The 13 most dreadful neurological disorders…and the groups standing up to them

Neurology embodies some of the most dreadful diseases known to man. Every neurological disorder is disheartening, each characterised by unique frustrations for patients and their families. It is difficult to quantify the distress and misery these afflictions impose on their victims, and even harder to appreciate the despair and anguish they evoke in those who care for them.

Brain Art. Ars Electronica on Flikr.

It is clearly hard to compare the impact of different neurological diseases. Some neurological disorders however stand out because of the consternation their names evoke, and the terror that follows in their wake. These diseases come with unimaginable physical and psychological burdens, and crushing demands on human and material resources. They impose either a debilitating morbidity, or a hasty mortality.

Neural pathways in the brain. NICHD on Flikr.

The nervous system ailments in the list below pose exacting therapeutic challenges, resistant as they are to all attempts at treatment or cure. This list sets out to emphasise the urgency for neuroscience to find a remedy for each of them, but it does not intend to belittle the horror of the disorders omitted from it. The choice of the number 13 is, sadly, self-evident. Here then are the top 13 most dreadful neurological disorders…all with gold links to the associations helping to defeat them.

Working Brain. Gontzal García del Caño on Flikr.


Ataxia, in lay terms, is incoordination. This typically manifests as an unsteady gait and clumsiness. Ataxia converts all activities of daily living into burdensome chores. Whilst many types of ataxia are preventable or reversible, primary ataxias are progressive and carry a dismal outlook. In this category are Spinocerebellar ataxia (SCA)Friedreich’s ataxia, and Ataxia telangiectasia. You may read more about ataxia in these previous blog posts: The 43 spinocerebellar ataxias: the complete checklistsOld drugs, new roles?, and Will Riluzole really be good for cerebellar ataxia?

Brain tumours

Brain cancers hardly need any description. They are either primary, arising from the brain cells, or metastatic, spreading to the brain from other organs. Some primary brain cancers, such as meningiomas and pituitary tumours, are, relatively, treatable. Many others are unfortunately ominously malignant. The most dreadful in this category is surely the spine-chilling glioblastoma multiforme. You may check out these previous blog posts for more on these tumuors: Calming the rage of brain tumours: hope for a dreaded cancerMaggots, viruses and lasers: some innovations for brain tumoursand Are steroids detrimental to survival in brain tumours?

Peripheral neuropathy

Peripheral neuropathy is ubiquitous in the neurology clinic. Neuropathy may result from reversible situations such as overindulgence in alcohol, uncontrolled diabetes, or Vitamin B12 deficiency. Neuropathy is often just a minor inconvenience when it manifests with sensory symptoms such as tingling and numbness. It may however be debilitating when it presents as limb paralysis, or complicated by major skeletal deformities. At the severe end of the spectrum of neuropathy are the hereditary forms such as Charcot Marie Tooth disease (CMT) and Familial amyloid polyneuropathy. Read more in these blog posts: The 52 variants of CMT… and their practical checklistsWhat’s looming at the frontline of peripheral neuropathy? and Will a pill really hold the cure for CMT?

Creutzfeldt Jakob disease (CJD)

CJD is the most iconic of the prion diseases. These disorders are as horrendous as they are enigmatic, defying categorisation as either infections or neurodegenerative diseases. More puzzling is their ability to be either hereditary and acquired. CJD exists in the classic or variant form, but both share a relentlessly rapid course, and a uniformly fatal end. You may read more in these previous blog posts titled Final day of ANA 2015- Prions center stage, and What are the links between Prion diseases and Parkinsonian disorders?


Dementia is the scourge of longevity. Its name strikes terror because it insidiously colonises the cells that make us who we are. The most prominent dementia is Alzheimer’s disease, but it has equally dreadful companions such as Frontotemporal dementia (FTD) and Dementia with Lewy bodies (DLB). Read more on dementia in these blog posts: How bright is the future for Alzheimer’s disease?Alzheimer’s disease: a few curious things, and Alzheimers disease and its promising links with diabetes.


Dystonia marks its presence by distressing movements and painful postures. At its most benign, dystonia is only a twitch of the eyelid (blepharospasm) or a flicker of one side of the face (hemifacial spasm). At the extreme end, it produces continuous twisting and swirling motions, often defying all treatments. The causes of dystonia are legion, but the primary dystonias stand out by their hereditary transmission and marked severity. Read more on dystonia in these blog posts: Why does dystonia fascinate and challenge neurology? and Making sense of the dystonias: the practical checklists.

Huntington’s disease (HD)

Huntington’s disease is an iconic eponymous neurological disorder which is marked by the vicious triumvirate of chorea, dementia, and a positive family history. It is an awful condition, often driving its victims to suicide. It is a so-called trinucleotide repeat expansion disorder, implying that successive generations manifest the disease at an earlier age, and in more severe forms (genetic anticipation). You may read more on HD in the previous blog post titled What are the prospects of stamping out Huntington’s disease? 

Motor neurone disease (MND) 

Also known as Amyotrophic lateral sclerosis (ALS), MND is simply devastating. Recognising no anatomical boundaries, it ravages the central and peripheral nervous systems equally. MND creeps up on the neurones and causes early muscle twitching (fasciculations) and cramps. It then gradually devours the nerves resulting in muscle wasting, loss of speech, ineffectual breathing, and impaired swallowing. It is no wonder that one of the most read post on this blog is titled Is neurology research finally breaking the resolve of MND? Other previous blog posts on MND are The emerging links between depression and MNDWhat is the relationship of MND and cancer?Does diabetes protect from MND?, and MND and funeral directors-really?

