Introduction Medical students trawl the hospital looking for clinical signs and are seemingly disappointed by the common acute neurological presentations to medical admissions units (MAU) of seizures and headaches. A delight however is a cranial neuropathy, and although less frequent, still probably present on an average of one per week to a large District General Hospital (DGH). Herein an acute cranial neuropathy case series, underlying aetiology and implications for clinical practice and teaching is described.

Methods Cases were ascertained in the MAU in a large DGH by a neurology registrar over a 12 month period.

Results A total of 25 patients were assessed and overall the commonest cranial neuropathy in the acute medical setting was an isolated oculomotor palsy (6), followed by a bulbar (6) and then an isolated abducent nerve palsy (5). Less common presentations included a trigeminal neuropathy (3), facial palsy (3) and hypoglossal nerve palsies (2). One patient had multiple cranial neuropathies. Vascular causes (12/25 cases; four oculomotor and four abducent) followed by malignancy (7/25 cases; three oculomotor, one facial, one hypoglossal) were the commonest identified aetiologies. Others included myasthenia gravis (2), motor neurone disease (2), idiopathic intracranial hypotension and a Bell's.

Conclusion This series suggests that although acute neurology is dominated by headaches and seizures, clinical examination and localisation skills are still essential and in the absence of vascular causes clinicians should have a low threshold for hunting for an underlying malignancy.