Neurology a clinician’s approach 2016

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Andrew Tarulli Neurology A Clinician’s Approach Second Edition 123 Neurology Andrew Tarulli Neurology A Clinician’s Approach Second Edition Andrew Tarulli Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA ISBN 978-3-319-29630-2 ISBN 978-3-319-29632-6 DOI 10.1007/978-3-319-29632-6 (eBook) Library of Congress Control Number: 2016931864 © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms 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 The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland To my wife, Susan, and my daughter, Madeline Foreword A month before I started my neurology residency, a copy of Andrew’s book was given to me by the departing neurology chief residents Attached was a letter, the thinly veiled point being that this should be read (and possibly re-read) prior to starting the junior year What an invaluable early influence it became Perhaps so much so, in fact, that I now find it hard to remember a time when my cognitive framework for analyzing a patient’s complaint seriously differed from that which Andrew’s book provides Therein lies its strength; as the title suggests, this really gives the student an insight into the clinician’s approach Clinical reasoning is the absolute bedrock of neurology; knowledge of a thousand obscure diagnoses or mastery of neuroradiology or neuropathology is useless unless there is a level-headed approach to using the history and a focused exam to sort out a complaint Though there are many published compendia of facts, no other book provides this conceptual framework of learning how to think properly at a level which can be accessed by the medical student or junior resident They need to be taught how to think like a neurologist from the start This niche, crucially important, is rarely filled I had the privilege of being the chief resident on the stroke service in July and when my junior residents arrived, they asked me which books they ought to buy I gave them a long list, but I made sure to explain why Andrew’s should be the first to be read I think that is true for any medical student, future neurology resident (or current resident who has not done so), and internist Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA Marc Albert Bouffard, M.D vii Foreword Since the time of Hippocrates, there has always been, and there probably always will be an element of apprenticeship in learning to be a physician: both figuratively, in that by reading a single-author text we absorb the condensed insights of an experienced predecessor, and quite literally since the art of history taking and technique of the physical exam cannot truly be grasped from reading alone In neurology in particular, where even today modern imaging and sophisticated electrophysiology cannot supplant a careful history and exam, our clinical skills are a composite of what we once saw particularly well demonstrated by one or another of our teachers, adapted to and modified by our own needs and experiences We are always indebted to the ones who taught us At the very beginning of my neurology training, I was doubly fortunate to work with Andrew as the first attending on my first month on the neurology wards and, at nearly the same time, to read Neurology A Clinician’s Approach as my first clinical neurology book in residency The move from the previous year of medical internship to neurology proper was at first exciting, even exhilarating (it was, after all, my chosen field) but even so it