Neurology for Nurses
From the Editors’ Desk
Neurology for Nurses
(A). Clinical Assessment in Neurology
(1). Richard Rees, et al. Taking a neurological history. Medicine 2023;51(8):P527-530.
A detailed neurological history is the foundation of the neurological diagnosis. In many cases, it is more valuable than the clinical examination in determining the location and nature of the underlying aetiology. Collateral information gathering is mandatory in some situations. The history-taking should be patient centred, and preconceived biases must be avoided. At the end of the history-taking, those features that heavily influence the clinician’s formulation should be double-checked and can be referred to when explaining the diagnostic formulation and management plan to the patient. A systemic and structured approach should include a review of the medical and neurological systemic enquiry to ensure a full grasp of the clinical and social situation.
(2). Richard Rees et al. How to perform a neurological examination. Medicine 2023;51(8):P531-533.
The neurological examination should be focused on the clinical history and seen as a means of testing the hypotheses generated while listening to the patient. However, pursuing the classically taught systematic interrogation of the neurological hierarchy is seldom necessary and sometimes impractical. A rapid screening neurological assessment should be used in all cases where it is possible, focusing on detecting high-yield clinical anomalies.
(3). Gordon T. Plant. Visual disturbances in neurology. Medicine 2023;51(8):P534-539.
The eyes, ocular motor system and visual pathways of the central nervous system are frequent sites of neurological disease. As individuals with visual symptoms often present first to an ophthalmologist or optometrist, it is as important for these two specialists to have some knowledge of neurological disorders affecting vision as it is for neurologists and general physicians. This article outlines the basic assessment of a person presenting with impaired vision, either as a primary complaint or as part of a more generalized neurological or systemic disorder.
(4). Louisa Murdin, et al. Assessment of dizziness in neurology. Medicine 2023;51(8):P540-544.
Dizziness and vertigo are common symptoms. In acute vertigo, expert clinical assessment is critically important in discerning stroke from non-stroke causes because the results of stroke-protocol brain magnetic resonance imaging, including diffusion-weighted imaging, can be falsely negative in the first 24 hours. It follows that acute medical services must have access to clinicians expert in assessing acute vertigo. Expertise in clinical examination and interpretation of the findings requires appropriate training, but here we outline the basic diagnostic and therapeutic approach to patients with dizziness. Appropriate early management of these conditions is part of the prevention of disabling chronic functional dizziness conditions. Furthermore, the availability of effective treatments for other vestibular disorders means it is always important to make an accurate diagnosis.
(5). Lauren Harris. Epilepsy update: diagnosis, classification and management. Medicine 2023;51(8): P545-551.
Careful clinical evaluation differentiates epileptic seizures from syncope (vasovagal or cardiogenic), dissociative seizures (non-epileptic attack disorder) and other rarer paroxysmal events. The initial diagnosis of epilepsy is incorrect in 20%-30% of patients. Investigations can include blood tests, electrocardiograms, electroencephalograms and neuro-imaging. Patients should be informed and counselled about the diagnosis. Anti-seizure medications (ASMs) are the first-line treatment for epilepsy, the choice depending on the epilepsy syndrome, seizure type, patient and their co-morbidities. Surgical options are available for refractory epilepsy. Status epilepticus is a medical emergency and all clinicians should be aware of the treatment algorithm. This update additionally explores autoimmune-related epilepsy, developments in ASMs, including cannabinoids, and automated systems for seizure detection.
(6). Robin S. Howard. Coma and brainstem death. Medicine 2023;51(8):P552-557.
The patient in a coma needs a rigorous clinical assessment that requires a meticulous approach to history-taking, and a systematic approach to the neurological examination. After immediate resuscitation and acute management, the clinician must establish the level of consciousness and seek evidence of meningism and localizing neurological signs. The prognosis depends on the underlying cause and the time taken to implement appropriate management. The diagnosis of brain death depends on establishing the aetiology of irreversible brain damage, excluding reversible causes, and establishing the absence of any brainstem reflexes.
(7). Pyae Phyo San. Autoantibody-mediated neurological diseases. Medicine 2023;51(8):P558-568.
