Neurology Revision Guide ✅

🧠 Neurology is localisation plus time course. Start with two questions: where is the lesion? and how quickly did it happen? Sudden symptoms suggest vascular disease or seizure; hours–days suggests inflammation, infection or compression; weeks–months suggests tumour, neurodegeneration or chronic inflammatory disease. For exams, always describe the neurological syndrome before naming the disease.

✅ 1. Core Neurology Principles

📍 1.1 Localisation

• Cortex: seizures, aphasia, neglect, visual field defects, higher cognitive problems.
• Brainstem: cranial nerve signs, crossed motor/sensory signs, diplopia, dysarthria, ataxia, reduced consciousness.
• Cerebellum: ataxia, dysmetria, intention tremor, nystagmus, scanning speech.
• Spinal cord: bilateral weakness/sensory level, bladder/bowel dysfunction, upper motor neurone signs below lesion.
• Nerve root: dermatomal pain/sensory loss with myotomal weakness.
• Peripheral nerve: sensory/motor loss in named nerve distribution.
• Neuromuscular junction: fatigable weakness, ocular/bulbar symptoms, normal sensation.
• Muscle: proximal weakness, myalgia, raised CK, normal sensation.

⏱️ 1.2 Time Course

• Seconds-minutes: stroke, seizure, syncope, migraine aura, hypoglycaemia.
• Hours-days: infection, inflammation, demyelination, Guillain-Barré syndrome, cord compression.
• Weeks-months: tumour, neurodegenerative disease, chronic neuropathy, myopathy.
• Relapsing-remitting: multiple sclerosis, migraine, epilepsy, functional neurological disorder, inflammatory disease.

🧠 Exam pearl: “Weakness” is not enough. Decide whether it is upper motor neurone, lower motor neurone, neuromuscular junction or muscle weakness - the differential changes completely.

🧪 1.3 Neurological Examination Framework

• Higher function: speech, cognition, neglect, praxis.
• Cranial nerves: pupils, eye movements, facial power/sensation, hearing, palate, tongue.
• Motor: tone, power, reflexes, plantar responses, wasting, fasciculations.
• Sensory: light touch, pinprick, vibration, proprioception, sensory level.
• Coordination: finger-nose, heel-shin, dysdiadochokinesis.
• Gait: broad-based, shuffling, high-stepping, spastic, ataxic, Trendelenburg.
• Function: swallowing, speech, continence, falls, driving, work and ADLs.

🚨 2. Stroke and Transient Ischaemic Attack

Stroke is an acute focal neurological deficit caused by cerebral infarction or haemorrhage. NICE NG128 covers acute diagnosis and initial management of stroke and TIA in over-16s and was last reviewed in March 2026.

⚡ 2.1 Recognition

• Use FAST: Face weakness, Arm weakness, Speech disturbance, Time to call emergency services.
• Exclude hypoglycaemia in any sudden neurological deficit.
• Symptoms are usually sudden and focal: weakness, sensory loss, aphasia, neglect, visual field loss, ataxia, diplopia.
• Posterior circulation stroke can present with vertigo, vomiting, dysarthria, diplopia, ataxia and reduced consciousness.
• Do not dismiss stroke because symptoms are “dizzy” or “confused” if there are focal neurological signs.

🧠 2.2 Stroke Syndromes

🩻 2.3 Initial Management

• Urgent brain imaging distinguishes ischaemic stroke from haemorrhage and guides reperfusion decisions.
• Consider thrombolysis and/or thrombectomy depending on time window, imaging, severity and contraindications.
• Check glucose, oxygen saturation, blood pressure, temperature and swallow safety.
• Aspirin is used after haemorrhage is excluded and when appropriate; timing depends on thrombolysis and local protocol.
• Assess swallowing before oral intake to reduce aspiration risk.
• Admit to a stroke unit where possible; stroke-unit care improves outcomes.