was not easy The year in internal medicine was of course an important preparation in many ways It taught me the mechanics of being a doctor and an understanding of the inner workings of the hospital, and it certainly provided a solid clinical foundation Nevertheless, it could not have prepared me for the subtleties and complexities of clinical neurology, where the difference between a trivial condition and a malignant brain disease sometimes hinges on the size of a pupil or the exact pattern of weakness in a limb From big textbooks to online databases, there was certainly no lack of information, and everyone from my chief residents to Dr Clifford Saper, the neurologist-in-chief, was handing out papers and references But where was the key to all this knowledge? Andrew’s book provided exactly the guidance I needed at this time of transition—to paraphrase William Osler, it became the first chart to help me sail the sea of neurology It went straight to the point: here were the 23 most common neurological chief complaints and diseases, and practical approaches to each one of them Just like Andrew’s personal teaching, his writing is easy to follow and logical in its organization, and while always concise, it does not shy away from ix 421 Index Gait disorders antalgic gait, 282 ataxic gait, 281 difficulties, 55 examination, 198–199 frontal gait, 280 general neurologic examination, 280 heel and toe walking, 278 multifactorial gait disorder, 282 natural gait, 277–278 Parkinsonian gait, 280–281 parkinsonism, 196 provocative maneuvers, 278 proximal weakness, 154 PSP gait, 281 psychogenic gait, 282 pull test, 279 recommendations, 283 Romberg sign, 279 spastic gait, 280 steppage gait, 281–282 stress gait, 279 tandem gait, 279 Trendelenburg and Gowers sign, 278 waddling gait, 281 Galantamine, 66 Gamma-knife radiosurgery, 393 Gammopathy, 237 Ganglionopathy, 234 Gastrocnemius, 151 GBS See Guillain–Barre syndrome (GBS) Generalized pain disorders, 243, 244 Generalized tonic–clonic seizure (GTCS), 309–310, 314 Glasgow coma score (GCS), 369, 370 Glatiramer acetate, 388–389 Gliomas deterioration, 402 low-grade, 402 meningiomas, 403–404 multiple sclerosis, 406 radiation necrosis, 403 radiation-induced pseudoprogression, 402 recurrence, 402 Global aphasia, 48 Globus pallidus interna (GPi), 203 Glossopharyngeal nerves, dysphagia, 129–130 Glossopharyngeal neuralgia facial pain, 304–305 MRI, 305 Glucose imbalance, seizures, 317 Gowers sign, 278 GTCS See Generalized tonic–clonic seizure (GTCS) Guillain–Barre syndrome (GBS), 184 albuminocytologic dissociation, 187 neurophysiologic hallmark, 185 H Hallucinations, 205 Haloperidol, 21 Hand and finger weakness C8–T1 radiculopathy, 175 cerebral causes, 175 motor neuron disease, 175 ulnar neuropathy, 174 Hashimoto encephalopathy, 78 Headache alleviating factors, 288 aura, 287 carotid artery dissection, 291–292 character, 286 chronic daily headache, 302–303 CVST, 293–294 diurnal variation, 286 duration, 286 epidemiology, 285 etiology, 285 exacerbating factors, 287–288 frequency, 288 hypertensive encephalopathy, 295 lifestyle modifications, 296 medication-related, 299 meningitis, 294 migraine, 293, 296–297 neurologic symptoms, 287 occipital neuralgia, 300 pituitary apoplexy, 292 post-lumbar puncture, 300 in pregnancy, 303 prior evaluation and treatment, 288–289 pseudotumor cerebri, 294–295 rapidity of onset, 286 RCVS, 292 SAH, 289–290 secondary to mass lesions, 294 severity and disability level, 288 status migrainosus, 301–302 TACs, 298 cluster headache, 298 paroxysmal hemicrania, 299 