In 1672 Thomas Willis first described a patient with fatiguable muscle weakness, which is likely to have been myasthenia gravis (MG), a prototypic antibody-mediated neuroimmunological condition. However, the linking between MG and anti-acetylcholine receptor antibody only began 3 centuries later in the 1970s, a few years after discovering the antibody structure.
Several clinical syndromes and autoantibodies of neuroimmunological disorders have been identified since, especially in the past two decades. The presentation is typically subacute and can span the whole nervous system and occasionally involve other systems. Some of these conditions tend to be associated with malignancy, demanding a thorough and persistent tumour hunt.
The incidence has increased with the ability to test for autoantibodies and the increasing availability of imaging and other supportive investigations. Early recognition and immunotherapy are crucial to better patient outcomes. More than ever, it is now essential for any practising clinician to become familiar with common and important neuroimmunological conditions.
Here we summarize central and peripheral neuroimmunological conditions with well-characterized antibodies in terms of ‘typical’ clinical presentations, investigations and standard management. These conditions include autoimmune encephalitis, paraneoplastic disorders, neuromyelitis optica, stiff person syndrome, paranodopathies and myasthenic syndromes. We also briefly describe novel immunotherapies, which are gathering increasing evidence in these conditions.
(B). Investigations in neurology
(1). Catherine Morgan, et al. Lumbar punctures and cerebrospinal fluid analysis. Medicine 2023;51(8):P569-572.
Lumbar puncture is an essential neurological investigation. The anatomy of the spinal canal allows cerebrospinal fluid (CSF) to be sampled from the lumbar region. We describe how, with adequate preparation and correct patient positioning, the procedure can be performed quickly and safely. The range of investigations that can be performed on CSF and their interpretation are discussed.
(2). Mohamed Wafi, et al. Genetic testing in neurology. Medicine 2023;51(8):P573-580.
‘Neurogenetics’ spans almost every category of neurological disease (World Health Organization International Disease Classification: https://www.who.int/standards/classifications/classification-of-diseases), and genomic testing is increasingly important in the diagnosis and personalized management of these conditions. An understanding of the genetic basis of disease, genomic technologies and interpretation of increasingly complicated genomic data is essential for all clinicians. The likely disease aetiology and the utility of genomic testing must be considered as conditions might be caused by environmental adverse exposures (e.g. traumatic brain injury, infectious illness) or multifactorial risk factors (a combination of environmental and monogenic/polygenic influences). In this chapter, we focus on the basic concepts of neurogenetic disease, inheritance patterns and the laboratory techniques used in diagnosis. We also address important aspects in clinical practice, such as the resources used to guide clinicians to choose the ‘right’ test for their patients and families, the different types of genetic test and the clinical indications for each, the framework used to interpret genomic variants, ‘pre-test counselling’ and other ethical considerations.
(C). Cognitive Neurology
(1). Peter O. Jenkins. Persistent symptoms after a mild traumatic brain injury: assessment and management. Medicine 2023;51(8):P581-585.
Mild traumatic brain injuries are common. Most patients make a quick and complete recovery but a proportion report persistent symptoms that can have a major impact on work and social functioning. The cause of persistent symptoms is complex, with numerous interacting biological, psychological and social factors implicated in their generation. Detailed assessment to determine the cause(s) for an individual patient is important to allow the tailoring of an appropriate treatment plan.
(2). Meher Lad et al Dementia and disorders of cognition. Medicine 2023;51(8):P586-589.
Dementia is a progressive deterioration in cognitive function caused by degenerative brain disease. It is one of the most common presentations encountered in general medical practice, especially in elderly individuals. Dementia is a syndrome that can be caused by different types of brain pathology including, commonly, Alzheimer’s disease and brain vascular disease. Different pathologies have different ‘signatures’, especially at an early stage, based on combinations of cognitive, behavioural and neurological features. We describe common examples here, in addition to less common causes that must not be missed because they are treatable. Brain imaging and biochemical tests on blood and cerebrospinal fluid (‘biomarkers’) are increasingly contributing to the accurate early diagnosis of dementia types, especially Alzheimer’s disease. These will potentially facilitate the early use of new specific treatments for Alzheimer’s disease that are being evaluated, as well as help families to confront the problem early.