⏳ 2.4 TIA

• TIA causes transient focal neurological symptoms due to cerebral or retinal ischaemia without acute infarction.
• Symptoms usually resolve fully, but early stroke risk is significant.
• Urgent specialist assessment is needed; do not reassure solely because symptoms resolved.
• Start secondary prevention according to local pathway after haemorrhage/mimics considered.
• Investigate for carotid stenosis, atrial fibrillation, hypertension, diabetes and dyslipidaemia.

🚨 Safety pearl: Sudden focal neurology is stroke until proven otherwise, but always check glucose - hypoglycaemia is a reversible stroke mimic.

🩸 3. Intracranial Haemorrhage and Subarachnoid Haemorrhage

🧠 3.1 Intracerebral Haemorrhage

• Causes: hypertension, cerebral amyloid angiopathy, anticoagulation, vascular malformation, tumour, trauma.
• Features: sudden focal deficit, headache, vomiting, reduced consciousness, seizures.
• CT head is usually diagnostic acutely.
• Management: reverse anticoagulation if appropriate, control blood pressure, manage raised intracranial pressure, neurosurgical/stroke input.

⚡ 3.2 Subarachnoid Haemorrhage

• Classically presents with sudden “thunderclap” headache reaching maximal intensity within seconds.
• Associated features: neck stiffness, photophobia, vomiting, collapse, seizures, reduced consciousness.
• Common cause: ruptured berry aneurysm in circle of Willis.
• Initial test: urgent non-contrast CT head; lumbar puncture may be needed if CT negative and suspicion remains, depending on timing/pathway.
• Complications: rebleeding, vasospasm, hydrocephalus, seizures, hyponatraemia.
• Management: neurosurgical centre, aneurysm coiling/clipping, nimodipine to reduce delayed cerebral ischaemia risk, supportive care.

🚨 Exam pearl: Thunderclap headache is subarachnoid haemorrhage until proven otherwise, even if neurological examination is normal.

🤕 4. Headache

NICE CG150 covers diagnosis and management of headaches in people over 12, including migraine, tension-type headache, cluster headache and medication-overuse headache.

🚩 4.1 Headache Red Flags

• Thunderclap onset.
• New neurological deficit, seizure, confusion or reduced consciousness.
• Fever, meningism, rash or immunosuppression.
• New headache after age 50.
• Headache with jaw claudication or scalp tenderness.
• Headache triggered by cough, exertion or sex.
• Progressively worsening headache, especially with morning vomiting or papilloedema.
• Pregnancy/postpartum headache.
• Headache after head injury or with cancer history.

🧠 4.2 Migraine

• Recurrent headache lasting hours to days, often unilateral, pulsating, moderate-severe and worsened by activity.
• Associated symptoms: nausea, vomiting, photophobia, phonophobia.
• Aura: reversible visual, sensory or speech symptoms developing gradually and usually resolving within 60 minutes.
• Acute treatment may include NSAID/paracetamol plus triptan if suitable; antiemetic can help nausea and gastric stasis.
• Consider prevention if frequent, disabling or medication overuse risk.
• Avoid opioids for migraine because they worsen outcomes and medication-overuse risk.

🪢 4.3 Tension-Type Headache

• Bilateral pressing/tight band-like headache, mild-moderate, not worsened by routine activity.
• No significant nausea; photophobia or phonophobia may occur but not both typically.
• Management: reassurance, trigger management, simple analgesia occasionally, avoid medication overuse.

🧨 4.4 Cluster Headache

• Severe unilateral orbital/temporal pain lasting 15–180 minutes, often in clusters over weeks.
• Autonomic features: red/watery eye, nasal congestion, rhinorrhoea, ptosis, miosis, facial sweating.
• Patients are often restless/agitated rather than lying still.
• Acute treatment: high-flow oxygen and/or subcutaneous/intranasal triptan where appropriate.
• Preventive therapy such as verapamil requires ECG monitoring.

