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Practicing Neurology C URRENT CLINICAL N EUROLOGY Daniel Tarsy, MD, SERIES EDITOR Stroke Recovery: Cellular and Genetic Therapies, edited by Daniel M. Rosen- baum and Sean I. Savitz, 2007 Practicing Neurology: What You Need to Know, What You Need to Do, Second Edition, by Rahman Pourmand, 2007 Sleep Disorders in Women: From Menarche Through Pregnancy to Menopause, edited by Hrayr P. Attarian, 2006 Diagnostic Criteria in Neurology, edited by Alan J. Lerner, 2006 Psychiatry for Neurologists, edited by Dilip V. Jeste and Joseph H. Friedman, 2006 Status Epilepticus: A Clinical Perspective, edited by Frank W. Drislane, 2005 Thrombolytic Therapy for Acute Stroke, Second Edition, edited by Patrick D. Lyden, 2005 Parkinson’s Disease and Nonmotor Dysfunction, edited by Ronald F. Pfeiffer and Ivan Bodis-Wollner, 2005 Movement Disorder Emergencies: Diagnosis and Treatment, edited by Steven J. Frucht and Stanley Fahn, 2005 ,QÁDPPDWRU\'LVRUGHUVRIWKH1HUYRXV6\VWHPPathogenesis, Immunology, and Clinical Management, edited by Alireza Minagar and J. Steven Alexander, Practicing Neurology What You Need to Know, What You Need to Do Second Edition By Rahman Pourmand, MD Department of Neurology, Stony Brook University Hospital, Stony Brook, NY © 2008 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or WUDQVPLWWHGLQDQ\IRUPRUE\DQ\PHDQVHOHFWURQLFPHFKDQLFDOSKRWRFRS\LQJPLFURÀOPLQJ recording, or otherwise without written permission from the Publisher. All papers, comments, opinions, conclusions, or recommendations are those of the author(s), DQGGRQRWQHFHVVDULO\UHÁHFWWKHYLHZVRIWKHSXEOLVKHU Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contribu- tors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Not- withstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. d ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials. For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699; Fax: 973-256-8314; E-mail: [email protected], or visit our website: http://humanapress.com Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of VSHFLÀFFOLHQWVLVJUDQWHGE\+XPDQD3UHVV,QFSURYLGHGWKDWWKHEDVHIHHRI86SHUFRS\ is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for XVHUVRIWKH7UDQVDFWLRQDO5HSRUWLQJ6HUYLFHLV>@ 3ULQWHGLQWKH8QLWHG6WDWHVRI$PHULFD Library of Congress Cataloging in Publication Data E-ISBN: 978-1-59745-297-7 Pourmand, Rahman. Practicing neurology : what you need to know, what you need to do / by Rahman Pourmand. -- 2nd ed. p. ; cm. -- (Current clinical neurology) Includes index. ISBN 1-58829-609-1 (alk. paper) 1. Neurology--Handbooks, manuals, etc. 2. Nervous system--Diseases--Handbooks, manuals, etc. I. Title. II. Series. [DNLM: 1. Nervous System Diseases--diagnosis--Handbooks. 2. Nervous System Diseases-- WKHUDS\+DQGERRNV:/3S@ RC346.P68 2007 Series Editor’s Introduction The neurological examination and neurologic differential diagnosis are all too often regarded as daunting because of their perceived complexity by physicians in training as well as by more mature practicing doctors. Neu- URORJLFDOH[DPLQDWLRQVDVGRFXPHQWHGLQKRVSLWDORURIÀFHUHFRUGVRIWHQ EHWUD\WKLVSHUFHSWLRQE\WKHLUIUHTXHQWEUHYLW\DQGODFNRIVLJQLÀFDQWDQG useful information. Practicing Neurology, now in its 2nd edition, is meant for the non-neurologist and seeks to demystify this traditional view of the neurological evaluation. As indicated by the author, medical students and non-neurology residents wish to learn how to carry out a good neurological H[DPLQDWLRQKRZWRSURSHUO\LQWHUSUHWDEQRUPDOQHXURORJLFDOÀQGLQJVKRZ to formulate the clinical problem, what tests and procedures to consider, and how to begin to treat neurological disorders. In order to achieve these goals, Dr. Pourmand takes as his jumping off point the fact that the experienced neurologist typically tailors his exami- QDWLRQWRWKHVSHFLÀFSUREOHPSUHVHQWHGE\WKHSDWLHQW(DFKH[DPLQDWLRQ is