Multiple sclerosis (MS)

Multiple sclerosis is a very common disease, and gets more common the further away you get from the equator. It is the subject of intense research because of the devastation it foists on predominantly young people. Many drugs now ameliorate, and even seem to halt the progression of, relapsing remitting MS (RRMS). This is however not the case with primary progressive MS (PPMS) which, until the introduction of ocrelizumab, defied all treatments. There are many contenders vying for the cause of MS, but the reason nerves in the central nervous system inexplicably lose their myelin sheaths remains elusive. You may read more on MS in these blog posts: The emerging progress from the world of MS , What are the remarkable drugs which have transformed the treatment of MS?, and Is low vitamin D a cause of multiple sclerosis?

Muscular dystrophy 

Muscular dystrophy is an umbrella term that covers a diverse range of inherited muscle diseases. The most devastating, on account of its early onset and unrelenting progression, is Duchenne muscular dystrophy (DMD). Adult neurologists will be more familiar with late onset muscular dystrophies such as Myotonic dystrophy and Facioscapulohumeral muscular dystrophy (FSHD). Read more on muscular dystrophy in these previous blog posts: How is neurology stamping out the anguish of Duchenne? and The A–Z of limb girdle muscular dystrophy (LGMD).


Rabies, a rhabdovirus, is a zoonosis-it is transmitted to man by a wide range of animals such as dogs, bats, racoons, and skunks. It is the quintessential deadly neurological disease, popularised by the Steven King book and film, Cujo. Rabies manifests either as the encephalitic (furious) or the paralytic (dumb) forms. It wreaks havoc by causing irritability, hydrophobia (fear of water),  excessive sweating, altered consciousness, and inevitably death. Whilst there are vaccines to protect against rabies, a cure has eluded neuroscientists. This blog is yet to do justice to rabies but it is, at least, listed in the post titled What are the most iconic neurological disorders? But you could better by checking neurochecklists for details of the clinical features and management of rabies.

Spinal cord injury

Nothing is quite as heart-wrenching as the sudden loss of body function that results from spinal cord trauma. This often causes paralysis of both legs (paraplegia), or all four limbs (quadriplegia). This life-changing disorder is often accompanied by loss of control over bowel and bladder functions, and complications such as bed sores and painful spasms. You may read about the heroic efforts to treat spinal cord injury in the blog posts titled 6 innovations in the treatment of spinal cord injury and Head transplant, anyone?


Tetanus is an eminently preventable disease, now almost wiped out in developed countries by simple immunisation. It however continues its pillage and plunder in the developing world. It strikes young and old alike, often invading the body through innocuous wounds. Tetanus is caused by tetanospasmin and tetanolysin, the deadly toxins of the bacterium Clostridium tetani. The disease is classified as generalised, localised, cephalic, or neonatal tetanus. It is characterised by painful spasms which manifest as lockjaw (trismus), facial contortions (risus sardonicus), trunkal rigidity (opisthotonus), and vocal cord spasms (laryngospasm). The disease is awfully distressing and, when advanced, untreatable. It is a stain on the world that this avoidable disorder continuous to threaten a large number of its inhabitants. Check neurochecklists for more on the pathology, clinical features, and management of tetanus.


Light brain. Mario D’Amore on Flikr.

As for all lists, this will surely be subject to debate, or perhaps some healthy controversy. Please leave a comment.

20 things we now know for certain about the Zika virus

Zika virus exploded into the news with striking images of children born with small heads in Brazil. This was at a time the country was struggling to plan for the Rio Olympics, and also embroiled in political turmoil. These all helped to embed the virus firmly in the public’s mind.


Events have unfolded very rapidly, with shifting certainties and swirling speculations. The storm is however now settling, and a clearer picture emerging. And neurology is right at the centre of this viral catastrophe. What is the current state of play? Here are 20 things we now know about the Zika virus.

1. Zika is an arbovirus of the family Flaviviridae

By Manuel Almagro Rivas - Own work, CC BY-SA 4.0,
By Manuel Almagro RivasOwn work, CC BY-SA 4.0,

2. Zika was first identified in Uganda in 1947


By User TShilo12 on en.wikipedia, Public Domain,
By User TShilo12 on en.wikipedia, Public Domain,

3. Zika was first isolated from a Rhesus macaque monkey

Rhesus Macaque. Robert Martinez on Flikr.
Rhesus Macaque. Robert Martinez on Flikr.

4. The first human cases were reported from Nigeria

Nigeria flag. Global Panorama on Flikr.
Nigeria flag. Global Panorama on Flikr.

5. Outbreaks of Zika have ocurred in BrazilMicronesia, and French Polynesia

French Polynesia Grunge Flag. Nicholas Raymond on Flikr.
French Polynesia Grunge Flag. Nicholas Raymond on Flikr.


