• Functions: executive function, motivation, personality, motor planning (primary motor cortex).
• Lesions:
o Disinhibition, apathy.
o Broca’s aphasia (dominant hemisphere): non-fluent, intact comprehension.
• Functions: sensory integration, visuospatial processing.
• Dominant hemisphere (usually left):
o Gerstmann syndrome: agraphia, acalculia, finger agnosia, left-right disorientation.
• Non-dominant hemisphere:
o Hemispatial neglect.
• Functions: memory (hippocampus), auditory processing.
• Lesions:
o Wernicke’s aphasia (fluent but nonsensical speech, poor comprehension).
o Visual field defect: superior quadrantanopia (“pie in the sky”).
• Functions: visual processing.
• Lesions:
o Homonymous hemianopia with macular sparing.
o Anton syndrome: cortical blindness with denial of visual loss.
o Early episodic memory impairment.
o MRI: medial temporal (hippocampal) atrophy.
o Biomarkers: ↓ CSF Aβ42, ↑ tau.
o Stepwise decline.
o Focal signs (e.g., hemiparesis).
o Strategic infarcts.
o Fluctuating cognition, detailed visual hallucinations.
o Parkinsonism.
o Neuroleptic sensitivity.
o Early personality and behavioural change (disinhibition, apathy).
o Language variants (primary progressive aphasia).
• Focal: often preceded by aura; can become generalised.
• Generalised: absence (3 Hz spike-and-wave), tonic-clonic, myoclonic.
First Seizure Work-up
• Blood glucose, electrolytes, calcium, renal and liver function.
• MRI brain (structural lesion exclusion).
• EEG (supportive, not diagnostic alone).
Drug Choices
• Valproate: broad-spectrum; avoid in women of childbearing potential (teratogenicity, PCOS risk).
• Lamotrigine: preferred in young women.
• Levetiracetam: fewer interactions; can cause mood disturbance.
Features
• Optic neuritis (painful visual loss, RAPD).
• INO: impaired adduction, abducting nystagmus.
• Sensory level, Lhermitte’s sign.
Diagnosis
• MRI: T2/FLAIR hyperintense periventricular lesions ("Dawson fingers").
• CSF: oligoclonal bands (intrathecal IgG synthesis).
Treatment
• Acute relapse: IV methylprednisolone.
• Long-term disease modification: interferon-beta, glatiramer acetate, natalizumab, fingolimod.
• Features: subacute onset memory deficits, psychiatric symptoms, seizures, dyskinesias.
• Anti-NMDA receptor encephalitis:
o Common in young women, ovarian teratoma association.
• Investigations: MRI (medial temporal hyperintensities), CSF (pleocytosis, oligoclonal bands), EEG (slow waves).
Extra Revision Pearls
• Pie in the sky defect clue → temporal lobe lesion
• Gerstmann syndrome clue → dominant parietal lobe lesion
• Hemineglect clue → non-dominant parietal lobe
• Fluctuating cognition + hallucinations clue → Lewy body dementia
• Painful visual loss clue → optic neuritis (MS)
• Young woman with psychosis + ovarian mass clue → NMDA receptor encephalitis
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