💊 4.5 Medication-Overuse Headache

• Headache on many days due to frequent analgesic or triptan use.
• Risk increases with opioids, combination analgesics, triptans and frequent NSAID/paracetamol use.
• Management involves explanation and withdrawal plan with support.

⚡ 5. Seizures and Epilepsy

NICE NG217 covers diagnosing and managing epilepsy in children, young people and adults. Epilepsy diagnosis should be made carefully because many events mimic seizures.

⚡ 5.1 First Seizure Assessment

• Take witness history: onset, awareness, movements, eyes, colour, breathing, tongue biting, incontinence, duration, recovery.
• Differentiate from syncope, panic, migraine, sleep disorders, tics, functional seizures and cardiac arrhythmia.
• Check glucose, sodium, calcium, infection, toxins/drugs, alcohol withdrawal and pregnancy where relevant.
• ECG is important because arrhythmias can mimic seizures.
• Urgent imaging if focal deficit, head injury, immunosuppression, cancer, persistent altered consciousness or focal seizure features.

🧠 5.2 Seizure Types

🚨 5.3 Status Epilepticus

• Convulsive seizure lasting 5 minutes or recurrent seizures without recovery is an emergency.
• ABCDE, protect from injury, oxygen if needed, glucose check, IV access, identify cause.
• Give benzodiazepine according to local protocol; escalate to second-line antiseizure medication if ongoing.
• Refractory status requires anaesthetic/ICU support.
• Common causes: missed medication, alcohol withdrawal, infection, stroke, tumour, metabolic disturbance.

💊 5.4 Antiseizure Medication Principles

• Choose medication based on seizure type, epilepsy syndrome, sex/pregnancy potential, comorbidities and interactions.
• Valproate is highly teratogenic and has major restrictions in people who could become pregnant.
• Lamotrigine levels can fall in pregnancy and with oestrogen-containing contraception.
• Enzyme-inducing antiseizure medications can reduce effectiveness of hormonal contraception.
• Discuss driving, swimming, bathing, heights, machinery, alcohol, sleep deprivation and SUDEP risk.

⚠️ Safety pearl: Not every collapse with shaking is epilepsy. Syncope can cause brief jerks, so history of prodrome, posture, pallor, rapid recovery and ECG matter.

🧬 6. Multiple Sclerosis and Demyelination

🧠 6.1 Multiple Sclerosis

• MS is immune-mediated demyelination within the central nervous system, disseminated in time and space.
• Common presentations: optic neuritis, sensory symptoms, limb weakness, diplopia, ataxia, Lhermitte phenomenon, bladder symptoms.
• Optic neuritis: painful visual loss with reduced colour vision, often worsened by eye movement.
• Uhthoff phenomenon: symptoms worsen with heat/exercise.
• Diagnosis uses clinical history, MRI brain/spine and sometimes CSF oligoclonal bands.
• Differentials: NMOSD, MOG antibody disease, B12 deficiency, vasculitis, infection, structural lesions.

💊 6.2 MS Management

• Relapses may be treated with high-dose corticosteroids after excluding infection.
• Disease-modifying therapies reduce relapse/activity in appropriate MS subtypes.
• Symptom management: spasticity, neuropathic pain, fatigue, bladder dysfunction, mood, cognition and mobility.
• Multidisciplinary care is essential: neurology, MS nurses, physiotherapy, OT, bladder/bowel services and psychology.

🧠 Exam pearl: MS affects the CNS, so it should not cause lower motor neurone signs or a purely peripheral nerve distribution. If it does, reconsider localisation.

🤲 7. Peripheral Neuropathy and Nerve Lesions

🧦 7.1 Peripheral Neuropathy

• Typical pattern: distal symmetrical glove-and-stocking sensory loss, pain, paraesthesia and reduced ankle reflexes.
• Common causes: diabetes, alcohol, B12 deficiency, CKD, hypothyroidism, chemotherapy, HIV, paraproteinaemia, autoimmune disease.
• Small fibre neuropathy causes burning pain and temperature/pinprick loss with preserved vibration/reflexes early.
• Large fibre neuropathy causes numbness, sensory ataxia, loss of vibration/proprioception and reduced reflexes.
• Investigations: HbA1c, B12, folate, TFT, U&E, LFT, FBC, serum electrophoresis, autoimmune/infection tests if indicated.

