A Concise and Succinct Guide to Neurology! Illustrated in Full Color This full-color guide to the essentials of neurology provides Adams Mayo Clinic practicing clinicians and students with one of the most focused Throughout presentations in the field today. Essential Neurology MAYO CLINIC ESSENTIAL NEUROLOGY covers the full scope of neurology by combining a focused need-to-know format with core knowledge Andrea C. Adams, MD as well as diagnosis and treatment guidelines. More than 75 color illustrations and numerous therapeutic tables help you diagnose, treat, and manage the Clinic Essential Neurology Mayo most commonly encountered neurologic problems. TOPICS INCLUDE: • The Neurologic Examination • Cognitive Loss • Diagnostic Tests • Spells • Headache • Pain • Spine and Limb Pain • Cerebrovascular Disease • Dizziness • Movement Disorders • Sensory Loss and Paresthesias • Immune and Infectious Diseases • Weakness • Neuro-oncology The perfect introduction for medical students, and a great daily reference for residents and clinicians, Mayo Clinic Essential Neurology’s current and consultative full-color format provides a fresh alternative to the current library of neurology references in print today. ABOUT THE AUTHOR ANDREA C. ADAMS, M.D., is a Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota, and Assistant Professor of Neurology, College of Medicine, Mayo Clinic. MAYO CLINIC SCIENTIFIC PRESS Mayo Clinic Essential Neurology Andrea C. Adams, MD Mayo Clinic Essential Neurology Andrea C. Adams, MD Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, College of Medicine, Mayo Clinic MAYO CLINIC SCIENTIFIC PRESS AND INFORMA HEALTHCARE USA, INC ISBN-13 9781420079739 The triple-shield Mayo logo and the words MAYO, MAYO CLINIC, and MAYO CLINIC SCIENTIFIC PRESS are marks of Mayo Foundation for Medical Education and Research. ©2008 Mayo Foundation for Medical Education and Research. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the prior written consent of the copyright holder, except for brief quotations embodied in critical articles and reviews. Inquiries should be addressed to Scientific Publications, Plummer 10, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. For order inquiries, contact Informa Healthcare, Kentucky Distribution Center, 7625 Empire Drive, Florence, KY 41042 USA. E-mail: [email protected]. www.informahealthcare.com Library of Congress Cataloging-in-Publication Data Mayo Clinic essential neurology / Andrea C. Adams. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-4200-7973-9 (pbk. : alk. paper) ISBN-10: 1-4200-7973-5 (pbk. : alk. paper) 1. Neurology--Handbooks, manuals, etc. 2. Nervous system--Diseases-- Handbooks, manuals, etc. 3. Neurologic examination--Handbooks, manuals, etc. I. Adams, Andrea C., 1955- II. Mayo Clinic. III. Title: Essential neurology. [DNLM: 1. Nervous System Diseases--diagnosis--Handbooks. 2. Diagnostic Techniques, Neurological--Handbooks. 3. Nervous System Diseases--physiopathology--Handbooks. 4. Nervous System Diseases--therapy--Handbooks. WL 39 M478 2008] RC355.M39 2008 616.8--dc22 2007049858 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from appli- cation of the information in this book and make no warranty, express or implied, with respect to the contents of the pub- lication. This book should not be relied on apart from the advice of a qualified health care provider. The authors, editors, and publisher have exerted efforts to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the heath care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. About the Cover The cover is a camera lucida drawing of a 160-μm–thick section of part of the striatum and adjoining globus pallidus. Brain tissue from a 19-day-old rat was processed according to the rapid Golgi method, which selectively impregnates neuronal cell bodies, dendrites, and axons. The cells on the left of the dashed line are medium spiny neurons typical of the striatum. They are the target of the dopaminergic axons that arise in the substantia nigra. Degeneration of these dopaminergic axons alters the function of the medium spiny neurons, leading to Parkinson disease. The medium spiny neurons send axons to neurons in the globus pallidus (cells on the right). These striopal- lidal axons form the fiber bundles that cross the section diagonally. The pal- lidal neurons are larger than the medium spiny neurons and have fewer but longer and thicker dendrites; their axons form the major efferent pathways of the basal ganglia. Image from Millhouse, OE: Pallidal neurons in the rat. J Comp Neurol 254:209-227, 1986. Used with permission. v To Gene and Maude vii Foreword The field of neurology continues to evolve rapidly. Treatment options are increasing in number and improving in efficacy, diagnostic imaging allows us to see more detail in a noninvasive manner, and there are few areas of the field not affected by the tools of molec- ular genetics. Despite all this, it is the clinical interaction with the patient—the history and examination—that continues to be the underpinnings of the specialty. It is within this framework that Mayo Clinic Essential Neurology, by Dr. Andrea Adams, has a promi- nent role on the desk or bookshelf. The book has been written by a most experienced neurology clinician-educator. As a highly regarded educator in a large neurology residency program and medical school basic neuroscience course and as a neurologist involved in the evaluation and manage- ment of patients with virtually all symptoms and disease types, she has made use of her wealth of experience in developing this textbook. The text, tables, figures, and images are a concise source of information that will be useful to the neurologist or nonneurol- ogist evaluating patients with a wide array of neurologic conditions and symptoms, as seen in the office or hospital. It also is a superb review text for neurology in-service exami- nations and the neurology boards. For nonneurologists, Mayo Clinic Essential Neurology contains a wealth of information presented in a learner-friendly manner that will demys- tify many aspects of the evaluation and management of neurologic problems encountered in most any field of medicine. I congratulate Dr. Adams on the completion of this textbook and thank her for her dedication to the education of those interested in the field of neurology across the spec- trum of specialties and levels of experience and for making a major impact on the care of our patients by sharing her knowledge in this manner. Robert D. Brown, Jr, MD, MPH Chair, Department of Neurology, Mayo Clinic Professor of Neurology, College of Medicine, Mayo Clinic Rochester, MN ix Preface Mayo Clinic Essential Neurology is intended to provide succinct and essential neu- rologic information. Because time is a rare commodity for physicians, the text, tables, and illustrations have been designed to provide information quickly and concisely. The book is similar to the earlier Neurology in Primary Care. The book consists of three sections: the neurologic examination and diagnostic testing, common neurologic symptoms, and common neurologic diseases. Neurology is a rapidly changing specialty, with an increasing number of therapeutic options available for managing neurologic disease. Neurologic symptoms such as headache, backache, and dizziness are frequent complaints that cause patients to seek medical care. Mayo Clinic Essential Neurology is designed to provide clinicians the necessary neuro- logic information for the diagnosis and management of these common neurologic problems. This book will be useful to all clinicians who evaluate patients who have neurologic problems. It will be useful for medical students and residents in neurology, internal med- icine, and psychiatry. The book also will be helpful to paramedical personnel who need a concise source of information on outpatient neurologic practice. I want to thank O. Eugene Millhouse, PhD, Roberta J. Schwartz, Virginia Dunt, Traci Post, and Ann Ihrke of the Section of Scientific Publications for their conscientious help in editing and preparing the manuscript for publication. I also want to thank Jonathan Goebel, Karen Barrie, James J. Tidwell, and Jim Postier for their expert help with the illustrations. Thanks also to Doctors Marian McEvoy and Mark Pittelkow and the Department of Dermatology. Special thanks to my colleagues