Addendum I: Specific Learning Objectives for the Neurology Clerkship

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1 Addendum I: Specific Learning Objectives for the Neurology Clerkship Below is a list of the specific neurology objectives (by topic) that we expect you to know by the end of the neurology rotation. Below each topic, a recommended reading list is provided. The reading list is from Gelb Introduction to Clinical Neurology fourth edition, High Yield Neuroanatomy third or fourth edition by James D Fix, Harrison s Principles of Internal Medicine or from resources posted on Emerge. 1. Neuroanatomy a. Be able to identify various neuroanatomic structures in cross sections of the brain. b. Describe the 3 layers of the meninges, the meningeal spaces, CSF synthesis and absorption. Be able to apply this knowledge to understand hydrocephalus and herniation syndromes. c. Describe the blood supply of the various parts of the brain and spinal cord. Describe the neurological deficits that may occur with vascular compromise related damage of the various arterial territories such as middle cerebral artery territory. d. Describe the blood brain barrier and the resulting changes seen when there is a breakdown of blood brain barrier (vasogenic edema, enhancement seen on CT or MRI when a study with contrast is performed). e. Be familiar with the functional areas of the cerebral cortex, particularly the primary areas of the brain including: primary motor, sensory, olfactory, taste, auditory and visual areas. Describe the function of these areas and the deficits seen when they are damaged. f. Describe association pathways of the brain and deficits that result from their damage including: language deficits, agnosias and apraxias. g. List the language areas of the brain including Broca, Wernicke, arcuate fasciculus. Describe features of the various aphasias resulting from lesions of these areas including: Broca s, Wernicke s and Conductive aphasia. Can also describe the transcortical sensory and motor aphasias. h. Describe the motor pathway starting from the cerebral cortex and ending above the anterior horn cell in the spinal cord. Also describe the path of the motor nerve from the anterior horn cell to the neuromuscular junction. i. Explain what the upper and lower motor neurons are. Define the features of upper motor neuron and lower motor neuron lesions. j. Describe the sensory pathways starting at the peripheral nerve and ending in the primary sensory cortex. k. Be able to describe the direct and indirect pathways in the basal ganglia and the deficits arising from dysfunction of each, such as parkinsonism and chorea. l. List the 3 parts of the brain stem (midbrain, pons and medulla) and be familiar with the cross sectional anatomy at various levels including origin of the cranial nerves arise and the 3 cerebellar peduncles. m. List the cranial nerves, including point of origin, their function and deficits resulting from their lesions. n. List the functions of the cerebellum, including posture, tone and coordination of voluntary motor activity.

2 o. Describe the clinical findings produced by lesions of the cerebellar vermis (trunk and gait ataxia) vs. the cerebellar hemispheres (limb dysmetria). p. Describe the cross section of the spinal cord at the cervical, thoracic and lumbosacral level. Apply this knowledge to describe the deficits in transection of the cord at different levels, brown sequard syndrome, anterior cord syndrome, cauda equina syndrome and central cord syndrome (cervical level). q. Identify the various dermatomes. Be able to recognize the difference between sensory and motor deficits that follow a peripheral nerve vs. dermatomal vs. plexus vs. cord distribution. r. Describe the anatomy of the neuromuscular junction and the pathophysiology of myasthenia gravis. s. Understand the most common peripheral nerve injuries such as median, ulnar and peroneal (fibular) nerve palsies.. High Yield Neuroanatomy third or fourth edition by James D Fix Aids to examination of the peripheral nervous system, fourth edition (Elsevier Saunders)- can have as reference Dr. Perkin s notes from SBM 2. Neurological examination a. Demonstrate the ability to perform a screening neurological examination. b. Be able to perform a focused neurological examination based on the patient s history and initial findings from the screening neurological examination. Dr Gourineni s neurological examination notes (emerge) Video: Please note there are some minor differences between the notes and video, but that is alright. There are many different but correct methods in which the neurological examination may be performed. If you understand the basic principles, you will be able to perform an accurate examination. 3. Neuroradiology a. Identify various anatomical structures from the various cross sections on brain CT. List the structures that are hyperdense vs. hypodense. b. Identify various anatomical structures from the different cross sections on brain MRI. c. Identify the different MRI sequences including: T1, T2, Flair, diffusion weighted, gradient echo and post contrast. Understand which structures or lesions are bright vs. dark (increased or reduced intensity) in various sequences. Eg. CSF is bright on T2, but dark on T1. d. Be able to identify the following on CT: subdural hematoma, epidural hematoma, subarachnoid hemorrhage, intracerebral hemorrhage, obstructive and nonobstructive hydrocephalus, stroke, and mass effect due to tumor or stroke.

