Common neurological presentations such as headaches, dizziness, gait disturbances, and visual deficits are frequent in emergency and general medical settings. Rapid pattern recognition, thorough history-taking, and neurological examination are key to differentiating life-threatening conditions from more benign causes. This page outlines the typical clinical patterns, diagnostic considerations, and localisation principles essential for final-year medical students.
Overview Headaches are one of the most common reasons for emergency department presentations. While many are benign, some represent serious pathology requiring urgent intervention.
Life-Threatening Differentials Common Benign Causes Migraine Tension-type headache Post-traumatic headache Sinus disease Classification Primary Headaches (no underlying structural cause):Migraine Tension headache Cluster headache Secondary Headaches (due to underlying pathology):Infection Intracranial haemorrhage Tumour Clinical Patterns Pattern Probable Diagnosis Isolated severe headache with thunderclap onset Subarachnoid haemorrhage Headache after head injury with LOC and lucid interval Extradural haemorrhage Worsening headache days-weeks after mild trauma Subdural haematoma Subacute headache + fever, rash, photophobia Meningitis or encephalitis Chronic/recurrent with vague symptoms Tension headache, migraine, sinusitis Headache worse lying down, straining Space-occupying lesion with raised ICP Headache + scalp tenderness in elderly Temporal arteritis
Pattern Probable Diagnosis Light-headedness, unsteadiness Orthostatic hypotension, panic, anaemia, palpitations Sensation of movement or spinning Vestibular pathology (e.g., vestibulocochlear nerve , acoustic neuroma) ALOC or falling spells Syncope, epilepsy , hypoglycaemia, anaemia
Gait Abnormalities and Causes Pattern Probable Diagnosis Stiff, jerky, narrow-based gait Spastic diplegia, cerebral palsy, MS, spinal cord injury Unilateral circumduction Stroke, unilateral spinal cord lesion Short shuffling steps, stooped posture Parkinson’s disease Broad-based, tremulous gait Cerebellar ataxia (lateral lobe) Truncal instability, falls Midline cerebellar (vermis) disease High-stepping, stamping gait, worse with eyes closed Sensory ataxia (e.g. polyneuropathy) Slapping gait Common peroneal nerve palsyWaddling gait, difficulty rising from chair Proximal muscle weakness (e.g. muscular dystrophy) Hesitant gait, small steps, preserved leg movements when supine Gait apraxia (frontal lobe lesion)
Lesion Location Visual Field Defect Retina Paracentral scotoma Optic nerve Monocular vision loss Optic chiasm Bitemporal hemianopia Optic tract Contralateral homonymous hemianopia Temporal optic radiation Contralateral lower quadrantanopia Parietal optic radiation Contralateral upper quadrantanopia Entire optic radiation Contralateral homonymous hemianopia Occipital cortex Homonymous hemiscotoma
Source: Dattilo, Michael et al. “Functional and simulated visual loss.” Handbook of clinical neurology 139 (2016): 329-341 . Afferent Pupillary Defect (Optic nerve, chiasm, tract lesion) Affected pupil unreactive to light Consensual reflex intact in affected eye No consensual reflex in contralateral eye Efferent Pupillary Defect (Oculomotor nerve or ciliary nerve lesion) Affected pupil unreactive Absent consensual reflex in affected eye Consensual reflex preserved in contralateral eye
https://healthjade.net/pupillary-light-reflex/ Pathophysiology Lesions above the anterior horn (corticospinal tract, motor cortex ) Typical causes:Stroke Cerebral palsy Traumatic brain injury Clinical Features Common Lesion Patterns Lesion Site Effect Unilateral motor cortex Contralateral hemiplegia Internal capsule Contralateral hemiplegia Cervical cord injury above brachial plexus Quadriplegia Spinal cord lesion below brachial plexus Paraplegia
Pathophysiology Lesions below the anterior horn (peripheral nerves or motor nuclei) Typical causes: Clinical Features
Source: Timothy Warner: https://www.researchgate.net/figure/Species-divergent-organisation-of-motor-systems-A-The-corticospinal-tracts-CSTs_fig1_337215634 Conscious Sensory Pathways Pathway Modality Decussation Dorsal column (medial lemniscus) Vibration, proprioception Medulla Spinothalamic Pain, temperature Spinal cord level Trigeminal Facial sensation Medulla
Unconscious Sensory Pathway Spinocerebellar tract: Proprioception and balance (does not reach consciousness)
Source: https://www.grepmed.com/images/3568/brownsequard-patterns-loss-diagnosis-bilaterality-neurology-sensory Common neurological presentations encompass a wide range of symptoms including headaches, visual deficits, gait abnormalities, and altered sensation. Careful pattern recognition and localisation are critical to identifying underlying pathology, from benign conditions to serious structural or systemic disease. For a broader context, see our Emergency Medicine Overview page.
