Nervous System Disorders

1. Bacterial Meningitis
Causes: H influenza, N meningitides, strep pneumococcus, L monocytogenes, E coli, Proteus, Strep.
Clinical features:
Fever, rigor, malaise, headache, confusion, nausea, vomiting, neck stiffness/rigidity and pain, delirium,
lethargy, coma. (May get complicated leading to CN palsies, focal neurological defects, drowsiness, cerebral
edema, hydrocephalus), seizures.
• Neck rigidity (reflex spasm of paravertebral muscles)
• Kernings Sign +ive (flex hip at 90° and extend leg at knee, patient feels pain)
• Brudzinkis Sign +ive (simultaneous flexion of hip and leg with neck flexion)
• Rash
(No fever in elderly, no fever or neck rigidity in neonates, they have restlessness, high pitched crying and
irritability instead). Neurological signs like seizures more prominent in bacterial.
Investigations:
Lumbar puncture – CSF analysis (inc proteins, dec glucose, inc opening pressure, inc cell count), CSF
culture and PCR. Blood culture. Blood CP. Xray. Ct scan. Serum Urea creatinine electrolytes.
Management:
General (bed rest, IV fluids, airway patency), with Rash (benzyl penicillin), without rash(ceftraixone
which is avoided in neonates), adjunctive therapy, mannitol (to dec ICP), dexamathesone
(glucocorticoids), antiepileptics (barbiturates, diazepam, phenytoin)
{Meningococcus – benzylpenicillin
S. Pneumonia – ceftriaxone
H influenza – ceftriaxone
Listeria – ampicillin}
Prophylaxis: oral rifampicin/ciprofloxacin. Vaccination for A and C, not B.
Complications: septicemia, DIC, shock, CN palsies, seizures, mental retardation, inc ICP.

2. Tuberculous Meningitis
Miliary (disseminated) TB. Rupture of meningeal tuberculoma. Base of brain-thick exudates that involve nerves
– leads to CN palsies.
Clinical features:

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Fever, headache, stiff neck, confusion, family history of TB, nerve palsy (abducent/occulomotor).
Anorexia, lassitude, irritability, vomiting, convulsions, coma, hemiplegia, behavioural changes.
Ophthalmoscope may reveal choroids tubercles (with miliary TB).
Signs: meningism, occulomotor palsies, pappiledema, dec conscious level.
Investigations:
Lumbar puncture – CSF examination (dec glucose, inc proteins, normal chloride, inc pressure, fluid may
be slightly hazy because of proteins. Leukocyte inc, AFB staining (bacilli) CSF PCR.
CT Scan – hydrocephalus. Tuberculoma as ring lesion (manifests as seizures, palsies, hemi/paraplegia).
Chest Xray – features of TB.
Management:
>Antituberculous therapy (ATT) – 12 months. First 2 months- all 4 drugs. Next 10 months – 3 except
pyrazinamide. Drugs are rifampicin, isoniazid, pyrazinamide, ethambutol (RIPE). >Steriods – to reduce
inflammation and dec ICP. (Dexamathasone, prednisolone). >Surgery:
ventriculoatrial/ventriculoperitoneal shunt.
Complications:
Hydrocephalus, CN palsies, mental retardation, hemiplegia, blindness, epilepsy.

3. Viral Meningitis
Causes: mumps, measles, AIDS, Hep virus, coxsackie, herpes zoster, infectious mononucleosis.
Clinical features:
Mostly young patients. Acute fever, headache, neck stiffness, meningeal irritation, vomiting, neurological
signs not really prominent.
Investigations:
CSF examination- proteins slightly increased. Slight haziness, inc ICP, normal glucose, normal chloride,
leukocytes.
Management:
No specific treatment. Self limiting disease. Bed rest, analgesics, hydration, electrolyte and fluid balance.

