Neurology Learning Objectives

Author: Kristofer Smith

Editor: Lauren Peccoralo

I. Educational Rationale

All general internists must be familiar with common presentations of neurological diseases, such as stroke, TIA, and syncope. In many instances, a general internist should be able to evaluate and treat these common conditions without specialist consultation.

II. General Learning Objectives

A. Clinical Skills

1. Obtain an accurate and thorough neurological history.

2. Perform and interpret a neurological examination.

3. Articulate the appropriate indications for commonly ordered neurology tests and ,

including: EEG, EMG, nerve conduction studies, carotid dopplers, tilt table, lumbar

puncture, CT and MR imaging of brain and spinal cord

4. Manage, using the most up-to-date evidence, common inpatient neurological

problems.

B. Interpersonal Skills

1. Clearly and accurately communicate to patients and families the prognosis and

likelihood of recovery after an acute neurological event

2. Recognize when patients have lost decision making capacity secondary to the

neurological event

3. Understand NYS law regarding proxy and surrogate decision making

C. Procedural Skills

1. Safely and competently perform and teach a lumbar puncture.

2. Readings

a) Ellenby MS, Tegtmeyer K, Lai S, Braner DA. Lumbar Puncture. NEJM. 2006;355:e12.

http://eresources.library.mssm.edu:2368/cgi/content/video_preview/355/13/e12

*Intern Focused Topics

III. Medical Knowledge Learning Objectives

A. Stroke *

1. Recognize common signs and symptoms of ischemic and hemorrhagic stroke.

2. Use the details from the history and physical to localize the process in the brain.

3. Identify and urgently refer patients with ischemic stroke who are eligible for

thrombolysis.

4. Evaluate patients for etiology of stroke.

5. Readings

a) Goldstein LB, Simel DL. Is This Patient Having a Stroke? JAMA. 2005;293:2391-2402

http://eresources.library.mssm.edu:2213/cgi/content/full/293/19/2391

b) The national collaborating center for chronic conditions. STROKE: National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). Access on March 25, 2009. Available at http://www.nice.org.uk/nicemedia/pdf/CG68FullGuideline.pdf

c) Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333:1581.

http://eresources.library.mssm.edu:2368/cgi/content/full/333/24/1581

d) Hacke, W, Kaste, M, Bluhmki, E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317.

http://eresources.library.mssm.edu:2368/cgi/content/full/359/13/1317

B. Transient Ischemic Attack *

1. Distinguish a transient ischemic attack from a stroke.

2. Risk stratify patients according to the likelihood of having future stroke or death.

3. Recognize the need to start patients with suspected TIA on antiplatelet therapy.

4. Identify the etiology of the TIA, i.e. vascular versus embolic, through judicious use

of further testing such as MRI/A, CT, carotid dopplers and echocardiogram.

5. Understand the indications and risk/benefit considerations of carotid endarterectomy.

6. Readings

a) Johnston, SC, Rothwell, PM, Nguyen-Huynh, MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283.

http://eresources.library.mssm.edu:2080/science?_ob=ArticleURL&_udi=B6T1B-4MX0997-16&_user=30742&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000000333&_version=1&_urlVersion=0&_userid=30742&md5=8a8f7ddd20d4aa07e128d2a0eab937c8

b) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.

http://eresources.library.mssm.edu:2789/cgi/content/full/324/7329/71?view=long&pmid=11786451

c) Rothwell, PM, Eliasziw, M, Gutnikov, SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361:107.

http://eresources.library.mssm.edu:2080/science?_ob=ArticleURL&_udi=B6T1B-47N592R-9&_user=30742&_coverDate=01%2F11%2F2003&_alid=936628545&_rdoc=1&_fmt=high&_orig=search&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000000333&_version=1&_urlVersion=0&_userid=30742&md5=4210c06ca7ebc1c7ffa6eb6e0abb8188

C. Intracranial Bleeds *

1. Understand the difference in mechanism, etiology, and clinical presentation of

subdural, epidural and subarachnoid hemorrhage.

2. Recognize the need for timely head imaging and when urgent referral for specialized

care, i.e. neurosurgical, is necessary.

