Neurologic Disorders: Localize, Then Prognosticate
Localize, then prognosticate
Every neurologic question gets easier if you first name the lesion and then the functional consequence. Stroke: know the thrombolytic window (up to 4.5 h in selected patients) and thrombectomy eligibility, but rehabilitation questions focus on syndromes - MCA (contralateral hemiparesis, aphasia, hemi-inattention), PCA (homonymous hemianopia), lacunar (pure motor or pure sensory), basilar (locked-in). Pusher syndrome and hemi-inattention predict slower gait recovery and are not the same as simple weakness. Traumatic brain injury: memorize Rancho Los Amigos levels in order (I no response, II generalized, III localized, IV confused-agitated, V confused-inappropriate, VI confused-appropriate, VII automatic-appropriate, VIII purposeful-appropriate); agitation at level IV is expected, not a psychiatric diagnosis. Spinal cord injury: the ASIA examination defines the neurologic level as the most caudal segment with intact sensation and antigravity strength, and sacral sparing (anal sensation, deep anal pressure, voluntary anal contraction) separates complete from incomplete injury. AIS B is sensory incomplete with no motor preservation more than three levels below the motor level on either side. Multiple sclerosis: fatigue and heat sensitivity (Uhthoff phenomenon) are the classic traps; exercise is beneficial, not harmful. Guillain-Barré: monitor vital capacity and autonomic instability, treat with IVIG or plasma exchange - not steroids. Parkinson disease: time levodopa to function and expect freezing and postural instability to respond poorly.
Rule of thumb
For prognosis, motor completeness at 72 hours and sacral sparing predict ambulation better than imaging: AIS A cervical injuries rarely walk, while AIS C injuries often do.