3 e. Be able to identify the following on MRI- all of above, plus lesions consistent with multiple sclerosis, brain tumor Introduction to Head CT: Introduction to Neuroimaging slides (emerge) Image card (emerge) 4. Localization a. Explain how to localize hemiparesis. Explain the distinguishing features of hemiparesis due to lesion in the cortex, subcortical region, brainstem or high cervical cord. b. Explain the difference between upper motor neuron vs. lower motor neuron lesions. c. Explain how to localize lesions of the spinal cord including: transection of the cord at different levels, brown sequard syndrome, anterior cord syndrome, cauda equina syndrome and central cord syndrome (cervical level). d. Explain when to suspect multifocal lesions of the central nervous system. e. Explain how to localize peripheral nerve lesions such as: radiculopathy, plexopathy, mononeuropathy, diffuse peripheral nerve involvement, neuromuscular junction and muscle disease. The cases from Localization class should help you review the principles of localization. You can also refer to chapter 1 in Gelb pages: This chapter is lengthy and if you feel you are short of time, you can skip this. 5. Epilepsy a. Define seizure and epilepsy and explain the difference between the 2. b. Describe the difference between provoked and unprovoked seizure. c. Explain the pathophysiology of epilepsy. d. Discuss the classification of seizures and epilepsy: focal vs. generalized. Old terminology (partial and complex partial seizure) is still commonly used by neurology residents and faculty and may be seen in textbooks. e. Describe the clinical characteristics of different seizure types, eg. focal seizure arising in the motor cortex will produce rhythmic (clonic) shaking of the body part represented by the involved motor cortex. f. Be familiar with the various causes of epilepsy: genetic, structural, metabolic and unknown. g. Describe various epilepsy syndromes such as juvenile myoclonic epilepsy and childhood absence epilepsy, including the prognosis and treatment. h. Discuss the differential diagnosis of epilepsy including: syncope, cardiac convulsions, TIA, aura without migraine, metabolic disturbances (hypoglycemia), cataplexy and nonepileptic events. i. Outline the diagnostic evaluation of seizures/ epilepsy, including CT (if needed emergently)/ MRI and EEG. Should also understand work-up of potential underlying cause of the event (such as reduced sleep, alcohol etc). Discuss when epilepsy monitoring may be helpful.

