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The
NEUROLOGY
BOOK
Ever
11
Need
TheOnlyNEUROLOGYBOOKYou’llEver Need
ALISONI.THALERMD MALCOLMS.THALERMD
AcquisitionsEditor:JoeCho DevelopmentEditor:ThomasCelona EditorialCoordinator:OliverRaj MarketingManager:KirstenWatrud SeniorProductionProjectManager:AliciaJackson Manager,GraphicArts&Design:StephenDruding ArtDirector,Illustration:JenniferClements Illustrator:TNQTechnologies SeniorManufacturingCoordinator:BethWelsh PrepressVendor:TNQTechnologies
Copyright©2023WoltersKluwer
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Thisworkisnosubstituteforindividualpatientassessmentbaseduponhealthcareprofessionals’ examinationofeachpatientandconsiderationof,amongotherthings,age,weight,gender,currentorprior medicalconditions,medicationhistory,laboratorydataandotherfactorsuniquetothepatient.The publisherdoesnotprovidemedicaladviceorguidanceandthisworkismerelyareferencetool. Healthcareprofessionals,andnotthepublisher,aresolelyresponsiblefortheuseofthisworkincluding allmedicaljudgmentsandforanyresultingdiagnosisandtreatments.
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shop.lww.com
Foreword
Inthisbook,Drs.AlisonI.ThalerandMalcolmS.Thalerhavemanagedtocompleteanalmost impossibletask:totakeaclinicaldisciplineascomplicatedasneurologyandbreakitdownintoits simpleanddigestiblecomponents.Youwilllearnaboutstroke,seizures,aneurysms,neuropathies, migraines,andallmannerofneurologicaldisease.Butyouwillalsolearntheapproachtothe neurologicalpatient,toldwiththevoicesofthosewhohavebeenthereandseenitall.Itisacompanion thatyouwantatyourside.
Intheearlyyearsofpreclinicaltraining,studentsareintroducedtotheendlesslycomplicated neuroanatomicalpathways.Later,whentheyenterthewardsandareconfrontedwithpatientssuffering fromneurologicaldiseaseorinjury,theycanfinditdifficulttoputthosepathwaysintoclinicalpractice. Howshouldyouapproachapatientwhopresentswithaneurologicalproblem?Whenpatientstellyou thattheyhaven’tbeenabletomovetheirrightlegforthepasttwohours,whatshouldyoudo?How worriedshouldyoube,andshouldyoucallforhelp?Whatmightbegoingon,andwhatkindsofdisease processesmightleavethepatientdevastatedifyoudon’treactquicklyandappropriately?Thisbook providesyouwiththecriticaltoolsthatyou’llneedtobeabletothinkthroughquestionsliketheseina clearandconcisemanner.
Thisisnotatextbookinneurology.Itisnotanencyclopedicreviewofneuroanatomyor pathophysiology.Instead,ithighlightswhatyouneedtoknow—asathird-yearmedicalstudentstudying fortheshelf;aneurologyresidentpreparingfornightfloat;oranurse,physician’sassistant,orphysician facedwithevaluatingandtreatingneurologicdisease.Therelevantneuroanatomyandpathophysiology arebroughttolifeandgivenclinicalcontext.
Looktothisbookforpearlsaboutwhattodoinvariousclinicalscenarioshowtotriage,howtogeta senseofwhichkindsofneurologicalpresentationsareemergenciesandwhichcanwaituntilthenextday totrytofigureout.Youwilllearnhowtodiagnoseandtreatthesepatientsinastraightforwardand alwaysevidence-basedmanner.Andwhilelearningabouttheseneurologicalconditions,youwillalsobe takenonawonderfultourofthefundamentalsofclinicalneurology.
MichaelFara,MD,PhD
AssistantProfessorofNeurology
InterimDirector,StrokeCenteratMountSinaiHospital
IcahnSchoolofMedicineatMountSinai
NewYork,NewYork
StevenGaletta,MD
ChairoftheDepartmentofNeurology
ProfessorofNeurologyandNeuro-Ophthalmology
NYUGrossmanSchoolofMedicine
NewYork,NewYork
https://t.me/med1917
Preface
Neurologyhasthereputation—well-deserved,ifperhapsoverstated—ofbeinghard.Fascinating—yes. Intellectuallystimulating—ofcourse.Worththeinvestmentintimeandoverworkedneurons—withouta doubt!Buthard.Sothat’swhywe’rehere,andwhywecreatedthisbook.Nottomakeiteasy—that wouldbeaclaimyoucouldseethroughfromamileaway—buttomakeiteasier.Tohelpyoumakesense ofitall.Totakeallthatanatomyandphysiology,allthosesyndromesandcategoriesandtreatment protocols,andwrapthemupintomanageablebundlesthatareclear,concise,andpractical.Andwhile we’reatit,wearegoingtomakeitfun.No,really.Wepromiseyouaregoingtoenjoymasteringthis material(OK,weadmitthatmemorizingthebrachialplexusmaynotbeyouridealversionoffun,butwe willdoourbest!).