4. Encephalitis
Inflammation of brain parenchyma. Any cause but imp is HSV infection via olfactory nerve.
Clinical features:
Headache, fever, meningism, drowsiness, severe illness – CN palsies, hemiplegia, seizures, coma, altered
consciousness. Patient is agitated (in Meningitis patient is non-agitated, drowsy, calm)

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Investigations:
CT scan (edema, low density lesions, also done to exclude mass lesions), EEG (slow wave changes), viral
serology (blood and CSF), CSF examination (lymphocytes inc, inc proteins normal glucose), PCR (HSV
DNA detection).
Treatment:
Unconscious patient nursing according to that of stroke. Dexamethasone (to dec ICP). Acyclovir (for
HSV infection). Antiepileptics (if seizures develop).

5. Brain Abscess
Direct contact with organism eg from skull fracture, hematogeneously, bronchiectasis, endocarditis, dental
abscess. Organisms may be strep melleri, enterobacteria, staph, bacteroides.
Clinical features:
Fever, headache, drowsiness, confusion. Later – inc ICP, seizures, focal neurological defects like
hemiplegia. Discharge from ear.
Investigations:
Blood CP/ESR (raised, leukocytosis), CT scan (single/multiple low density areas with ring appearance-
central low density and surrounding cerebral edema), Lumbar puncture is contraindicated. No use of
CSF exam.
Management:
Antibiotics (benzyl penicillin, chloramphenicol, metronidazole), steroids (dexamethasone).

6. Poliomyelitis
4 Presentations (inapparent, abortive, non paralytic, paralytic). Clinical diagnosis. Management is complete bed
rest, tracheostomy if breathing difficulties, later physiotherapy and orthopedic measures.

7. Rabies
Rhabdovirus. Travels in nerves and affects CNS and salivary glands.
Clinical features:
Fatal. Fever and paresthesia at site. Anxiousness, hydrophobia, sensitive to air currents, CNS involvement 10
days later (delusion, biting, mania), CN lesions, hyperpyrexia, coma, autonomic dysfunction.
Investigations:
Brain of rabid animal examined. PCR of CSF or saliva.
Treatment:

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Local- cleaning, debridement, flushing of wound with soap and water. Wound not sutured. Rabies
immunoglobulin or antiserum given near wound and remaining IM.
Symptomatic – no Treatment. Poor survival rate. Death in 5 – 7 days after symptoms. Sedation can be done
with diazepam.
Prevention: vaccination of animal.

8. Epilepsy
Tendency to have recurrent seizures.
Causes: P°/idiopathic (btw 5-20 y/o) genetic causes. S° (after 20 y) – metabolic, vascular, infections, drugs,
hypo/hyperglycemia, renal failure, hepatic failure, head injury, tumors, stroke.
Classification:
• Partial/focal (localized to 1 hemisphere)
>simple >complex >evolve to generalised
• Generalised (involves both hemispheres)
>Absence (typical/atypical) >atonic >myoclonic >tonic-clonic
Clinical features:
Focal (simple) consciousness not Generalised (tonic clonic)
impaired
Jacksonian March (Jerky movements • Prodromal- uneasy irritability hours
of mouth that spread to limbs in before attack.
seconds). • Aura – specific feelings before
Todds paralysis (localized paresis) attack.
Paraesthesia or tingling sensation • Tonic – rapid muscle contractions
Sensation of falling or vertigo. and loss of consciousness (10 -30
Unusual sounds and odours. sec).
Visual hallucinations. • Clonic – violent face and limb
jerking, tongue biting, incontinence
Focal (complex) altered (1-5min).
consciousness • Post-ictal phase – deep
Psychomotor seizures. Patient stops unconsciousness, loss of corneal
and stares blankly with smacking of reflex and extensor plantar response.
lips. Flaccid muscles.

(Atonic)
Loss of muscle tone.

(Myoclonic)
Single/multiple myoclonic jerks.