4 j. Discuss whether a first time unprovoked seizure should be treated. k. Discuss topics of patient education after first seizure, including driving restrictions, regardless of whether an AED (antiepileptic medications) is started. l. Discuss the process in how an AED is selected based on type of seizure, gender and potential for child bearing, other comorbidities and side effect profile of the medication. m. Define status epilepticus (SE) and discuss the potential causes. n. Discuss the treatment algorithm for SE, including concurrent diagnostic work-up. Gelb chapter 5, pages: 147 to 184. Alternatively you can also read Dr. Schuele s lecture notes from SBM (Schuele Epilepsy notes- emerge) For a better understanding of AEDs, read AED notes (emerge)- Read about how to initiate therapy in Gelb. New concepts in classification of the epilepsies: Entering the 21st century. Special attention to table 1 (right hand side of the table discussed the new terminology (emerge). 6. Stroke a. Describe the classification of stroke by etiology, including thrombotic, embolic, lacunar and hypercoaguable states. b. Recognize the difference between ischemic and hemorrhagic strokes. c. Recognize typical syndromes produced by occlusion of various arteries, such as symptoms due to MCA infarct, ACA infarct, or symptoms found in posterior circulation (ie basilar, vertebral and posterior cerebral arteries) infarcts. d. Recognize typical location of lacunar infarcts and risk factors for lacunar infarcts such as diabetes, hypertension, hyperlipidemia and smoking. e. Discuss immediate evaluation of an acute stroke patient including the role and choice of appropriate cerebral, cardiac, and vascular imaging. f. Identify laboratory testing (eg glucose, platelets, coagulation profile-pt, PTT and INR) that is needed acutely in the management of a stroke patient. g. Identify what criteria are used to determine if a patient is a tpa candidate. Also discuss contraindications for tpa in an acute stroke as well as the risks associated with tpa administration. h. Discuss evaluation of a stroke patient beyond the emergency room setting. This includes appropriate brain and vascular imaging as well as cardiac evaluation. Also recognize appropriate laboratory studies needed in the evaluation of stroke patients (eg including but not limited to lipid profiles, hypercoaguable studies). Be able to elucidate how each test will influence patient management. Be able to discuss how evaluation will differ based on the stroke subtype. i. Discuss secondary stroke prevention based on various subtype, (eg risk factor modification such as treatment of hyperlipidemia and hypertension; antiplatelet therapy for lacunar infarcts and anticoagulation for patients with embolic disease due to atrial fibrillation). j. Discuss the work up needed to determine whether a patient has symptomatic vs asymptomatic carotid atrtery stenosis (ultrasound, MRA, CT angiogram).

5 k. Determine whether someone is a candidate for carotid endarterectomy based on NASCET criteria for symptomatic and asymptomatic carotid stenoses. Gelb chapter 4 pages: Can refer to American academy of neurology guidelines for various topics 7. CNS infections a. Explain the pathogenesis of meningitis and encephalitis. b. List the common organisms that cause acute, aseptic and subacute or chronic meningitis. c. Distinguish the microorganisms causing community-acquired and post-neurosurgical meningitis. d. Describe the classic clinical presentation of bacterial, aseptic and subacute or chronic meningitis and meningoencephalitis. e. Describe the CSF findings in bacterial, viral and TB/ fungal meningitis. f. Describe the complications of meningoencephalitis including: hydrocephalus, seizures, focal neurological symptoms, elevated ICP, cranial nerve palsies, mental retardation and coma. Describe the pathophysiology of each of these complications. g. Describe the pathophysiology and clinical features of brain abscess and spinal epidural abscess. h. Discuss the differential diagnosis of CNS mass lesion in patients with HIV/ AIDs. i. Recognize the role of diagnostic testing including CT/ MRI and LP in patients with suspected CNS infection and the importance of early diagnosis and treatment. j. Discuss antibiotic therapy and the role of steroids treatment of the different types of meningoencephalitis. Dr. John Flaherty s scientific basis of medicine notes are excellent. 2 articles: community acquired bacterial meningitis in adults and nosocomial infections are present in emerge. Review the tables on antibiotic therapy in these articles. You can also read selectively in Harrison s for a better understanding of certain topics. 8. Neuromuscular Conditions a. Describe the clinical features which localize a lesion to the following anatomic areas: anterior horn cell, nerve root, plexus, peripheral nerve, neuromuscular junction, and muscle. b. Discuss the common clinical symptoms and signs of polyneuropathy. Be able to identify common causes of length-dependant polyneuropathy such as diabetes, vitamin B12 deficiency, hypothyroidism and medications. c. Discuss the clinical presentation, work-up, and treatment of Guillain-Barre syndrome (acute inflammatory demyelinating polyneuropathy-aidp). d. Discuss the clinical features of Amyotrophic Lateral Sclerosis (ALS).