Thisbookisdifferentfromotherneurologybooksyoumayhaveencountered.Thetextis conversational.Therearetonsofillustrationsandimages.Clinicalpearls—thekindsofthingsyouwon’t findinotherbooks—aresprinkledliberallythroughout.Mostimportantly,wefocusonthoseelementsof neurologythatmattermostforpatientcare.Ourgoalisnottoimpressyouwithvastquantitiesof neuroanatomicesoterica;rather,wewillstressoverandoveragainthebasicprinciplesunderlying neurologicdiagnosisandmanagement.
Andthereissomethingelsethatwebelievemakesthisbookspecial.Itoffersadualperspectiveon neurology.Oneofusisaneurologist,theotheraninternist.Bothofusdevotealargeportionofourtime toacademicclinicalteaching.Bycombiningtheperspectivesofourtwospecialties,wecansharewith youthemostreal-lifeandup-to-datedetailsthatonlyaneurologistwouldknow,aswellasthebroader perspectiveandpatient-orientedapproachthatisaninternist’sstockintrade.Wedigdeepwhenwehave toandthenpullbacktomakesurethateverythingwediscussisclinicallyrelevantandpatientcentered.
Thisbookcanandshouldbeuseddifferentlydependingonwhoyouareandwhatyouwantoutofit.It coverseverythingyouneedforthemedicalstudentshelfexaminationbutattimesgoesaboveandbeyond, soifyouwantonlystreamlinedandtestablematerial,focusontheflashcardsinthecompanionebookand boldedtopicsinthetext;usetherestofthebookasareference,tohelpclarifywhensomethingdoesn’t makesense,whenyoufindyourselfwantingtoknowmoreaboutaparticulartopic,orwhenyouneedto prepareapresentationforrounds.Forpreliminaryinternsandjuniorneurologyresidents,readitcover­to-cover.Wehavedoneourbesttomakesureitreadslightlyandquickly(atleastasfarasmedical textbooksgo!),anditcontainseverythingwewishwe’dknownatthestartofourcareers.Youwillbeas wellpreparedforneurologyresidencyasispossible,wepromise.Andfornon-neurologytrained physicians,nurses,NPAsandPAswhotreatpatientswithneurologicillness,keepthisbyyoursideasa companion—aneasilydigestiblewhat-you-really-need-to-knowguidetothediagnosisandmanagement ofneurologicdisease.
https://t.me/med1917
Wecan’tletyougetstartedwithoutfirstacknowledgingalloftheextraordinarycliniciansand academicianswhoreviewedourchapters,offeredtheirsubspecializedwisdom,rolledtheireyesattimes butwerealwayskind,supportive,andasexcitedaboutthisbookasweare.Inparticular,wewantto thankDrs.LauraStein,MichaelFara,StephenKrieger,RajeevMotiwala,SusanShin,JoannaJen,Allison Navis,MarkGreen,AnnaPace,AnuradhaSingh,CarolineCrooms,NoamHarel,AmyChan,Praveen Raju,JoshuaFriedman,BenjaminBrush,KennethLeung,EmilySchorr,andStevenGaletta.Wecouldn’t havedonethiswithoutyou.WealsowanttothanktheamazingfolksatWoltersKluwerwhosawthisbook throughfrominceptiontoreality:SharonZinner,LindsayRies,OliRaj,ThomasCelona,ChrisTeja,Joe Cho,andtheincrediblytalentedartistsatTNQ.Andlastly,wewanttoexpressourgratitudetoour studentsformakingusbetterteachers,andourpatientswhoeverydaymakeusbetterhumanbeings.
Wededicatethisbooktoourfamilies.Itisatiresomeclichetostatehowtheystoodbyusevenaswe drovethemcrazywithallthetimeandenergywedevotedtothisproject,butclichesareclichesfora reason.SothankyouBenandNancyandJonandTracey—weloveyou,couldn’tlivewithoutyou,and promisewewillbebackintouchassoonaswefinishplottingoutthenextedition!