6. Zika is mainly transmitted by Aedes mosquitoes

By Rafaelgilo - Praca własna, Domena publiczna,
By RafaelgiloPraca własna, Domena publiczna,

7. Zika virus is transmitted perinatally

By Øyvind Holmstad - Own work, CC BY-SA 4.0,
By Øyvind HolmstadOwn work, CC BY-SA 4.0,

The Centre for Disease Control (CDC) recommendations for pregnant women are

  • To avoid travel to affected countries
  • To be tested if they travel to affected countries
  • To have 3–4 weekly foetal ultrasound if they test positive for the virus
  • To have their babies tested at birth if they were infected

8. Zika virus is also sexually transmitted 


9. Zika virus is most likely transmissible through the skin

223 [Pocari Sweat]. Evan Blaser on Flikr.
223 [Pocari Sweat]. Evan Blaser on Flikr.
  • fatal case report of Zika infection from the New England Journal of Medicine strongly suggests Zika may be transmitted through sweat or tears

10. Zika virus primarily infects neural stem cells

Adult neural stem cells. California Institute for Regenerative Medicine on Flikr.
Adult neural stem cells. California Institute for Regenerative Medicine on Flikr.

11. Zika infection usually only causes mild and self-limiting symptoms

By Beth.herlin - Own work, CC BY-SA 4.0,
By Beth.herlinOwn work, CC BY-SA 4.0,

The typical symptoms of Zika virus infection are

  • Fever
  • Skin rash
  • Conjunctivitis
  • Joint pains
  • Muscle aches
  • Headache

12. Microcephaly is the striking feature of congenital Zika

By Centers for Disease Control and Prevention -, Public Domain,
By Centers for Disease Control and Prevention –, Public Domain,


13. Zika infection causes several other brain abnormalities

By Ralphelg - Own work, CC BY-SA 3.0,
By RalphelgOwn work, CC BY-SA 3.0,

Brain abnormalities with congenital Zika infection include:

  • Calcification of the brain’s white matter
  • Cerebellar dysgenesis: abnormal development of the cerebellum
  • Craniosynostosis: premature closure of the bones of the brain
  • Lissencephaly: an abnormal shape of the brain 
  • Ventriculomegaly: enlargement of the brain’s fluid-containing spaces

These abnormalities may be seen on brain imaging

14. Adult Zika infection causes Guillain Barre syndrome (GBS)


By Doctor Jana -;, CC BY 4.0,
By Doctor Jana –;, CC BY 4.0,

15. Zika virus infection causes other neurological diseases

Knitted Neurology. estonia76 on Flikr.
Knitted Neurology. estonia76 on Flikr.

There are other neurological diseases associated with Zika virus such as


16. Zika virus infection causes many eye abnormalities

By JDrewes - Own work, CC BY-SA 3.0,
By JDrewesOwn work, CC BY-SA 3.0,

Eye abnormalities reported with Zika virus infection include

  • Mottling and atrophy of the retina
  • Abnormalities of the optic nerve
  • Coloboma (defects) of the iris
  • Subluxation (dislocation) of the lens


17. Zika virus may cause impairments in other organ systems

By Mikael Häggström - Image:Respiratory system complete numbered.svg (Public domain licence), Public Domain,
By Mikael HäggströmImage:Respiratory system complete numbered.svg (Public domain licence), Public Domain,

Other organs affected by Zika virus lead to disorders such as

  • Pulmonary hypoplasia, or underdeveloped lungs
  • Severe thrombocytopaenia, or low platelet counts
  • Urinary and genital symptoms

18. Zika virus infection is confirmed by laboratory tests

CC BY-SA 3.0,
CC BY-SA 3.0,
  • rRT-PCR (real time reverse transcriptase polymerase chain reaction) is the best test for the Zika virus
  • This is done on urine and blood samples collected within 2 weeks of infection

19. There is an experimental human vaccine trial for the Zika virus




20. There are promising antiviral treatments for Zika virus



Want to explore more? You may check out the following:

7 ominous signs that suggest you need to see a neurologist

Neurologists spend most of their time diagnosing benign conditions which are curable or treatable, or at least people learn to live with. Every now and then we see people with startling symptoms such as coma, convulsions, neck stiffness, or paralysis. These are obviously concerning to patients and their families who have a foreboding of diseases such as meningitis, epilepsy, and stroke. Serious as these disorders are, they at least announce themselves and show their hands. Many other neurological symptoms unfortunately give no hint of the serious diseases that follow in their trail. That is when things get a bit tricky.

Ominous. Ankakay on Flikr.
Ominous. Ankakay on Flikr.

What are these seemingly benign symptoms which jolt neurologists out of their blissful complacency? What are these red flag symptoms that pretend they are grey? Here are my 7 deceptively ominous neurological signs everyone should know about.

7. A numb chin

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Gray's Anatomy, Plate 784, Public Domain,
By Henry Vandyke CarterHenry Gray (1918) Anatomy of the Human Body (See “Book” section below) Gray’s Anatomy, Plate 784, Public Domain,

This must be the most deceptive sinister symptom in neurology. Not many people will rush to their doctors to complain about a numb chin, but it is a symptom that makes neurologists very nervous. This is because the chin gets its sensory supply from the mandibular branch of the fifth cranial nerve, also called the trigeminal nerve because it has three branches. And neurologists know that, for some bizarre reason, cancers from other parts of the body occasionally send deposits to this nerve. The numb chin syndrome is therefore not to be treated lightly.