SUNCT, 299 temporal arteritis, 293 tension, 297–298 (see Tension headache) visual strain, 299 Head-thrust test, 139 Hearing loss, 136 422 Heel–knee–shin test, 137 Hemicraniectomy, 358 Hemifacial spasm, 225 Hemiparesis, 180 Hemiplegia, 180 Hemodialysis, 323 Heparin, 367 Hepatic encephalopathy, 11, 317 Hereditary neuropathy with liability to pressure palsies (HNPP), 182 Hereditary spastic paraplegia (HSP), 271 Herniated nucleus pulposus, 264–265 Herpes simplex virus-1 (HSV-1), 14 Herpes simplex virus-2 (HSV-2), 15 Herpes zoster, 306 Highly active antiretroviral therapy (HAART), 72 Hip and proximal leg weakness L2–3 radiculopathy, 176–177 lumbosacral plexopathy, 177 Hollenhorst plaques, 349 Homonymous hemianopsia, 85 Homonymous upper quadrantanopsia, 90–91 Horizontal nystagmus, 138 Horizontal-torsional nystagmus, 138 Human immunodeficiency virus (HIV), 15, 238 dementia, 72 Human T-cell leukemia virus (HTLV), 270 Huntington disease (HD), 197, 220, 221 Hyperacute ischemic stroke acute anticoagulation, 357 acute antiplatelet therapy, 356 blood pressure management, 357 clot retrieval devices, 356–357 intravenous rt-PA, 354–356 surgical treatment, 357, 358 Hypercarbia, 38 Hyperglycemia stroke, 347 supportive care, 364 Hyperintensity, 14, 15 Hyperkinetic movement disorders abnormal facial movements, 225 jerking movements, 216–219 stiffness and cramping, 223–225 tardive dyskinesia, 226 tremor, 211–216 twisting and repetitive movements, 220–223 twitching, 219 Hyperlipidemia, 361 Hypertension, 368 Hypertensive encephalopathy, 295 Hyperthermia, with antipyretics, 364–365 Hypoglossal nucleus, 128–129 Index Hypoglycemia, stroke, 347 Hypotension, 134 Hypoxic-ischemic injury, 34 I Iatrogenic myopathies alcohol-related myopathies, 162 statin-induced myopathy, 161–162 steroid myopathy, 162 Ice test, 108 ICH See Intracranial hemorrhage (ICH) Ictal bradycardia, 144 Ictal semiology absence seizures, 311 atonic seizures, 312 CPS, 311 GTCS, 309–310 myoclonus, 312 partial seizures, 310 sensory seizures, 311 SPS, 310–311 Ideomotor apraxia, 58, 59 Idiopathic brachial neuritis, 249 Idiopathic intracranial hypertension, 294–295 Idiopathic lumbosacral plexitis, 257 Idiopathic polyneuropathy, 239 Idiopathic seizures, 321 Imbalance, 135 Immunocompromised patients fungal abscesses, 409 PCNSL, 408 toxoplasmosis, 408 Immunomodulatory therapy, 257 Inclusion body myositis (IBM), 160 Incoherence, Incontinence, 392 Infarction ophthalmic artery, 89 vertigo, 140 Inferior oblique, 103 Inferior rectus, 103 Inflammatory myopathies dermatomyositis, 159–160 IBM, 160 overlap myopathies, 160 polymyositis, 159 proximal weakness, 158–159 Inflammatory radiculopathies, 271–273 Interferon β, 388, 389 Interferon therapy, 388 Intermediate stage, 202–204 Intermedius neuralgia, 305 Internal carotid artery (ICA), 339–340 423 Index International Study of Unruptured Intracranial Aneurysms (ISUIA), 291 Internuclear ophthalmoplegia (INO), 99–100, 376 Intervertebral disc herniation syndromes, 265 Intra-arterial tPA, stroke, 356–357 Intracranial aneurysms, 291 Intracranial hemorrhage (ICH) acute life support, 366 blood pressure treatment, 368 etiology, 368–369 intraparenchymal hemorrhage, 368 noncontrast head CT, 350 prognosis, 369 restarting anticoagulation, 369–370 reversing anticoagulation heparin, 367 warfarin, 367 surgical hematoma evacuation, 368 Intracranial mass CPA, 407 headaches from, 294 immunocompromised patients fungal abscesses, 409 PCNSL, 408 toxoplasmosis, 408 lesions, 399 neurocysticercosis, 409–410 sellar region, 406–407 supratentorial masses