AlisonI.Thaler
MalcolmS.Thaler
https://t.me/med1917
Contents
Chapter1
Let’sGetStarted:YourNeurologicToolbox
CASE1
Neuroanatomy:TheBasics
ElectrophysiologyinTwoPages
TheGoodNews! TheNeurologicHistory TheNeurologicExamination
MentalStatus CranialNerves TheMotorSystem TheSomatosensorySystem Reflexes Coordination Gait
NoteTemplate:AnExampleofHowYouMightDocumentaNormalNeurologicExamination IsitNeurologic? DiagnosticTools
AQuickOverviewofHeadImaging
LumbarPuncture
Electroencephalography
NerveConductionStudiesandElectromyography
CASE1:FOLLOW-UP
Chapter2
StrokeandCerebrovascularDisease
CASE2
BadNewsButGoodNewsToo TheBasics CerebrovascularAnatomy IschemicStroke
Etiology
StrokeSyndromes
Management IntracerebralHemorrhage(ICH)
Symptoms
Etiology
Management SubarachnoidHemorrhage(SAH)
Presentation
Diagnosis
TreatmentandComplications AFewOtherCerebrovascularDisorderstoKnow
CervicocephalicArterialDissection
https://t.me/med1917
CerebralVenousSinusThrombosis
ReversibleCerebralVasoconstrictionSyndrome(RCVS)
Vasculitis
CASE2:FOLLOW-UP
Chapter3
Headache
CASE3
HeadacheRedFlags PrimaryHeadacheDisorders
Migraine
Tension-typeHeadache
TrigeminalAutonomicCephalalgias(TACs)
SinusHeadache
Neuralgias
EpisodicVersusChronicHeadache SecondaryHeadacheDisorders
MedicationOveruseHeadache(MOH)
GiantCellArteritis(GCA)
SpontaneousIntracranialHypotension(SIH)
PseudotumorCerebri
PosteriorReversibleEncephalopathySyndrome(PRES)
CardiacCephalalgia Post-traumaticHeadache
TheGeneralApproachtotheHeadachePatient
CASE3:FOLLOW-UP
Chapter4
Concussion(akaMildTraumaticBrainInjury)
CASE4
IsItMildorSevere? SoWhatIsaConcussion? Sports-relatedConcussion PostconcussionSyndrome ChronicTraumaticEncephalopathy
CASE4:FOLLOW-UP
Chapter5
Dizziness
CASE5
ASimpleWaytoCategorizeDizziness Vertigo:AnOverview
Anatomy
PeripheralVersusCentralVertigo PeripheralVertigo CentralVertigo
ABriefWordonSyncope
CASE5:FOLLOW-UP
Chapter6
Seizures
CASE6
Epilepsy
ProvokedVersusUnprovokedSeizures
https://t.me/med1917
WhatConditionsIncreasetheRiskofRecurrenceAfteraSingleSeizure?
First-TimeSeizure SeizureTypes
AQuickNoteontheDifferentialDiagnosisofSeizures SeizureEtiology
EpileptogenicLesions
Toxic-MetabolicDerangements
MedicationsandOtherSubstances
EpilepsySyndromes Anti-EpilepticDrugs(AEDs)
StatusEpilepticus PsychogenicNonepilepticSeizures(PNES)
CASE6:FOLLOW-UP
Chapter7
NeurocognitiveDisordersandDementia
CASE7
CognitiveImpairment Dementia(akaMajorNeurocognitiveDisorder)
AlzheimerDisease(AD)
VascularDementia
DementiaWithLewyBodies(DLB)
FrontotemporalDementia(FTD)
PrionDiseasesandCreutzfeldt-JakobDisease ReversibleDementias
CASE7:FOLLOW-UP
Chapter8
Meningitis,Encephalitis,andOtherInfectiousDiseasesoftheNervousSystem
CASE8
Meningitis
BacterialMeningitis
OtherCausesofMeningitis
ChronicMeningitis Encephalitis
AnOverview
HerpesEncephalitis
Arthropod-BorneEncephalitis HIVInfection:NeurologicComplications
Neurosyphilis LymeDisease:NeurologicManifestations COVID-19:NeurologicManifestations AFewOtherCNSInfectionstoKnowAbout
Neurocysticercosis
Leprosy
Poliomyelitis
Botulism BrainAbscess
CASE8:FOLLOW-UP
Chapter9
MultipleSclerosis(andOtherImmunologicDiseasesoftheCentralNervousSystem)
CASE9
MultipleSclerosis(MS)
SomeBasicBackgroundFacts
https://t.me/med1917
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