(Typical absence)
Stops activity, stares, blinks, rolls eyes up,
fails to respond to commands.
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Diagnosis:
History (symptoms before, during, after attack, tongue biting, urinary/stool incontinence, injury, identify
precipitating/predisposing factors). Examination – mental status, language, abstract thinking.
Investigations – blood CP, ESR, serum urea creatinine electrolytes, random sugar, serum Ca and Mg,
LFTs, screen for toxins, Lumbar puncture, EEG (spikes and wave pattern), ECG, CT and MRI, PET,
SPECT.
Management:
Immediate care (to move away from stimulus, semiprone position, don’t leave patient alone, don’t put
anything in mouth, airway clear, summon help). Medical care - O2, IV anticonvulsants if continuous
seizures, blood to see drug levels. Avoid precipitating factors. Treat underlying conditions.
Anticonvulsant Drug Therapy (considered after 2 seizures, drug acc to type of seizures, slowly increase
dose and add drugs, monitor for side effects, gradually reduce dose).
{Drugs of Choice:
• Partial or S° generalised tonic clonic – lamotrigine, sodium valproate, topiramate.
• P° generalised tonic clonic – lamotrigine, topiramate, carbamazepine.
• Myoclonic – clonazepam.
• Absence – sodium valproate}

9. Status epilepticus
Medical emergency, if seizures 15-30 mins or if no consciousness in btw.
Management:
Secure IV access. Administer O2. Diazepam 10 mg. Anticonvulsants patient is already taking. If seizures
continue then;
Diazepam 10 mg IV > diazepam 10 mg IV after 15 min > phenytoin 20 mg > phenytoin 5-10 mg >
phenobarbital 20 mg > phenobarbital 5-10 mg > barbiturate or benzodiazepine anesthesia.

10. Stroke
Focal neurological deficit due to vascular lesions.
Causes: HT, smoking, MI, diabetes, hyperlipidemia, high alcohol intake.
Types:
• Transient Ischemic Attack (symptoms last less than 24 hrs, because of emboli).
• Evolving Stroke (slowly worsens over hours and days)
• Complete stroke (symptoms last more than 24 hrs, evolves rapidly, reaches max peak within hour)
• Minor stroke (recovers without deficit in one week).
Clinical features:
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Age 40-60, H/O of diabetes, loss of consciousness, vertigo, weakness of one side of body, balancing and
sensory loss of affected side, aphasia, diplopia.
Investigations:
CT scan, carotid dipper, Angiography, blood sugar, hemoglobin, ECG, echo, blood CP, serum
cholesterol, xray chest, blood culture.
Management:
Careful nursing (head flat position, semiprone position to prevent tongue from falling back, frequent
change of position), maintain airway and fluid balance, care of skin, bladder, bowel and eyes.
Physiotherapy, BP control, antiplatelet therapy, anticoagulants(heparin, warfarin) edema reducers
(mannitol etc). Thrombolytic therapy. Surgical (angioplasty, stent).
Complications: chest infection, dehydration, hyponatremia, hypoxia, seizure, hyperglycemia, pulmonary
embolism, DVT, UTI.

11. Subarachnoid Hemorrhage

Causes: Berry aneurysm, arteriovenous malformation, bleeding disorders, brain tumours, Marfan syndrome,
Meningitis.
Clinical feature:
Symptoms after straining, inc ICP with meningeal irritation, headache (sudden severe radiating to
occipital region – very severe), vomiting, loss of consciousness, neck stiffness, photophobia, visual
disturbances.
Investigations:
Fundoscopy, CF (choice), Lumbar puncture, Angiography.
Management:
Control hypertension. Dexamethasone. Clipping of aneurysm.
{Scenario: all features of Meningitis but no fever and there is SEVERE headache > subarachnoid Hemorrhage).

12. Trigeminal Neuralgia

Facial pain syndrome.
Clinical features:
Unilateral (usually involved 2nd and 3rd division of trigeminal nerve) facial pain, episodic electric shock
like. Trigger zones of face, eating, drinking, shaving, touching, cold wind etc. Lasting seconds. Diagnosis
made clinically.
Management:

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Anticonvulsants: Carbamazepine (DOC) 3 divided doses, pain relief in 24 hours. Phenytoin, clonazepam,
lamotrigine. Surgical: inj of trigeminal ganglion with alcohol/phenol. Radio-frequency
thrombocoagulation of branch of ganglion. Decompression of vascular loop, steroids, gabapentin.

