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Daniel Kondziella · Gunhild Waldemar Neurology at the Bedside

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Daniel Kondziella · Gunhild Waldemar Neurology at the Bedside Daniel Kondziella · Gunhild Waldemar Neurology at the Bedside 123 Neurology at the Bedside Daniel Kondziella • Gunhild Waldemar Neurology at the Bedside Daniel Kondziella, MD, PhD, FEBN Gunhild Waldemar, MD, DMSC Department of Neurology Department of Neurology Rigshospitalet Rigshospitalet Copenhagen University Hospital Copenhagen University Hospital Copenhagen Copenhagen Denmark Denmark ISBN 978-1-4471-5250-7 ISBN 978-1-4471-5251-4 (eBook) DOI 10.1007/978-1-4471-5251-4 Springer London Heidelberg New York Dordrecht Library of Congress Control Number: 2013944580 © Springer-Verlag London 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword The days of textbooks are numbered but not for this one. In the modern computer age, most of our knowledge is gained online and the need for weighty textbooks is over. Much of our learning comes from clinical experience and seeing our col- leagues, senior and junior, at work. During the early stages of a neurologists’ career, there is a tremendous need for a reasonably short book which enables the beginner to grasp the whole span of the subject, a book which will provide a framework on which to graft their growing bedside experience. This is that book. It takes its stance at the bedside, be that the outpatient clinic couch or the hospital bed. The winning combination of junior neu- rologist Daniel Kondziella and senior professor Gunhild Waldemar covers the spec- trum from anatomy and physiology, through history and examination, to differential diagnosis, investigation, and treatment. Concise, clear, and written in impeccable English, each chapter could be consumed in an evening, leaving the reader with a sound basis for their clinical practice, further enquiry, and lifelong learning. Each generation needs its own text to tackle the problems of the modern era. This text is modern and full of wisdom. I warmly recommend it to the neurologist in training and the more senior neurologist who wants to match their knowledge against an authoritative template. London, 2013 Richard Hughes, MD, FRCP, FMedSci v Discl aimer Medicine, including neurology, is an ever-changing fi eld. As new research and clin- ical experience extends our knowledge, revisions of diagnostic procedures, treat- ment protocols, and drug therapy may become necessary. While the authors have made considerable efforts to describe generally accepted practices and to confi rm the accuracy of the data, they are not responsible for errors or omissions or for any consequences from application of the information in this publication. To the fullest extent of the law, neither the authors nor the publisher assumes any liability for any damage and/or injury to persons or property arising from this book. The application of the information in this book remains the professional responsibility of the practi- tioner. In particular, the reader is urged to confi rm the accuracy of the information relating to drug therapy by checking the most current product information provided by the drug manufacturer and by consulting other pharmaceutical literature to verify the recommended dose, the method and duration of administration, as well as pos- sible contraindications and drug side effects. The treating physician is responsible for the decision on dosages and the best available treatment for each individual patient. vii Acknowledgments The authors are grateful for the invaluable suggestions and comments to the manu- script made by Poul Brodersen, Siska Frahm-Falkenberg (Copenhagen), Fredrik Asztely (Gothenburg), and Lawrence A. Zeidman (Chicago). Further, the authors would like to thank Vibeke Andrée Larsen and Annika Reynberg Langkilde (Copenhagen) for their excellent help in providing many of the neuroimaging fi gures. The authors wish also to express their gratitude for the support and help they have received from their families during the writing of this book. Finally, the authors would like to thank all their patients and colleagues – you have taught us neurology, it is a pleasure working with you! Copenhagen, Denmark Daniel Kondziella Gunhild Waldemar ix Contents 1 What to Expect from This Book (and What Not to) . 1 2 Clinical History and Neuroanatomy: “Where Is the Lesion?” . 5 2.1 Muscle . 8 2.2 Neuromuscular Junction . 10 2.3 Peripheral Nerves, the Plexus, and Spinal Nerve Roots . 12 2.3.1 Peripheral Nerves . 14 2.3.2 Brachial Plexus and Lumbosacral Plexus . 23 2.3.3 Spinal Nerve Roots . 25 2.4 Spinal Cord . 27 2.4.1 Complete or Near-Complete Transection of the Spinal Cord . 29 2.4.2 Brown-Séquard Syndrome . 31 2.4.3 Anterior Cord Syndrome . 32 2.4.4 Dorsal Cord Syndrome . 33 2.4.5 Syringomyelia . 34 2.4.6 Central Cord Syndrome . 35 2.4.7 Conus Medullaris Syndrome . 35 2.5 Brainstem . 36 2.6 Cranial Nerves . 38 2.6.1 Olfactory Nerve . 38 2.6.2 Optic Nerve . 38 2.6.3 Oculomotor Nerve, Trochlear Nerve, Abducens Nerve . 41 2.6.4 Trigeminal Nerve . 48 2.6.5 Facial Nerve . 50 2.6.6 Vestibulocochlear Nerve . 53 2.6.7 Glossopharyngeal Nerve . 54 2.6.8 Vagus Nerve . 55 2.6.9 Spinal Accessory Nerve . 56 2.6.10 Hypoglossal Nerve . 57 2.7 Cerebellum . 57 xi xii Contents 2.8 Subcortical Gray Matter . 58 2.8.1 Basal Ganglia . 58 2.8.2 Diencephalon . 60 2.9 Subcortical White Matter . 61 2.10 Cortex. 65 2.10.1 Frontal Lobes . 66 2.10.2 Temporal Lobes . 68 2.10.3 Parietal Lobes . 70 2.10.4 Occipital Lobes . 72 2.11 Cerebrovascular System. 74 2.11.1 Anterior Circulation . 76 2.11.2 Posterior Circulation . 77 2.12 The Healthy Brain . 80 References and Suggested Reading . 81 3 Neurological Bedside Examination: “Can I Confi rm My Anatomical Hypothesis?” . 83 3.1 Cognitive and Mental Functions . 86 3.1.1 The History as Part of the Cognitive Examination . 86 3.1.2 Bedside Examination of Mental and Cognitive Functions . 90 3.1.3 General Neurological Examination in the Cognitively Impaired Patient . 93 3.2 Cranial Nerves . 94 3.3 Motor Function . 102 3.4 Sensory Function . 108 3.5 Cerebellar Function . 109 3.6 Gait . 110 3.7 System Overview . 112 3.8 Examination of the Comatose Patient . 116 3.8.1 Verifi cation and Quantifi cation of Unconsciousness . 117 3.8.2 Assessment of Neurological Defi cits, in Particular Signs of Brainstem Injury . 118 3.8.3 Neurological Causes for Coma . 120 3.8.4 Prognostication of Neurological Outcome Following Cardiac Arrest . 123 3.8.5 Diagnosis of Brain Death . 124 3.9 Examination of the Patient with an Acute Ischemic Stroke . 126 3.10 Examination of the Patient with an Epileptic Seizure . 127 3.10.1 Taking the History of a Patient with a Seizure . 127 3.10.2 The Examination and Management of a Patient with a Seizure . 129 3.11 Examination of the Patient with Functional/Nonorganic Defi cits . .130 References and Suggested Reading . 135 Contents xiii 4 Differential Diagnosis: “What Is the Lesion?” . 137 4.1 The Differential Diagnosis of Coma . 138 4.1.1 Structural Causes of Coma . 140 4.1.2 Non-structural Causes of Coma . 142 4.2 The Differential Diagnosis of Traumatic Brain Injury . 143 4.2.1 Assessing the Need for Observation and Imaging in Closed Head Injury . 144 4.3 The Differential Diagnosis of Headache . 146 4.3.1 Primary Headache Syndromes . 146 4.3.2 Symptomatic Headaches . 149 4.4 The Differential Diagnosis of Cognitive Impairment and Dementia . 152 4.4.1 Potentially Reversible Conditions . ..
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