6. Muscle twitching

OK, don’t panic yet. We have all experienced this; a flickering of an overused and tired muscle; a twitching of the odd finger; the quivering of the calf muscles in older people. Neurologists call these fasciculations, and they are only a concern if they are persistent, progressive, and widespread. And also usually only if the affected muscles are weak. In such cases neurologists worry that fasciculations are the harbingers of sinister diseases, particularly motor neurone disease (MND), better known in America as amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease. Many people with muscle twitching will however have nothing seriously wrong with them, and many will be shooed out of the consulting room with the label of benign fasciculations syndrome (we love our syndromes, especially when they are benign). There are many other causes of fasciculations, but MND is clearly the most sinister of them all.

5. Transient visual loss

Scott Maxwell on freestockphotos.
Scott Maxwell on freestockphotos.

Neurologists often ask people with headache if their vision blurs or disappears for brief periods of time. These visual obscurations are not as dramatic as the visual loss that accompanies minor strokes or transient ischaemic attacks (TIAs). Visual obscurations affect both eyes and last only a few seconds. They are the result of sudden but brief increases in an already elevated pressure in the head. This may occur with relatively benign conditions such as idiopathic intracranial hypertension (IIH), but it may also portend a serious disorder such as a brain tumour.

4. Sudden loss of bowel or bladder control


Loss of control down there would surely concern many people, but often not with the urgency it deserves. There are many non-neurological causes of bowel or bladder incontinence, but a sudden onset suggests that it is arising from the nervous system. The worrying diagnoses here are spinal cord compression and spinal cord inflammation (transverse myelitis). These disorders are often associated with other symptoms such as leg stiffness and weakness, but I really wouldn’t wait until these set in before I ask to see a neurologist.

3. Saddle anaesthesia


Whilst we are on the topic of things down there, a related sinister symptom is loss of sensation around the genitals and buttocks, something your doctor will prudently call saddle anaesthesia. This arises when the nerves coming off the lower end of the spinal cord, collectively called the cauda equina, are compressed. The unpalatable condition, cauda equina syndrome (CES), worries neurologists because the compression may be due to a tumour in the spinal canal.

PS: The bicycle saddle is an apt analogy, but if you prefer horse riding, below is an alternative image to soothe your hurt feelings.


By BLW - Own work, CC BY-SA 3.0,
By BLW – Own work, CC BY-SA 3.0,

2. A painful droopy eyelid

A droopy eyelid is a deceptively benign symptom which worries neurologists. This symptom, which neurologist prefer to call ptosis, is particularly concerning if it is accompanied by double vision. One worrying disorder which causes ptosis is myasthenia gravis (MG), and this presents with ptosis on both sides. More sinister is ptosis which is present only on one side, particularly if it is painful. This may be caused by brain aneurysms, especially those arising from a weakness of the posterior communicating artery (PCOM) artery. As the aneurysm grows, it presses on the third cranial or oculomotor nerve, one of three nerves that controls the eyeballs and keeps the eyelids open. An aneurysm is literally a time-bomb in the brain as they wield the threat of bursting and causing a catastrophic bleeding around the brain. This makes ptosis an ominous, but also a helpful, neurological symptom.

By Cumulus z niderlandzkiej Wikipedii, CC BY-SA 3.0,
By Cumulus z niderlandzkiej Wikipedii, CC BY-SA 3.0,

There are many other causes of ptosis including Horner’s syndrome, so don’t panic yet but get that eyelid checked out if it refuses to straighten out.


1. Thunderclap headache

By © Marie-Lan Nguyen / Wikimedia Commons, CC BY 2.5,
By © Marie-Lan Nguyen / Wikimedia Commons, CC BY 2.5,

thunderclap headache is a symptom that means exactly what it says on the label! Neurologists will ask if the onset felt as if one was hit by a cricket bat. Even though most people have never been so assaulted, almost everyone with thunderclap headache readily agree this is what it feels like. It is such a distressing symptom that it doesn’t strike the afflicted person (pun intended) that their doctors are more concerned about investigating them, then they are in curing their headache. They patient is rushed to the CT scanner, and then subjected to a lumbar puncture. The doctors then heave a huge sigh of relief when the spinal fluid shows no blood or blood products, reassured that the patient has not suffered a subarachnoid haemorrhage (SAH) from a ruptured a brain aneurysm. The patient, who now has just another headache, is left to get to grips with their now, suddenly, very uninteresting symptom. There are many other causes of a thunderclap headache, but a ruptured aneurysm is the most sinister. If you develop a thunderclap headache, don’t wait to see a neurologist…just get to the nearest hospital!

PS: Don’t feel aggrieved if you are across the Pacific; it is also a thunderclap headache if it felt like being hit by a baseball bat!

Baseball bat in sun. Peter Chen on Flikr
Baseball bat in sun. Peter Chen on Flikr


Want to check out more ominous signs? Check out Smart handles and red flags in neurological diagnosis by the neurologist Chris Hawkes in Hospital Medicine.


Imagine you have just suffered a devastating stroke!

Imagine you have just had a stroke!

Devastating,  distressing, life changing.

By Bhernandez from miami - stressed and worried, CC BY 2.0,
By Bhernandez from miami – stressed and worried, CC BY 2.0,

Imagine you are stuck in a wheelchair,

Helpless and speechless.


Now imagine you are transported back in time,

6 months before your stroke

Antique clock face with hands. Cindy Schultz on Flikr.
Antique clock face with hands. Cindy Schultz on Flikr.

You see your physically able self,

Master of your faculties,

Enjoying all the ‘good things’ of life.