13. Postherpetic Neuralgia

Acyclovir and prednisolone given during herpetic eruptions.
Management: tricyclic antidepressants. Combined with phenothiazone. Local application of lidocaine.

14. Bell’s Palsy

Lower moto neuron lesion. Same side and upper/lower both halves affected.
Clinical features:
Pain around ear and on half face. Impaired taste (chorda tympani), unilateral facial weakness, dribbling
of saliva a water from affected side, collection of food there. Loss of wrinkling on forehead, inability to
close eye. Bells phenomenon (upward rotation of eyeball on trying to close affected eye), flattening of
nasolabial fold, loss of retraction of angle of mouth while showing teeth.
Tests:
• Absence of wrinkling on forehead (when looks upward without moving head).
• Closure of eyes (difficult- Bells phenomenon)
• Inflation test (air escapes easily from affected side)
Management:
Most patients recover spontaneously (days to months). Medical > prednisolone, steroids, acyclovir.
Surgical > eyepad tarsorrhaphy, cosmetic surgery, decompression of nerve.
Complications:
Facial disfigurement, synkinesis, crocodile tears.
{Ramsay Hunt Syndrome > herpes zoster. Facial Paralysis + vesicles in external auditory meatus + impaired
taste sensation in that half.}

15. Parkinsonism
Depletion of dopaminergic neurons. Lesion in basal ganglia.
Clinical features:
Initially: tiredness, mental slowness, depression, aching limbs, small handwriting. Classical:
• Tremors (resting): first in fingers/thumbs. Flexion/extension. Pill rolling movements.
• Rigidity: inc tone, flexed posture, stiffness > leadpipe (uniform) rigidity, and when combined with
jerky movements it’s called Cogwheel rigidity.
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 • Hypokinesia: slowness of voluntary movements and reduction of automatic movements. Mask like
face. Infrequent blinking. Difficulty in fine and rapid movements (fastening buttons).
• Abnormal gait/posture: difficulty in getting up. Small step walk. Festinating gait (rapid small
steps). Reduced arm swing, impaired balance. Shuffling gait.
• Speech and cognition: monotonous speech (soft, rapid, distinct). Impaired postural reflexes.
Management:
(Block effect of acetylcholine and enhance dopaminergic transmission).
Anticholinergic Agents: for Tremors and rigidity, not for hypokinesia. Avoided in elderly as it causes
confusing and hallucination. Side effects > dry mouth, urinary Retention, defective accommodation reflex. Eg
benzhexol, procyclidine.
Amantidine: releases dopamine. Side effects > restlessness, confusion, cardiac arrhythmia.
Levodopa: converted to dopamine. Given along with decarboxylase inhibitor. Carbidopa (to prevent conversion
in GIT). Sinemet (levodopa+carbidopa) Side effects > nocturia (anti muscarinics for it), postural hypotension,
hallucinations (anti psychotic for it), dyskinesia. Dose increased gradually, 1 hour before or 2 hours after meals.
Bromocriptine (dopamine agonist): less effective than levodopa but less Side effects too.
Selegiline (mono amine oxidase type B inhibitor): inhibits breakdown of dopamine. For mild disease.
Surgical treatment: thalamotomy, pallidotomy.
Early Tremors + rigidity Under age 65 (anti
cholinergics + amantidine)
over age 65 (avoid anti
cholinergics)
Moderate Tremors + rigidity + Levodopa, anti cholinergics
hypokinesia (young) – bromocriptine +
levodopa
Severe Tremors + rigidity + Frequent small doses of
hypokinesis + dyskinesia + levodopa + selegiline + low
fluctuation dose bromocriptine