🖐️ 7.2 Common Mononeuropathies

🧠 7.3 Radiculopathy

• Root compression causes dermatomal pain, sensory symptoms and myotomal weakness.
• Cervical radiculopathy may cause neck/arm pain with reflex changes.
• Lumbar radiculopathy causes sciatica; L5 affects dorsiflexion/big toe extension, S1 affects plantarflexion/ankle reflex.
• Red flags: bladder/bowel dysfunction, saddle anaesthesia, bilateral sciatica, progressive weakness, cancer/infection risk.

🦵 8. Guillain-Barré Syndrome and Neuromuscular Emergencies

⬆️ 8.1 Guillain-Barré Syndrome

• Acute immune-mediated polyradiculoneuropathy, often following infection such as Campylobacter jejuni.
• Features: ascending weakness, areflexia, sensory symptoms, pain, facial weakness, autonomic instability.
• Respiratory failure can occur due to diaphragmatic/intercostal weakness.
• Investigations: nerve conduction studies; CSF may show high protein with normal cell count after first week.
• Management: admit, monitor forced vital capacity, ECG/BP, IVIG or plasma exchange in significant disease.

💪 8.2 Myasthenia Gravis

• Autoimmune neuromuscular junction disorder causing fatigable weakness.
• Features: ptosis, diplopia, dysarthria, dysphagia, chewing fatigue, limb weakness; sensation normal.
• Worse with exertion and later in day; improves with rest.
• Associated with thymic hyperplasia/thymoma.
• Tests: acetylcholine receptor antibodies, MuSK antibodies, neurophysiology, CT chest.
• Treatment: pyridostigmine, immunosuppression, thymectomy in selected patients.

🚨 8.3 Myasthenic Crisis

• Life-threatening respiratory or bulbar weakness in myasthenia.
• Features: breathlessness, weak cough, dysphagia, nasal speech, pooling secretions, falling vital capacity.
• Triggers: infection, surgery, pregnancy, medication, missed treatment.
• Avoid drugs that worsen myasthenia where possible, including some antibiotics, magnesium and beta-blockers.
• Requires urgent neurology/ICU input, respiratory monitoring, IVIG or plasma exchange.

🚨 Safety pearl: In Guillain-Barré or myasthenia, oxygen saturation can stay normal until late. Measure respiratory mechanics such as vital capacity when respiratory weakness is suspected.

🚶 9. Movement Disorders

🕺 9.1 Parkinson’s Disease

NICE NG71 covers diagnosis and management of Parkinson’s disease in adults, aiming to improve care from diagnosis through motor, non-motor and palliative stages.

• Core motor features: bradykinesia plus rest tremor and/or rigidity.
• Other features: shuffling gait, reduced arm swing, hypomimia, micrographia, postural instability later.
• Non-motor symptoms: anosmia, constipation, REM sleep behaviour disorder, depression, anxiety, cognitive impairment, autonomic dysfunction.
• Diagnosis is clinical; refer untreated suspected Parkinson’s disease to a specialist before starting treatment where possible.
• Treatment options include levodopa, dopamine agonists and MAO-B inhibitors depending on symptoms, age and adverse effect profile.
• Do not abruptly stop dopaminergic therapy because severe rigidity, fever and neuroleptic malignant-like syndrome can occur.

⚠️ 9.2 Parkinsonism Red Flags

• Early falls, early autonomic failure, vertical gaze palsy, cerebellar signs or poor levodopa response suggest atypical parkinsonism.
• Drug-induced parkinsonism is commonly caused by antipsychotics and antiemetics such as metoclopramide/prochlorperazine.
• Vascular parkinsonism often affects gait and lower body more than tremor.