By, CC BY 4.0,
By, CC BY 4.0,

Now feel the regret,

That you did nothing to prevent the stroke,

The sudden event that stole your dreams and aspirations.

Regret. Neil Moralee on Flikr.
Regret. Neil Moralee on Flikr.

Now you realise this is a second chance,

After such a close shave,

Imagine the relief.

Phew!. Tibor Miklos on Flikr.
Phew!. Tibor Miklos on Flikr.

Imagine the pleasure!


Now you have a choice to make.

To resume the pleasures you previously indulged in…

Sumptuous Lunch. Nadir Hashmi on Flikr.
Sumptuous Lunch. Nadir Hashmi on Flikr.

Or recollect the warnings you ignored before,

Which you turned a deaf ear to,

Which are now more valuable than all the gems in the world.


You wisely decide to turn a new leaf.

Turn page. andy.brandon50 on Flikr.
Turn page. andy.brandon50 on Flikr.

Now make a full list,

Of all the things you should have done,

And could have done,

To prevent the disastrous stroke.


Now take a hard look at your list,

And start acting on it,

Right now!

JUST DO IT. Paper Fold. the_fafa on Flikr.
JUST DO IT. Paper Fold. the_fafa on Flikr.


Get off the couch,

Walk round the block,

Put out that cigarette.

Ashtray. Jocelyn on Flikr.
Ashtray. Jocelyn on Flikr.

Switch off the TV

Get on that weighing scale

Check your blood pressure

By, CC BY-SA 3.0,
By, CC BY-SA 3.0,

Cut down internet time,

Cut out the fat and carbs,

Get on the treadmill.

Running on a treadmill. E'Lisa Campbell on Flikr.
Running on a treadmill. E’Lisa Campbell on Flikr.

Say ‘pass’ to that pint 

Top up with the greens

Invest in a good pair of walking shoes


Visit a garden or park this weekend

Mow the lawn

 Give up the stressful job

6/52³: Estrés / Stress. Andrés Nieto Porras on Flikr.
6/52³: Estrés / Stress. Andrés Nieto Porras on Flikr.


And now you have finally done it!

You have prevented a calamitous stroke.



It wasn’t that hard after all,

Now you can relax,

And be proud of yourself!


You may download the powerpoint version of this presentation below:

imagine a stroke

How to keep your distance from a neurologist

An apple a day will never be enough to avoid neurological diseases. For one, the nervous system is extensive, vulnerable from the top of the head to the tips of the toes. For another, the cells that constitute the nervous system are susceptible to an astonishing variety of insults. This explains the diversity and number of neurological diseases, and why medical students and doctors find neurology daunting.

brain.nervous.system.tumblr_lgnqxgo0bK1qbz7jdo1_500. Beth Scupham on Flikr.
brain.nervous.system.tumblr_lgnqxgo0bK1qbz7jdo1_500. Beth Scupham on Flikr.


There are many neurological diseases that we can do absolutely nothing to guard against. This is the case with genetic neurological diseases, unless we find a way of choosing our parents wisely! Proven ways of improving our defences include exercising regularly, eating healthily, and stopping smoking; these however have their limitations against many neurological disorders.

But don’t despair, there are measures we can take to shield ourselves against some avoidable neurological conditions. Many of these arise because of activities we engage in, often mindless of their consequences. The list is fairly long, but here are my  ‘12 Don’ts of Neurology’ to help avoid a meeting with a neurologist.

1. Don't get angry

Anger is an unpredictable negative emotion which hardly ever serves any useful purpose. If you need a very good reason to keep your cool, know that anger is a recognised trigger of stroke. On balance therefore, it’s not worth blowing a fuse.

2. Don’t stay too long at the hair-dressers sink
Lego hairdresser. RobethK on Flikr.
Lego hairdresser. RobethK on Flikr.

Excessive neck extension, as occurs at the hairdresser’s or the chiropractor, could stretch and tear the inner lining of a neck artery. This painful tear is called a dissection and it allows a blood clot to form. What happens next is the serious part; the clot may dislodge and travel up the blood vessel where it blocks blood flow to the brain. The result, understandably, is called the beauty parlor stroke syndrome.

3. Don’t cross your legs
By William Orpen - 1. Unknown2. National Maritime Museum, London3. Royal Museums Greenwich, Public Domain,*oil on canvas *96.5 x 91.5 cm *circa 1900 *signed b.r.: Orpen
By William Orpen – 1. Unknown2. National Maritime Museum, London3. Royal Museums Greenwich, Public Domain,*oil on canvas
*96.5 x 91.5 cm
*circa 1900
*signed b.r.: Orpen


We all do it: sit back and hang one leg over the other knee. Habitual crossed-leg sitting however puts your peroneal nerve at risk of compression where it crosses round the knee to innervate the leg and foot muscles. The result is foot drop. Sitting in the yoga lotus position causes a similar damage, as does prolonged squatting (strawberry pickers foot drop).

4. Don’t stay too long on the toilet seat
Monaco-toilet seat. waldopepper on Flikr.
Monaco-toilet seat. waldopepper on Flikr.

The sciatic nerve is the largest peripheral nerve in the body, and it traverses the buttock on its way to innervate most of the lower limb muscles. It is vulnerable to prolonged sitting on hard surfaces, and it’s a no-brainer that this is called toilet-seat neuropathy. You could of course have your toilet seat nicely padded! You may also protect your sciatic nerve by not putting thick wallets and coins in your back pocket.