16. Multiple Sclerosis

Multiple areas of demyelination. Impairs nerve conduction, ectopic impulse generation causes paraesthesia-
Lhermittes phenomenon (electric like sensations in spine and limb on flexion of neck).
Clinical features:
Blurring of vision (optic neuritis), papillodema, optic atrophy (pale on fundoscopy), diplopia (abducent
nerve palsy), ataxia, paraesthesia, urinary urgency, trigeminal Neuralgia, difficulty in walking, weakness
of limbs, relapsing and remitting course (symptoms may have been present a few years ago), plantar
upgoing. Hyperreflexia, hypertonia, extensor plantar response.
Course: types>
• Relapsing remitting (recurrent attacks – recovery)

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 • S° progressive ( same as above and gets progressive)
• P° progressive (gradual progression of disability)
• End stage – severely disabled.
Investigations:
CSF examination (inc lymphocytes, protein normal but inc IgG). CSF electrophoresis (oligoclonal bands
of IgG antibodies 75% of MS patients). MRI (multiple plaques/demyelination). Electrophysiological tests.
Routine tests (blood cp, xray, EEG, urine analysis).
Management:
Initial > methylprednisolone IV then orally. Prophylaxis > interferon, copolymer 1. Secondary >
methotrexate, azathioprine, cyclophosphamide. Supportive > physiotherapy (for spasticity), diazepam,
carbamazepine and amitriptyline (for painful paraesthesia and trigeminal Neuralgia), laxatives (for
constipation), anticholinergic and low fibre diet.

17. Hydrocephalus
Inc in CSF volume.
Types > Communicating (obstruction outside ventricles) Non communicating (obstruction within ventricles).
Clinical features:
Infants/young: irritability, impaired consciousness, vomiting, mental retardation, don’t thrive. In elderly:
Headache, vomiting, papilledema, dementia, ataxia, incontinence.
Investigations:
CT Scan (dilation of ventricles). Xray skull (large in infants/young).
Management:
Ventricular drainage, shunt, lumbar puncture.
{Normal pressure hydrocephalus- dilated ventricles but no atrophy.}

18. Headache
Displacement of arteries, venous sinuses, dura mater at base of brain sensitive to pain causes pain called
headache.
Causes: inflammation, vascular, inc ICP, dec ICP, referred pain, fever, drug intake.
Management:
Treatment of cause. Psychogenic/tension Headache- firm reassurance, Analgesics, tranquillisers, physical
treatment (massage) and anti depressants.

19. Migraine
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Episodic Headache. Unilateral vasoconstriction – vasodilation.
Causes: chocolate, cheese, alcohol, puberty, oral contraceptives.
Types:
• Classical (visual symptoms + headache)
• Common (no visual symptoms + headache + nausea + photophobia)
• Hemiplegic (prolonged headache followed by hemiparesis)
• Basilar (tingling + numbness of tongue + vertigo + diplopia + visual disturbances + headache)
Clinical features:
Unilateral, females, vomiting, history of sparkling or flashing signs, virtual defects.
Management:
Reassurance and relieve anxiety, avoid precipitating factors, aspirin, metoclopramide, sumatriptan,
zolmitriptan, ergotamine tartarate. For prevention: Ca channel blockers, B blockers, antidepressants,
anti seizures drugs.

20. Cluster Headache

Excruciating pain during sleep at night. Less than 2 hours. Pain around 1 eye daily for several weeks wit nasal
congestion, rhinorrhea, lacrimation, redness of eye, Horners syndrome.
Treatment: acute attack > 100% O2 for 15 minutes. Ergotamine tartrate inhaler. Same for Prophylaxis.

21. Giant cell arteritis

Clinical features:
Headache – over inflamed vessels. Touching skin causes pain. Lost arterial pulsation. Skin becomes red.
Facial pain – worse eating (jaw claudication). Visual problems (unilateral Visual loss). Muscle pain,
tenderness.
Investigations:
Inc ESR, Inc CRP, normochromic normocytic anemia, thrombocytosis, biopsy of superficial temporal
artery.
Treatment:
Prednisolone 60-100mg daily (before blindness ensues).