abscesses, 406 arteriovenous malformations, 404–406 gliomas (see Gliomas) metastatic tumors, 399–401 PCNSL, 404 tumefactive MS, 406 tuberculoma, 410 Intracranial pressure, 40–41 Intraparenchymal hemorrhage, 368 Intravenous narcotics, 302 Intravenous pyridostigmine, 130 Intravenous recombinant tissue plasminogen activator (IV rt-PA), 354–356 Ipsilateral cerebellar hemispheric dysfunction, 136 Ipsilateral Horner syndrome, 298 Ischemic strokes anterior circulation ACA syndrome, 339 ICA, 339–340 MCA syndromes, 337–339 CT, 351 hyperacute (see Hyperacute ischemic stroke) posterior circulation (see Posterior circulation ischemic strokes) J JCV antibodies, 389, 390 Joint position perception, sensory symptom, 232 Junctional scotoma, 85, 90 Juvenile myoclonic epilepsy (JME), 320, 321 K Kernig sign, 12 Ketorolac, 258, 302 Knee pain, 258 L Lacunar stroke, 344 Lambert–Eaton myasthenic syndrome (LEMS), 130 diagnosis, 165 myasthenia gravis, 165–166 treatment, 165 Lateral arm pain C6 radiculopathy, 250 lateral epicondylitis, 250 Lateral epicondylitis, 250 Lateral geniculate body (LGB) lesions, 85 Lateral hand pain CMC, 255 CTS, 252–253 de Quervain tenosynovitis, 253–255 Leber hereditary optic neuropathy (LHON), 89 Left-right symmetry, 196 LEMS See Lambert–Eaton myasthenic syndrome (LEMS) Length-dependent polyneuropathy, 230, 233 Lennox–Gastaut Syndrome (LGS), 312, 328, 330 Leptomeningeal metastasis, 16 Levator palpebrae, 103 Levodopa, 202, 203 Lhermitte symptom, 376 Lid retraction, 114 Light-headedness cardiogenic syncope, 134 cause of, 133 neurally mediated syncope, 134–135 orthostatic hypotension, 134 POTS, 135 Limb dysmetria, 136 Limb-girdle muscular dystrophies (LGMD), 161 Limbic encephalitis, 18 Limb pain, neurologic and musculoskeletal causes, 248 Limb-shaking transient ischemic attacks, 219 Line bisection test, Logopenic progressive aphasia, 71 424 Long thoracic neuropathy, 173–174 Lorazepam, 10 Lower brainstem symptoms, 121 Lower quadrantanopsia, 85 Lower trunk brachial plexopathy, 173, 251–252 Lumbar puncture, 315 bacterial meningitis, 12–14 coma, 35–36 oligoclonal bands, 382 visual evoked potentials, 382 Lumbosacral plexopathy, 177, 179 cancer, 257 diabetic amyotrophy, 257 idiopathic lumbosacral plexitis, 257 neoplasm-related, 257 retroperitoneal hematoma, 256 thigh and hip pain, 256 trauma, 256 Lumbosacral polyradiculopathy, 241 Luria test, 60 Lyme meningitis, 16–17 M Macular edema, 390 Macular-sparing homonymous hemianopsia, 85 Magnetic resonance angiography (MRA) cerebral vasculature, 353 RCVS, 292 stroke, 359 Magnetic resonance imaging (MRI) abscess, 406 ANM, 404 axial FLAIR, 400 brain, 200–201 convexal subarachnoid hemorrhage, 347, 348 glossopharyngeal neuralgia, 305 metastasis, 400 MS, 377–381 neurocysticercosis, 410 vertigo, 140 Magnetic resonance spectroscopy (MRS), 402 Magnetic resonance venography (MRV), 353 Malignant MCA syndrome, 358 MAO-B inhibitors, 202 Mass lesions, headache secondary, 294 MCA See Middle cerebral artery (MCA) MCI See Mild Cognitive Impairment (MCI) Medial epicondylitis, 252 Medial hand and arm pain C8 radiculopathy, 251 lower trunk brachial plexopathy, 251–252 medial epicondylitis, 252 ulnar neuropathy, 250–251 Index Medial longitudinal fasciculus (MLF), 98 Medication-related headache, 299 Medications, seizures, 318 Memantine, 66 Meniere disease, 142–143 Meningioma contrast-enhanced T1-weighted MRI, 403 CPA masses, 407 gliomas, 403–404 radiologic differential diagnosis, 404 Meningitis headache, 294 seizures, 318 Mental flexibility, 60 Mental retardation, 377 Mental status, 