5. Don’t build your muscles to excess
Venice muscle beach. Lin Mei on FLikr.
Venice muscle beach. Lin Mei on FLikr.

It is trendy to have a nice six-pack or firm pecs, but this may come at a price. As the muscles get stronger and bulkier, they may compress the nerves which pass through them. Most vulnerable are the thoracodorsal, the suprascapular, and the pectoral nerves. A shrunken pectoral muscle on one side is sure evidence that you have overdone it.

6. Don’t over-do the athletic thing

Athletic sports that involve excessive upper limb movements may stretch and compress the nerves. Particularly vulnerable is the axillary nerve which supplies the muscles you need to lift your arm away from your body. The culprit sports include volleyball, javelin, rock climbing, and rugby.

7. Don’t overload that backpack
Nile ruckpack. Zhao on Flikr.
Nile ruckpack. Zhao on Flikr.

It’s so convenient to sling a backpack over the shoulder, but it is not benign if you overload it. This is because the heavy weight of a backpack may damage the brachial plexus, the large network of nerves that innervate the upper limb. The resulting limp upper arm is called…you guessed it, rucksack paralysis.

8. Don’t ever be handcuffed
By No machine-readable author provided. Klaus with K assumed (based on copyright claims). - No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 3.0,
By No machine-readable author provided. Klaus with K assumed (based on copyright claims). – No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 3.0,


The wrist is the gateway to three important nerves, all vulnerable to compression. External pressure on the wrist particularly picks on the superficial branch of the radial nerve. The resulting handcuff palsy causes pain and tingling over the back of the hand. A similar effect may result from tight wristwatches and bracelets. A good reason to go bare below the elbows.

9. Don’t hold to tightly to your bicycle handlebars
By -, CC BY-SA 2.0,
By, CC BY-SA 2.0,


To avoid the so-called cyclists palsy, you must not only choose your machine carefully, but take care when riding. This is to protect your ulnar nerve which traverses the wrist just where the cycle handlebars would compress it. This causes paralysis of many of the small muscles of the hand, sparing only the thumb.

10. Don’t tighten your belt excessively

The victim nerve this time is a branch of the femoral nerve, the second largest nerve of the lower limb. This nerve migrates from the abdomen into the thigh by squeezing just under the belt line. It is vulnerable to compression here, and the result is meralgia paraesthetica. This is a fairly common condition, easily recognised by a combination of pain, tingling, and numbness over a well-demarcated patch on the outer thigh. Wearing skinny jeans is another recognised cause, as are prolonged sitting and weight gain.

11. Don’t use ill-fitting ski boots
By Amy Johnson, contesstant on EpicSki -, CC BY-SA 2.5,
By Amy Johnson, contesstant on EpicSki –, CC BY-SA 2.5,


Choosing the wrong ski boots may not just mess up your skiing holiday, it could result in compression of the peroneal nerve around the ankle . This causes tingling over the foot …but this may persist long after you have (angrily?) discarded the offending boots.

12. Don’t fail a hanging attempt
By Chris 73 / Wikimedia Commons, CC BY-SA 3.0,
By Chris 73 / Wikimedia Commons, CC BY-SA 3.0,


The nerves vulnerable to the hangman’s noose are the greater auricular nerves. These nerves transmit sensation from the ears; not a major problem if the hanging is successful; if the attempt fails however, be prepared for numb ears in resurrection.

Tree Nervous System. Sam Salt on Flikr.
Tree Nervous System. Sam Salt on Flikr.


To explore this topic in further detail, I recommend the following books:

Localization in Clinical Neurology 

Peripheral Neurology: Case Studies

What unconventional stroke risk factors are out there?

Stroke is a terrible disease. It comes unexpectedly out of the blue, strikes quickly, and leaves devastation in its wake.

Ischemic stroke. NIH Image Gallery on Flikr.
Ischemic stroke. NIH Image Gallery on Flikr.


Stroke treatment is advancing in leaps and bounds, but the best approach remains preventative. We are all aware of the need to guard against the conventional harbingers of stroke: hypertension, high cholesterol, diabetes mellitus, and smoking. We are also aware of the benefits of a healthy diet and exercise.

There are of course stroke risk factors we can do nothing about: age is one, and there is of course a long list of genetic stroke risk factors.

DNA rendering. ynse on Flikr.
DNA rendering. ynse on Flikr.


Just as we are getting used to monitoring our blood pressures and heading to the park, some neurologists are bent on making our task a little bit harder. It’s no longer enough to flex those biceps or stamp out that stub; we now have to take notice of unconventional stoke risk factors. The first of these is infection.

3D model of influenza virus
3D model of influenza virus

This paper in Neurology titled Infection, vaccination, and childhood arterial ischemic stroke establishes the association between infection and stroke. The authors showed that 18% of children with stroke had an infection in the preceding week, compared to only 3% of those that did not have a stroke. Adults should not count themselves lucky going by another paper in the journal Vaccine titled Influenza vaccination and risk of stroke: Self-controlled case-series study. Both papers reassure us that immunisation helps to counter the stroke hazard of infections- one strong reason not to skip the next round of flu vaccinations.