6 e. Describe clinical features of Myasthenia Gravis. Discuss the ancillary testing that is useful in confirming the diagnosis. f. Discuss the different therapies of myasthenia gravis including acetylcholinesterase inhibitors, immunomodulation and thymectomy. g. Discuss the clinical features and common acquired causes of myopathies (medication induced, endocrine). h. Discuss when electromyography (EMG) and nerve conduction studies (NCS) are useful in evaluating neuromuscular disorders. i. Recognize neuromuscular emergencies (Guillain-Barre and myasthenic crisis). Understand what defines an emergency and the immediate work-up is necessary including: respiratory parameters and management of these crises. Gelb chapter 6 pages Altered mental status with special emphasis on head trauma a. Grade concussions based on AAN guidelines. b. Discuss the evaluation of a patient with acute change in mental status c. Discuss various types of traumatic brain injury including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, diffuse axonal injury, and intraparenchymal hemorrhage, including the pathophysiology. d. Specifically discuss the lucid interval, which is most commonly seen with epidural hematoma, and its mechanism. (it may also be seen with acute subdural hematoma). e. Identify subdural hematoma, epidural hematoma, subarachnoid hemorrhage and intraparenchymal hemorrhage on CT brain. f. Discuss the various herniation syndromes, including: transtentorial, subfalcian and cerebellar tonsillar. g. Identify structures involved in transtentorial/uncal herniation. h. Discuss the mechanism of coma in patients with head injury. i. Discuss acute management of elevated intracranial pressure and brainstem herniation, including the role of hyperventilation, hypertonic solution, head elevation j. Discuss the indications and role of neurosurgical intervention in a patient with a traumatic brain injury- (large subdural or epidural hematoma, patients at risk of brain herniation. k. Discuss how to perform a brain death evaluation Gelb chapter 11 Can also refer to Harrisons chapters 15 and 16 for reference 10. Demyelinating illnesses a. Describe the typical presenting symptoms of multiple sclerosis including optic neuritis and transverse myelitis.

7 b. Discuss the diagnostic criteria for multiple sclerosis (Macdonald s criteria). c. Discuss four general categories or types of MS including: relapsing-remitting, primaryprogressive, secondary-progressive and progressive-relapsing. d. Discuss the diagnostic tests used to support the diagnosis of multiple sclerosis including: MRI, CSF studies and evoked potentials. e. Discuss the disease-modifying agents used to treat multiple sclerosis, including when they are indicated. f. Discuss the differential diagnosis of multiple sclerosis including other multifocal diseases of the CNS. Gelb chapter 10, pages Sleep disorders a. Discuss the difference between comorbid and primary insomnia. b. Discuss the various causes of comorbid insomnia including: underlying medical, psychiatric conditions, primary sleep disorders and medications. c. Discuss the clinical presentation, pathophysiology and treatment of the various primary sleep disorders that may cause insomnia including: obstructive sleep apnea, restless legs syndrome and circadian rhythm sleep disorders. d. Discuss the pathophysiology of psychophysiologic insomnia, along with various treatments including good sleep habits, cognitive and behavioral methods and hypnotic medications. e. Be familiar with the various hypnotic medications including benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplan), ramelteon (melatonin agonist) and antidepressants (trazodone and doxepin) that are used to treat insomnia. f. Discuss the various causes of daytime sleepiness or hypersomnia including insufficient sleep, disturbed nocturnal sleep and primary disorders of daytime sleepiness. g. Discuss the various causes of disturbed nocturnal sleep that result in daytime sleepiness including: medical and psychiatric conditions, medications, poor environment and primary sleep disorders as mentioned in c. h. Discuss the clinical manifestations, pathophysiology and treatment of the primary hypersomnias: narcolepsy and idiopathic hypersomnia (not a lot is written about idiopathic hypersomnia, but know what clinical characteristics separate the 2- see faculty version of hypersomnia case- neurotherapeutics I) i. Be familiar with clinical presentation and treatment of NREM parasomnias (confusional arousals, night terrors, sleep walking and night eating) and REM sleep parasomnia (REM behavior disorder). j. Be familiar with the various diagnostic tests that are used to evaluate sleep disorders including sleep diary and nocturnal polysomnography. Gelb chapter 9 pages Alternatively you can also read Harrisons chapter 13 pages: 169 to 183, or use this chapter as a reference. You can also refer to Dr. Gourineni s scientific basis of medicine notes and syllabus as needed.