different and emphasizes what is important for that particular patient while taking care not to neglect other important parts of the evaluation. The ‘focused’ or ‘directed’ neurological examination is what often emerges. By contrast, the beginner usually commits himself to doing the full and com- prehensive examination and elaborating all-inclusive differential diagnosis lest some important detail be inadvertently omitted. For the neophyte this is probably as it should be but at some point, with a bit of experience, it becomes possible and even necessary to plot a shorter road to correct diag- nosis and management. This volume helps to chart a path to that goal by outlining the essential but inclusive neurological examination including tips on what is important, ZKDWFDQVRPHWLPHVEHGLVSHQVHGZLWKDQGWKHSDUWLFXODUVLJQLÀFDQFH RIPDQ\ÀQGLQJV7KLVLVIROORZHGE\WKHGLDJQRVWLFIRUPXODWLRQZKLFK emphasizes the traditional ‘where and what is the lesion’ and a list of WUDGLWLRQDOQHXURORJLFDOVLJQVDQGWKHLUVLJQLÀFDQFH%ULHIEXWYHU\XVHIXO primers concerning neurological localization and common neurological constructs let the non-neurologist in on many useful tricks of the trade which are second nature to the neurologist in many useful tricks of the v vi Series Editor’s Introduction trade which are second to the neurologist but usually quite foreign to the non-neurologist. Useful focused sections on the approach to common neu- rological conditions and neurological urgencies and emergencies follow that provide additional invaluable lessons for the non-neurologist. Daniel Tarsy, MD Department of Neurology Beth Israel Deaconess Medical Center Harvard Medical School Boston MA Preface When medical students and non-neurology residents rotating through the neurology service are asked about their expectations, their responses are uniform: They want to learn how to conduct effective neurologic examina- tions, they want to know the value and indications of neurologic procedures and testing, and they want to know how to evaluate and manage common neurologic conditions. This book addresses those topics. After practicing neurology for more than 20 years in an academic setting, I believe I have met the expectations of my students, so I decided to put it in writing for others as well. In my opinion, knowing or reading thousands of pages of textbooks is not only impossible but also unnecessary to diagnose and treat the common neurologic conditions that physicians encounter in day-to-day practice, whether in the hospital, clinic, or emergency room. The second edition of this book again summarizes what and how much you need WRNQRZDQGGRWRFRQÀGHQWO\GLDJQRVHDQGPDQDJHPRVWQHXURORJLFFDVHV <RXGRQRWKDYHWREHDJHQLXVWRÀJXUHRXWZK\DSDWLHQWKDVIRRWGURS 7KHERWWRPOLQHLVWKDWQHXURORJ\LVQRWGLIÀFXOWLWMXVWWDNHVORQJHUWRGR and requires mental exercises to reach the diagnosis. This handbook makes neurology easy, stimulating, and fun. Rahman Pourmand, MD vii A Viewpoint from a Medical Student There is no doubt (at least in my mind) that the brain is the most mysteri- ous and fascinating organ in the body. This one organ is essentially who we are and what makes each of us unique. As a fourth year medical student, I know that other medical students frequently view the subject of neurology as complicated and abstract. The great strength of this book rests with the DXWKRU·VFOHDUDQGFRQFLVHH[SODQDWLRQVRIGLIÀFXOWQHXURORJLFDOWRSLFV7KLV small, easy to carry book somehow manages to cover all of the essential topics that we are expected to know about in neurology and it does so in a fun way that invites you to keep reading. I had no problem completing the book during my clerkship in neurology. The ability to perform a solid and thorough neurological exam is the core of what a medical student should master in their neurology rotation. This book accomplishes this task with its thorough explanation of all the components of the