By LaurMG. - Cropped from "File:Frustrated man at a desk.jpg"., CC BY-SA 3.0,
By LaurMG. – Cropped from “File:Frustrated man at a desk.jpg“., CC BY-SA 3.0,


Beyond infection come more bizarre unconventional stroke risk factors. We have always known that stress is no good; now we have some evidence to back this up. Just take the following factors now linked to stroke:

Add depression to this and you have a dangerous trio.


By BruceBlaus - Own work, CC BY-SA 4.0,
By BruceBlaus – Own work, CC BY-SA 4.0,


Some medical risk factors are difficult to relate with stroke. Take for example

By M. Adiputra - Own work, CC BY-SA 3.0,
By M. AdiputraOwn work, CC BY-SA 3.0,


Another risk factor to watch out for is air pollution. And to cap it off, being bilingual improves the chances of recovery from stroke. How unconventional is that!


And straight off the press, you can now add sleep apnoea and insomnia to the list of stroke risk factors.

10 bizarre things neurologists do to their patients

This is a follow-up to my previous blog post, So what is remarkable about neurology anyway? That post reviewed the challenging tasks neurologists face everyday. How do they go about it? How do they evaluate their patients with suspected neurological disorders?

Neurology by MV Maverick on Flikr.
Neurology by MV Maverick on Flikr.


For the uninitiated, the process of the neurological assessment must seem like an outlandish ritual. Unlike cardiologists who approach patients with the familiar stethoscope, neurologists come armed to the hilt with an arsenal of threatening equipment. Patients are often bewildered, and occasionally irritated, with the neurological exam. Admitted, they sometimes, they sometimes emerge from the assessment feeling battered and bruised-all for a good cause of course!

So what are these bizarre deeds that marks the neurological consultation?

1. Neurologists welcome you with an overly firm handshake 

By liftarn ( [Public domain], via Wikimedia Commons
By liftarn ( [Public domain], via Wikimedia Commons

The handshake is a valuable neurological tool. It tells the neurologist right from the beginning if there is any weakness or if there is a form of muscle stiffness called myotonia. Therefore avoid the neurologist’s handshake if you suffer with arthritis or other painful hand conditions.

2. Neurologists make you do the catwalk 

The way you walk, the gait, may show the neurologist a variety of clues or signs. There are a variety of abnormal gaits that often point to a diagnosis even before the consultation actually begins. Examples include the shuffling gait in Parkinson’s disease, the hemiparetic gait in Stroke, and the waddling gait in diseases that give rise to hip girdle weakness. More embarrassing for some patients is that the neurologist may actually ask them to do a catwalk, all for the sake of making a diagnosis you must understand!

Other bizarre associated tests are walking an imaginary tightrope, standing on one leg, standing on tip toes and then on the heels, and marching in one spot with eyes shut

3. Neurologists stare intently at you 

"Thisisbossi Symmetry" by Andrew Bossi - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
“Thisisbossi Symmetry” by Andrew Bossi – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons –


The face often give the neurologist the clue to many diagnoses. Conditions such as Bell’s palsy and Stroke are evident from the face as are Parkinson’s disease, myotonic dystrophy and facio-scapulo-humeral muscular dystrophy (FSHD). There’s no need to blush therefore when the intent gaze seems to go on endlessly.

4. Neurologists come up very close- to peer into your soul

If the eyes are the windows to the soul, then neurologists are second only to ophthalmologists in recognising this nebulous entity. The back of the eye, or retina, holds a variety of valuable clues for many neurological diseases. The neurologist typically looks for signs of increased pressure in the head and this may occur with brain tumours, meningitis, encephalitis, This may also occur without any obvious cause in a condition called idiopathic intracranial hypertension (IIH). Other eye signs such as cataracts and pigmented retina seen with disorders for example mitochondrial diseases. 

To peer into the soul, the neurologist may come very uncomfortably close, (hoping the aftershave isn’t too strong and that the morning deodorant has lasted till then). Don’t hold your breath however, as this gazing into the soul may take longer than you anticipate.

5. Neurologists ask you to roll your eyes-in all sorts of directions

Muscles of the eye, circa 1900 by Double-M on Flikr.
Muscles of the eye, circa 1900 by Double-M on Flikr.


Abnormal eye movements are key pointers to many neurological disorders. There are six muscles that move each eyeball, and these are under the control of three pairs of cranial nerves-the oculomotor, the trochlear, and the abducens nerves. These nerves in turn are coordinated by complex nerve cell bodies or nuclei in the brain stem.The eyelids and pupils are also muscles under control of nerves.

These cranial nuclei coordinate a symphony of unparalleled and unimaginable complexity. This allows us to focus on moving objects without any hinderance. Things may go wrong with this symphony, and this typically results in double vision (diplopia) and droopy eyelids (ptosis). Diseases that cause these symptoms include brain aneurysms, myasthenia gravis (MG), and brainstem stroke. Some diseases may cause the eyeballs to move in uncontrollable and chaotic ways called nystagmus, oscillopsia, and opsoclonus (neurologists love these names!) 

Don’t be shocked therefore when your neurologist asks you to look up, look down, look to the right and left; to follow this or the other hand; to look at this fist then at these fingers…. It’s all a helpful game-honest!

6. Neurologists ask you to pretend to brush your teeth 


"Marcel Marceau - 1974" by press photo - ebay. Licensed under Public Domain via Commons.
Marcel Marceau – 1974” by press photo – ebay. Licensed under Public Domain via Commons.