22. Dementia
Clinical features:
Decline in intellectual functions (memory, abstract thinking, judgement). Focal neurological deficits,
involuntary movements, positive grasp reflex, glabellar reflex, palmomental reflex.
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Management:
Treating cause and symptomatic treatment.

23. Alzheimers Disease

Atrophy of brain areas, depletion of cholinergic neurons.
Clinical features:
Dementia, can’t learn new things, can’t recall previous, forgets names, less understanding, less language
function, apraxia (can’t carry out motor activities), agnosia (can’t identify things), less executive
functioning, agitation, aggression, depression.
Investigations:
Blood CP, blood sugar, urea, electrolytes, LFTs, serum Ca, Vit B12, T3, T4, TSH, HIV antibodies, chest
xray, CT/MRI (atrophy of brain).
Treatment:
Correctable cause. No Treatment for it. Anticholinesterase drugs may be given (rivastigmine,
galantimine).

24. Transverse Myelitis

Inflammation of spinal cord after infection/vaccination.
Clinical features:
Fever, back and limb pain, sensory loss, paraplegia, bladder disturbance. (Sharp sensory level in this
differentiates it from Gullian Barre syndrome).
Investigations:
MRI (shows swelling of spinal cord).
Treatment:
Glucocorticoids (methylprednisolone injection then oral prednisolone).

25. Syringomyelia
Cavitation in spinal cord.
Clinical features:
Pain in neck and shoulder. Sensory loss in upper limb (only pain and temperature lost). Painless burns and
ulcers on hands and Painless deranged joints called Charcot joints. Motor symptoms: wasting of small muscles,
weakness of legs, kyphoscoliosis, pes cavus, spina bifida, syringobulbia.
Investigations: MRI.
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Treatment: surgical decompression of cavity.

26. Gullain Barre Syndrome

Acute polyneuropathy. Acute inflammatory and post-infective demyelinating polyneuropathy. H/o of diarrhea
or infection. Organism: EBV, CMV, C jejuni. Demyelination of spinal nerves.
Clinical features:
Muscle weakness – ascending paralysis. Plantar going down. Distal paraesthesia and limb pains.
Respiratory paralysis. Absent reflex in limbs. Facial and bulbar weakness. Resp weakness 20% sensory
loss.
Investigations:
CSF (inc proteins, normal white cells), NCV (slowing of nerve conduction), antibody (antibodies to
ganglioside)
Management:
Supportive treatment to prevent bed/pressure sores. Regular monitoring of Respiratory function.
Immunoglobulin therapy. Plasma exchange.

27. Myasthenia gravis

Neuromuscular junction disorder. Decreased acetylcholine receptors, autoimmune disorder. Skeletal muscle
fatiguability, weakness.
Associations: thyroid abscess, rheumatoid arthritis, pernicious anemia, SLE, penicilamine.
Clinical features:
Female predominance in young. Male predominance in Old. Weakness of muscles, ptosis, diplopia,
dysphagia. Weakness of limbs, unable to comb hair. Replacing and remitting course. Affects: ocular
muscles (weakness of lids and muscles), bulbar muscles (weakness of palate, tongue, pharynx, chewing,
swallowing, speaking). Tendon reflexes are normal. Resp muscle weakness.
Investigations:
• Tensilon test positive (edrophonium 2mg is given, if improvement occurs then it is positive. If no
change – give 8 mg(if improvement lasts for 2-3 minutes then test positive) atropine should be
there to manage effects.
• Serum acetylcholine receptor antibodies.
• Nerve stimulation.
• Xray, CT, MRI.
Management:
Oral cholinesterases (pyridostigmine). Thymectomy. Steroids (prednisolone). Cyclosporine, azathioprine.
Plasmaphoresis. Immunoglobulin.

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{Extra:
Signs in upper motor neuron lesion: Babinskis sign, loss of superficial reflexes, exaggerated deep reflexes,
pseudobulbar palsy, spastic paralysis, hypertonicity, no muscle atrophy, no muscle fasciculation, little or no
wasting of muscles.}

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