🫨 9.3 Tremor

🧬 9.4 Huntington’s Disease

• Autosomal dominant CAG repeat disorder causing chorea, psychiatric symptoms and cognitive decline.
• Anticipation can occur, especially paternal transmission.
• Features: choreiform movements, irritability, depression, impulsivity, executive dysfunction, dysphagia.
• Management is supportive and multidisciplinary with genetic counselling.

🧓 10. Cognitive Disorders and Dementia

🧠 10.1 Dementia Approach

• Dementia is progressive cognitive decline interfering with daily function.
• Assess memory, language, visuospatial function, executive function, mood, function and collateral history.
• Exclude reversible contributors: delirium, depression, B12 deficiency, hypothyroidism, medications, alcohol, sleep apnoea, normal pressure hydrocephalus.
• Basic tests: FBC, U&E, LFT, TFT, B12/folate, calcium, glucose/HbA1c, infection screen if acute change.
• Brain imaging helps identify vascular disease, tumour, subdural haematoma or normal pressure hydrocephalus.

📚 10.2 Dementia Types

🚨 10.3 Delirium

• Delirium is acute fluctuating disturbance of attention and cognition.
• Causes: infection, drugs, pain, constipation, urinary retention, dehydration, hypoxia, metabolic disturbance.
• Hypoactive delirium is easily missed and has poor outcomes.
• Management: treat cause, reorientation, hydration, glasses/hearing aids, sleep, mobilisation, avoid unnecessary sedatives.

🧠 Exam pearl: Acute confusion is delirium until proven otherwise, not “new dementia”. Always look for a reversible trigger.

🧠 11. Spinal Cord and Cauda Equina

🚨 11.1 Spinal Cord Compression

• Causes: metastatic cancer, epidural abscess, trauma, disc disease, haematoma.
• Features: back pain, bilateral weakness, sensory level, upper motor neurone signs, bladder/bowel dysfunction.
• Malignant cord compression often causes severe progressive back pain worse lying down or at night.
• Management: urgent MRI whole spine, steroids if malignant compression suspected and no contraindication, oncology/neurosurgical input.

🚨 11.2 Cauda Equina Syndrome

• Compression of lumbosacral nerve roots causing lower motor neurone bladder/bowel/sexual dysfunction.
• Red flags: urinary retention, reduced urinary sensation, saddle anaesthesia, bilateral sciatica, severe/progressive neurological deficit, faecal incontinence.
• Requires emergency MRI and spinal surgical referral.
• Do not rely on pain severity alone; bladder and saddle symptoms are key.

🦠 11.3 Spinal Epidural Abscess

• Risk factors: diabetes, IV drug use, immunosuppression, recent spinal procedure, bacteraemia.
• Features: back pain, fever, neurological deficit; full triad may be absent.
• Management: urgent MRI, blood cultures, IV antibiotics and neurosurgical input.

🦠 12. CNS Infection

🧫 12.1 Meningitis

• Features: fever, headache, neck stiffness, photophobia, vomiting, confusion, seizures, non-blanching rash.
• Older adults/immunosuppressed patients may present atypically with confusion or sepsis.
• Do not delay antibiotics if meningitis/sepsis is suspected.
• Blood cultures, antibiotics and adjunctive steroid timing depend on local protocol.
• CT before LP is needed if signs of raised ICP, focal neurology, seizures, immunosuppression or reduced consciousness.

🧠 12.2 Encephalitis

• Brain inflammation causing altered mental state, seizures, focal neurology or behavioural change.
• HSV encephalitis often affects temporal lobes and can cause personality change, seizures and dysphasia.
• Start IV aciclovir promptly if suspected; do not wait for PCR if clinically concerning.
• Autoimmune encephalitis can mimic psychiatric illness and seizures, especially in younger patients.