8 11. Dementing illnesses a. Define dementia and explain the difference between mild cognitive impairment (MCI) and dementia. b. Define Alzheimer s disease according to the DSM V. c. Discuss the differential diagnosis including vascular dementia, mass lesion, metabolic and endocrine and nutritional deficiencies, depression and other types of dementias such as Diffuse Lewy Body Disease (DLD) and Frontotemporal Dementia (FTD) d. Discuss workup for the reversible causes including B12, folate, TSH, CT or MRI to look for structural causes, depression screening, and if applicable screening for syphilis and HIV. e. Discuss the differential diagnosis of rapidly progressive dementia including: trauma (subdural hematoma), chronic meniningoencephalitis, normal pressure hydrocephalus, paraneoplastic limbic encephalitis and prion disorder (Creutzfeld Jacob Disease). f. Discuss the medications that are currently available and FDA approved for use in patients with AD, including: donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne) and memantine (Namenda). g. Discuss evaluation of the patient s social environment, ability to care for themselves, safety, advanced directives and caregiver burden issues, including the role of patient and family counseling. Gelb chapter 7, pages: Movement disorders a. Discuss the pathophysiology of parkinsonism. b. Recognize the cardinal features associated with parkinsonism including: tremor, rigidity, akinesia/bradykinesia. c. Discuss the differential diagnosis of parkinsonism including Parkinson s disease, drug induced parkinsonism, vascular parkinsonism. d. Recognize there are atypical parkinsonian syndromes such as progressive supranuclear palsy, multiple system atrophy, and Diffuse Lewy Body Disease (DLD) e. Discuss the diagnostic evaluation of Parkinsonism and when testing is necessary. f. List the medications use to treat Parkinson s disease (including carbidopa/levodopa, dopamine agonists and MAO-B inhibitors) and the most common side effects associated with each of them. g. Recognize which features of the disease (such as rigidity and bradykinesia) respond best to therapy. h. Discuss the complications which arise from long standing disease and its treatment (such as motor fluctuations including wearing off and dyskinesias and hallucinations). i. Recognize when deep brain stimulation is indicated in the treatment of Parkinson s disease.

9 j. Discuss the key clinical features and examination findings of essential tremor (ET) and how to distinguish it from Parkinson s disease (ET is a bilateral postural and action tremor that may to may not respond to alcohol consumption). k. Identify the most common medications used to treat essential tremor such as propranolol and primidone. l. Discuss the evaluation of essential tremor and when testing is necessary. Gelb Chapter 8 pages Can also refer to SBM lectures by Dr. Cindy Zadikoff 13. Brain tumors/cancer a. Discuss the most common clinical presentations of brain tumors (eg headache, focal neurological signs and seizures). b. Discuss unique features of headache due to elevated intracranial pressure (the headache worsens with: valsalva maneuver, when lying down and may wake the patient up in the middle of the night). c. Recognize consequences of elevated intracranial pressure and cerebral edema d. Discuss acute management of complications related to brain tumor, including role of steroids and antiepileptic medications. e. Be familiar with the most common cancers that metastasize to the brain including lung, breast cancer and melanoma. Various cases from the case based lectures address the above principles. For further reading, you can refer to Gelb, chapter 10, pages or Harrison s chapter 25 pages Headaches a. Discuss clinical features of the primary headache disorders including migraine, cluster and tension headache. b. Discuss how to differentiate a primary vs. secondary headache disorder (including but not limited to subarachnoid hemorrhage, pseudotumor cerebri, temporal arteritis). c. Discuss the commonly used prophylactic and abortive treatments for migraine as well as the nonpharmacologic approaches. d. Discuss the clinical features and management of medication overuse (rebound) headache. e. Discuss the prophylactic and abortive treatments for cluster headache. Gelb chapter 12 pages

10 13. Dizziness a. Describe the clinical features which distinguish central from peripheral vertigo. b. Discuss the pathophysiology of the two most common types of peripheral vertigo including benign paroxysmal positional vertigo (BPPV) and acute labyrinthitis. c. Be familiar with how to perform and interpret the Dix-Hallpike maneuver. d. Discuss use of the Epley Maneuver for the treatment of BPPV. e. Describe the clinical features of Meniere s disease. Gelb chapter 14, pages