Your neurologist may request you to brush your teeth or hair with an imaginary brush, or ask you to do victory sign or the thumbs-up sign (never thumbs-down mind you). Almost verging on the comedic, this is a serious test because these simple tasks are impaired in many diseases. The difficulty in performing tasks one has previously been proficient at is called dyspraxia, or apraxia if the ability is completely lost. Without any weakness or numbness, people with dyspraxia are unable to use common tools and equipment, reporting that they have no idea how to manipulate them. This could be seen in some forms of stroke and some dementias. Do decline however if she asks you to mimic the great mime Marcel Marceau.

7. Neurologists ask you to wiggle your tongue and poke it out 

New Zealand Maori culture 009 by Steve Evans on Flikr.
New Zealand Maori culture 009 by Steve Evans on Flikr.


The tongue is a very important muscle and holds countless clues for the neurologist. It is innervated by the last of the 12 cranial nerves, the hypoglossal nerve. which may be paralysed by a very localised stroke and this is often in the context of a condition called cervical artery dissection. This is a tear in one of the big arteries in the neck which take blood to the brain. The tear may arise from trivial neck movements and manipulations such as look up for a long time or staying too long on the hairdressers couch. A clot then forms at the site of the tear, and this then migrates to block a smaller blood vessel supplying the brainstem where the hypoglossal nerve sets off from…phew! Anyway, when this kind of stroke occurs, the tongue deviates to the the weaker side when it is poked out.

The more general weakness of the tongue is seen in conditions such as motor neurone disease (MND), in which the tongue also quivers at rest-something neurologists call fasciculations. The cheeky neurologist (pun intended) will ask you to push against her finger through your cheek to test its full strength.

Another problem that may affect the tongue is myotonia, a condition in which he tongue and other muscles are stiff and relax very slowly after they are activated. To test this, your neurologist may actually tap on your tongue, and then watches in fascination as it stiffens and then relaxes very slowly. Strong but slow moving tongues may be seen in Parkinson’s disease (PD). So, when next your neurologist says ‘open up’, he really means business.

8. Neurologists flex their muscles against yours


"FreestyleWrestling2" by Staff Sergeant Jason M. Carter, USMC -, VIRIN 040307-M-RS496-226. Licensed under Public Domain via Commons -
“FreestyleWrestling2” by Staff Sergeant Jason M. Carter, USMC –, VIRIN 040307-M-RS496-226. Licensed under Public Domain via Commons –


OK, she will not literally wrestle you to the ground but it may appear so at times. Pushing against your head, pressing down against your elbows, leaning hard against your leg-she will do everything to show she is stronger than you. Only if she fails will she score your power as grade 5/5-the best you can get. If you do not score full marks however you place the neurologist in a bit of a quagmire; a score between 0-5 is not always easy to allocate, and the obsessive neurologist may get in a bind and may give you marks such as 3+ or 4-. Just for fun let her win, and see her consternation!

9. Neurologists hit you with a hammer-in all sorts of places

Lego man and reflex hammer by Dr. Mark Kubert on Flikr.
Lego man and reflex hammer by Dr. Mark Kubert on Flikr.


The reflex hammer is perhaps the most well-recognised tool of the neurologist. These hammers come in all shapes and sizes, and some are really quite scary. People expect to have their knees tapped and look forward to what they have seen many times on TV-the leg kicking out. Most patients find this amusing. They are however often surprised  when the neurologist proceeds to use the hammer on their jaw, elbow, wrist and ankles. The then often bristle at having the soles of their feet stroked by the end of the hammer’s handle, a sharp uncomfortable end it is. All the hammer does is to stretch the tendons of muscles, and this elicits a reflex that causes the muscle to contract or tighten up. This response may be exaggerated (hypereflexia) if there is any problem in the central nervous system. Conversely the reflex response may be diminished (hyporeflexia) with problems of the peripheral nervous system.  Stroking the foot is called the Babinski response and gives a similar form of information to the neurologist. But beware the neurologist who then proceeds to stroke the side of your foot or squeeze your shins, all in an effort to get the same information-it is really an unnecessary and uncomfortable duplication of tests.

10. Neurologists prick and prod you with a sharp pin

Now this must take the cake, and quite rightly often comes at the end of the neurological examination. As threatening as this tests appears, this is probably the neurologist at his most acute. Using a sterile pin, the neurologist asks you to respond ‘yes’ if the sensation you perceive is sharp, and ‘no’ if it is dull. He then carefully proceeds to map out areas of reduced sensation or feeling, frowning as he struggles to keep track of your responses in his mind. He tries to establish if you have a glove and stocking pattern of sensory loss seen in peripheral neuropathy (nerve end damage). It may also be a dermatomal pattern seen with radiculopathy (trapped nerve in the spine). Unfortunately for the neurologist however many patients do not understand the rules of the game and give all sorts of unimaginable responses; not surprising when one is under the threat of a sharp pointy object!

"User-FastFission-brain". Licensed under CC BY-SA 3.0 via Wikimedia Commons -
“User-FastFission-brain”. Licensed under CC BY-SA 3.0 via Wikimedia Commons –


These are but a few of the bizarre doings of neurologists.  Seeing a neurologist soon? Be prepared-you have been warned!

PS. Images used in this blog post are for illustration purposes only and do not necessary depict the actual equipment used by neurologists. The examination steps described are however a good reflection of actual neurological practice.