3. Reading

a) Suarez, JI, Tarr, RW, Selman, WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006; 354:387.

http://eresources.library.mssm.edu:2368/cgi/content/full/354/4/387

b) Bullock, MR, Chesnut, R, Ghajar, J, et al. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58:S16.

http://journals.lww.com/neurosurgery/Abstract/2006/03001/Surgical_Management_of_Acute_Subdural_Hematomas.10.aspx

D. Syncope *

1. Stratify patients presenting with syncope based on their risk for future serious

adverse events.

2. Differentiate between cardiogenic syncope and neurogenic syncope based on history

of present illness, medical history, family history, lab work and ekg.

3. Appropriately order further testing on syncope patients for whom the diagnosis

remains unclear after initial workup described above.

4. Recognize the high cost and low diagnostic yield of several commonly ordered

diagnostic tests including but not limited to echocardiogram, electrophysiology studies, tilt table and telemetry.

5. Readings

a) Fenton AM. Hammill SC. Rea RF.Low PA. Shen WK. Vasovagal Syncope. Annals of Internal Medicine. 2000;133:714-25

http://eresources.library.mssm.edu:2299/cgi/content/full/133/9/714

b) Brignole, M, Alboni, P, Benditt, DG, et al. Guidelines on management (diagnosis and treatment) of syncope--update 2004. Europace 2004; 6:467.

http://eresources.library.mssm.edu:5868/cgi/content/full/6/6/467

c) Strickberger, SA, Benson, DW, Biaggioni, I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006; 113:316.

http://eresources.library.mssm.edu:2223/cgi/content/full/113/2/316

d) Krahn, AD, Klein, GJ, Yee, R, et al. The high cost of syncope: Cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart J 1999; 137:870.

http://eresources.library.mssm.edu:2080/science?_ob=ArticleURL&_udi=B6W9H-4HK02FS-M&_user=30742&_coverDate=05%2F31%2F1999&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000000333&_version=1&_urlVersion=0&_userid=30742&md5=907a17fcb447f4cc7db46f948e5c3911

e) Pires, LA, Ganji, JR, Jarandila, R, Steele, R. Diagnostic patterns and temporal trends in the evaluation of adult patients hospitalized with syncope. Arch Intern Med 2001; 161:1889.

http://eresources.library.mssm.edu:2217/cgi/content/full/161/15/1889

E. Seizure Disorder *

1. Distinguish between epileptic seizures, provoked seizures and non-epileptic seizures

2. Distinguish the different types of epileptic seizures

3. Evaluate patient presenting with provoked seizures for common precipitants

including uremia, hypoglycemia, drug overdose, withdrawal, meningitis and encephalitis.

4. Recognize patients, presenting with seizures, who need further testing such as EEG,

CT/MRI and/or LP.

5. Recognize the legal requirements to counsel patients with epilepsy to refrain from

driving until seizures are controlled

6. Initiate appropriate therapy for epileptic seizures

7. Readings

a) Krumholz A, Wiebe S, Gronseth G, et al. Evaluating an apparent unprovoked first seizure in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69:1996-2007.

b) Marson, AG, Al-Kharusi, AM, Alwaidh, M, et al. The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial. Lancet 2007; 369:1000.

http://eresources.library.mssm.edu:2080/science?_ob=ArticleURL&_udi=B6T1B-4N9XF65-15&_user=30742&_coverDate=03%2F30%2F2007&_alid=936632149&_rdoc=1&_fmt=high&_orig=search&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000000333&_version=1&_urlVersion=0&_userid=30742&md5=ea7bacb29b7edb48bc47576901ae772f

c) Marson, AG, Al-Kharusi, AM, Alwaidh, M, et al. The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial. Lancet 2007; 369:1016.

http://eresources.library.mssm.edu:2080/science?_ob=ArticleURL&_udi=B6T1B-4N9XF65-16&_user=30742&_coverDate=03%2F30%2F2007&_alid=936634137&_rdoc=1&_fmt=high&_orig=search&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=1&_acct=C000000333&_version=1&_urlVersion=0&_userid=30742&md5=44c260b6038141dd95414a1e9d857ffd

F. Parkinson’s Disease

1. Understand brief pathophysiology of parkinsons disease

2. Know common treatments of Parkinson’s Disease and side effects

3. Recognize several of the common complications of Parkinson’s disease leading to

hospitalization, including aspiration, dementia, psychosis, sleep disturbances,

caregiver fatigue, refractory depression, falls, orthosasis, and weight loss.

