, normal protein, normal white blood cells.

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Question 2

A 35-year-old right-handed man presents with a 3-month history of progressive weakness in his left hand, followed by weakness in his left arm. He occasionally notices twitching in the muscles of his left arm. On examination, he has atrophy and fasciculations in his left hand and arm muscles, with increased tone and hyperreflexia in the same distribution. Sensation is intact throughout. Cranial nerves are normal. What is the most likely diagnosis?

A) Carpal Tunnel Syndrome

B) Cervical Radiculopathy

C) Motor Neuron Disease (Amyotrophic Lateral Sclerosis variant)

D) Myasthenia Gravis

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Question 3

A 35-year-old man presents with a 6-month history of progressive weakness and stiffness in his legs, followed by similar symptoms in his arms. He reports fasciculations and muscle cramps. On examination, he has widespread muscle atrophy, hyperreflexia, and extensor plantar responses. Sensory examination is normal. Cranial nerve examination reveals tongue fasciculations but no ophthalmoplegia. Which of the following is the most likely diagnosis?

A) Multiple Sclerosis

B) Myasthenia Gravis

C) Amyotrophic Lateral Sclerosis (ALS)

D) Guillain-Barré Syndrome

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