199 Meralgia paresthetica, 256 Metabolic insult causing re-expression of old stroke (MICROS), 345 Metachromatic leukodystrophy (MLD), 270 Metastatic cord compression, 268 Metastatic tumors, 399–401 Methylphenidate, 314 Mid-basilar artery occlusion, 342 Mid-basilar penetrating branch occlusion, 342 Middle cerebral artery (MCA) branches, 337, 338 left vs right, 339 malignant, 358 syndromes, 337–339 Migraine differential diagnosis, 312–313 headache, 293, 296–297 prophylactic agents, 297 vertigo, 143–144 Migraine aura focal deficits in, 346 stroke deficits, 346 without headache, 89–90 Mild cognitive impairment (MCI), 73–74 Miller Fisher syndrome (MFS), 106 Minimally conscious state (MCS), 38 Mixed transcortical aphasia, 48–49 Modafinil, 314 Monoclonal gammopathy of undetermined significance (MGUS), 237 Monocular altitudinal defect, 85 Monocular visual loss, 85 Mononeuropathy multiplex, 181 Morton neuroma, 242 Motor impairments, 393–394 Motor nerve conduction, 157, 166, 167 Motor neuron disease, 175, 178 Motor pathways, 171 Index Motor seizures, 310 Motor syndromes, 376 Motor system, 172 Movement disorders dementia and, 73 differential diagnosis, 313 MRA See Magnetic resonance angiography (MRA) MRI See Magnetic resonance imaging (MRI) Multifocal demyelination, 384 Multifocal motor neuropathy with conduction block (MMNCB), 181–182 Multifocal weakness HNPP, 182 MMNCB, 181–182 vasculitic mononeuropathy multiplex, 181 Multi-infarct dementia, 68 Multiple sclerosis (MS) back pain, 269 CIS, 375 atypical symptoms, 377 diplopia, 376 disease-modifying treatment, 387 incoordination, 376 motor syndromes, 376 multifocal and progressive presentations, 377 myelopathy, 375 optic neuritis, 386–387 radiologically isolated syndrome, 377 sensory syndromes, 376 treatment, 387 visual loss, 375 cognitive dysfunction, 393 contrast-enhanced coronal MRI, 380 contrast-enhanced T1-weighted imaging, 379 CSF, 378, 381, 383, 384 dalfampridine, 394 depression and anxiety, 392 differential diagnosis, 385, 386 disease-modifying agents, 383 disease-modifying therapy, 391 evaluation, 378 fatigue, 392 FLAIR MRI, 379, 380, 394 fulminant variants, 394–395 immunomodulatory therapy, 393 lumbar puncture, 381, 382 motor impairments, 393–394 MRI, 378–381 pain and paresthesias, 393 past history, 378 patience, 382 425 physical examination, 378 primary demyelinating disorders ADEM, 383–384 neuromyelitis optica, 382–383 PML, 384 RRMS (see Relapsing-remitting MS (RRMS)) secondary demyelinating disorders, 384–386 spasticity, 391 spine MRI, 381 T1 black holes, 379–381 T2 and FLAIR, 378–379 tonic spasms, 394 tremor, 393 tumefactive, 406 urinary dysfunction, 391–392 Multiple sleep latency test (MSLT), 314 Multisystem atrophy (MSA), 207 Muscle atrophy, 150 Muscle biopsy, 156–157 Muscle bulk, 150–151, 153 Muscle relaxants, 298 Muscle strength, 153 Muscle weakness, 262 Muscular dystrophies DMD, 160 LGMD, 161 Musculoskeletal back pain coccygodynia, 274 sacroiliac joint dysfunction, 274 spinal fractures, 273–274 strains and sprains, 273 Musculoskeletal system dysfunction, 149 Myasthenia gravis, 107–108, 112, 163–165 Myasthenic crisis, 189 Myelopathy back pain, 262–263 (see also Back pain) CIS, 375 NMO, 383 Myoclonic epilepsy, 217 Myoclonic seizures, 312 Myoclonus, 62 acute post-anoxic, 217 chronic post-anoxic, 217 and dementia, 217 essential myoclonus, 218 physiologic myoclonus, 218 segmental myoclonus, 218 toxic and metabolic, 216 Myoedema, 155 Myofascial pain syndrome, 259 Myokymia, 225 Myopathic lesions, dysphagia, 130–131 Myopathy, 186 426 Myositis-associated