👁️ 13. Neuro-ophthalmology and Cranial Nerves

👁️ 13.1 Visual Field Defects

👀 13.2 Diplopia

• Binocular diplopia resolves when either eye is closed and suggests ocular misalignment.
• Third nerve palsy: ptosis, eye down and out; pupil involvement suggests compressive aneurysm until proven otherwise.
• Fourth nerve palsy: vertical diplopia worse looking down stairs.
• Sixth nerve palsy: impaired abduction, horizontal diplopia; can occur with raised intracranial pressure.
• Painful third nerve palsy with dilated pupil needs urgent imaging.

🙂 13.3 Facial Weakness

• UMN facial weakness spares forehead because of bilateral cortical innervation.
• LMN facial weakness affects forehead and lower face; Bell’s palsy is a diagnosis of exclusion.
• Red flags: gradual onset, recurrent palsy, other cranial nerves, vesicles, parotid mass, limb signs, bilateral palsy.
• Ramsay Hunt syndrome causes facial palsy with ear pain/vesicles and can be more severe than Bell’s palsy.

🧬 14. Motor Neurone Disease and Myopathy

🧠 14.1 Motor Neurone Disease

• Progressive neurodegenerative disease affecting upper and lower motor neurones.
• Features: progressive weakness, wasting, fasciculations, cramps, spasticity, brisk reflexes, bulbar symptoms.
• Sensation is usually preserved.
• Bulbar involvement: dysarthria, dysphagia, tongue fasciculations, emotional lability.
• Respiratory failure can develop; monitor FVC and symptoms of nocturnal hypoventilation.
• Management is multidisciplinary: neurology, respiratory, SALT, dietetics, physiotherapy, OT, palliative care.

💪 14.2 Myopathy

• Pattern: proximal weakness, difficulty rising from chair/climbing stairs/lifting arms.
• Sensation is normal; reflexes often preserved until severe.
• Causes: inflammatory myositis, endocrine disease, steroid myopathy, statins, muscular dystrophy, metabolic myopathy.
• Investigations: CK, TFT, vitamin D, autoimmune tests, EMG, MRI muscle, biopsy in selected cases.
• Dermatomyositis: proximal weakness plus heliotrope rash/Gottron’s papules; consider malignancy association in adults.

🚨 15. Neurology Emergencies

📚 16. OSCE / Exam Pearls

• Always localise: cortex, brainstem, cerebellum, cord, root, nerve, NMJ or muscle.
• Sudden focal neurology is stroke until proven otherwise - check glucose.
• Thunderclap headache needs urgent SAH assessment.
• UMN facial weakness spares the forehead; LMN facial weakness affects the forehead.
• Optic neuritis causes painful visual loss and reduced colour vision.
• MS causes CNS signs, not isolated peripheral nerve patterns.
• Ascending weakness with areflexia suggests Guillain-Barré.
• Fatigable ptosis/diplopia with normal sensation suggests myasthenia gravis.
• Back pain plus bladder/bowel/saddle symptoms is cauda equina until proven otherwise.
• Acute confusion is delirium until proven otherwise, not “just dementia”.

📌 17. Quick Differentials Table

📚 References

• NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NG128.
• NICE. Epilepsies in children, young people and adults. NG217.
• NICE. Headaches in over 12s: diagnosis and management. CG150.
• NICE. Parkinson’s disease in adults. NG71.
• NICE. Multiple sclerosis in adults: management. NG220.
• NICE. Dementia: assessment, management and support for people living with dementia and their carers. NG97.
• Association of British Neurologists and local stroke, seizure, thrombolysis/thrombectomy, meningitis, MS and neuromuscular pathways should be checked for specialist decisions.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local neurology, stroke, epilepsy, meningitis, neurosurgical, anticoagulation, imaging and emergency pathways, formularies, senior advice and national guidance. Neurological emergencies such as stroke, subarachnoid haemorrhage, meningitis/encephalitis, status epilepticus, cauda equina syndrome, cord compression, Guillain-Barré syndrome and myasthenic crisis require urgent senior input.