4. Understand the extreme importance of maintaining hospitalized patients on their

outpatient medication regimen.

5. Initiate appropriate treatments for the management of complications of Parkinson’s

disease.

6. Readings

a) Rao G, Fisch L, Srinivasan S, D'Amico F, Okada T, Eaton C, Robbins C. Does this patient have Parkinson disease? JAMA. 2003;289:347-53.

http://eresources.library.mssm.edu:2213/cgi/content/full/289/3/347

b) Ferreri F. Agbokou C. Gauthier S. Recognition and management of neuropsychiatric complications of Parkinson’s disease. CMAJ. 2006;175:1545-52.

http://eresources.library.mssm.edu:2152/articlerender.fcgi?tool=pubmed&pubmedid=17146092

c) Chan DK, Cordato DJ, O'Rourke F. Management for motor and non-motor complications in late Parkinson's disease. Geriatrics. 2008;63:22-7.

d) National Institute for Comparative Effectiveness. Parkinson’s Disease: National clinical guideline for diagnosis and management in primary and secondary care. Accessed March 25, 2009. Available at http://www.nice.org.uk/nicemedia/pdf/cg035fullguideline.pdf

G. Multiple Sclerosis

1. Identify neurological abnormalities commonly experienced in multiple sclerosis

relapses, including but not limited to: optic neuritis, loss of vision, visual disturbances parasthesias, foot drop, hemiplegias, nerve palsies.

2. Exclude or identify and, if possible, treat common precipitating events for a multiple

sclerosis exacerbation including but not limited to: infection, psychosocial stresses,

medication non-compliance.

3. Decide when a multiple sclerosis exacerbation requires the administration of high

dose steroids.

4. Readings

a) Frohman EM. Multiple sclerosis. Med Clin N Am. 2003;87:867-97.

http://eresources.library.mssm.edu:2125/das/article/body/145239663-2/jorg=journal&source=&sp=13661578&sid=0/N/356918/1.html?issn=0025-7125

b) Thrower BW. Relapse Management in Multiple Sclerosis. The Neurologist. 2009;15:1-5.

http://eresources.library.mssm.edu:8537/spa/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=00127893-200901000-00001&NEWS=N&CSC=Y&CHANNEL=PubMed

H. Myasthenia Gravis

1. Identify clinical manifestations of patients presenting with a myasthenia crisis such as

worsened weakness, dysphagia, and/or respiratory distress.

2. Triage patients with a myasthenia crisis, those with a drop of forced vital capacity

below 1 L or a negative inspiratory force of 20 cm H2O or less, to an ICU for

monitoring and possible intubation.

3. Exclude or identify and, if possible, treat common precipitating events for a

myasthenia crisis including but not limited to: infection, medications (aminoglycosids, lidocaine, procainamid, quinidine, phenothiazides and magnesium), recent surgery.

4. Recognize the importance of early initiation of either plasma exchange or IVIG,

followed soon after by initiation of immunomodulators such as prednisone, azathioprine, mycophenolate mofetil, or cyclosporine.

5. Readings

a) Scherer K, Bedlack RS, Simel DL. Does This Patient Have Myasthenia Gravis? JAMA. 2005;293:1906-1914.

http://eresources.library.mssm.edu:2213/cgi/content/full/293/15/1906

b) Lacomis D. Myasthenic Crisis. Neurocrit Care. 2005;3(3):189-94.

http://eresources.library.mssm.edu:2292/content/p30k7727k0141081/fulltext.pdf

c) Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. Semin Neurol 2004;24:75-81.

http://eresources.library.mssm.edu:2130/ejournals/html/sin/doi/10.1055/s-2004-829595

d) Gajdos, P, Chevret, S, Toyka, K. Intravenous immunoglobulin for myasthenia gravis. Cochrane Database Syst Rev 2006;CD002277 and update 2008.

http://eresources.library.mssm.edu:8221/cochrane/clsysrev/articles/CD002277/frame.html