Master Neurology
for MRCP Part 1

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