antibodies, 157–158 Myotomes, 262 Myotonia congenita, 224–225 myotonic dystrophy, 224 paramyotonia congenita, 224–225 N NAION See Nonarteritic Ischemic Optic Neuropathy (NAION) Narcolepsy, 314 Natalizumab PML, 384 RRMS, 389–390 NCSE See Nonconvulsive status epilepticus (NCSE) Neologisms, 44 Neoplasm back pain, 267–268 seizures, 319 Neoplastic meningitis, 16 Nerve biopsy, polyneuropathy, 235 Nerve conduction studies (NCS), 166 polyneuropathy, 235 proximal weakness, 156 rapidly progressive weakness, 185–187 Nerve lesions, dysphagia, 128–129 Neurally mediated syncope, light-headedness, 134–135 Neurocognitive symptoms, 244 Neurocysticercosis, 319, 409–410 Neurodegenerative diseases, seizures, 320 Neurogenic claudication, 267 Neurolabyrinthitis, 141 Neuroleptic malignant syndrome (NMS), 20–21 Neuromuscular junction lesions, 112–113, 130 Neuromuscular respiratory failure, 183 Neuromyelitis optica (NMO), 382–383 Neuropathic pain, 229 Neuropathic tremor, 215 Neurosyphilis, 72–73 Neutralizing antibodies (NAbs), 389 NMS See Neuroleptic malignant syndrome (NMS) Nociceptive pain treatment, 258–259 Nonarteritic ischemic optic neuropathy (NAION), 88 Noncontrast head CT convexal subarachnoid hemorrhage, 348 intracranial hemorrhage, 350 SAH, 289 seizure, 315 stroke, 349–351 Index subarachnoid hemorrhage, 290 subdural hematoma, 347 Nonconvulsive status epilepticus (NCSE), 19 Nonfluent aphasics, 44 Nonfluent progressive aphasia, 71 Non-length-dependent polyneuropathy, 234 Nonmotor symptoms treatment constipation, 205–206 dementia, 205 depression, 204–205 dysarthria, 206 dysphagia, 206 hallucinations and psychosis, 205 Non-neurologic back pain, 273 Nonsteroidal anti-inflammatory drugs (NSAIDs), 244, 258 Normal pressure hydrocephalus (NPH), 69–71 Nuclear lesions, 129 Numbness, 229 Nystagmus bruns, 138 downbeating, 138 due to vestibular neuritis, 141 endpoint, 138 horizontal/horizontal-torsional, 138 torsional, 138 upbeating, 138 vertigo, 137–138 O Obstructive sleep apnea (OSA), 74–75 Obturator neuropathy, 179 Occipital neuralgia, 300 Oculopharyngeal muscular dystrophy (OPMD), 113, 130 Oculosympathetic pathway, 113 Oligoclonal bands (OCBs), 382 Ophthalmic artery infarction, 89 Opsoclonus, 139, 217–218 Optic disc pallor, 86 Optic neuritis, 386–387 Optic Neuritis Treatment Trial (ONTT), 386 Optic neuropathy, 386 Oral phase dysphagia hypoglossal nucleus and nerve lesions, 128–129 trigeminal nerve lesions, 128 Oral triptan, 296 Orbit lesions, 99, 101 Orbitofrontal automatisms, 311 Oromandibular dystonia, 225 Oropharyngeal bradykinesia, 206 Orthostasis, 200 427 Index Orthostatic hypotension, 134 OSA See Obstructive sleep apnea (OSA) Osteoarthritis, 258 Overlap myopathies, 160 Overshoot phenomenon, vertigo, 137 P Palatal tremor, 215 Palmar sensory branch, 253 Pan-plexopathy, 173 Papilledema, 295 Paramedian thalamic-subthalamic artery, 343 Paramyotonia congenita, 224–225 Paraneoplastic cerebellar degeneration, 146 Paraneoplastic epilepsy, 321 Paraphasic errors, 44 Paratonia, 62, 151 Paresthesia, 229 Parkinson disease (PD), 127, 196 advanced stage treatment, 204 cardinal features, 201 early-stage treatment, 201–202 intermediate stage, 202–204 medications, 205 nonmotor symptoms constipation, 205–206 dementia, 205 depression, 204–205 dysarthria, 206 dysphagia, 206 hallucinations and psychosis, 205 Parkinsonian gait, 280–281 Parkinsonian tremor, 214–215 Parkinsonism, 62 activities of daily living, 197 age of onset, 195 ataxia, 196 atypical (see Atypical parkinsonism) autonomic dysfunction, 196 brain MRI, 200–201 dementia, 197 diagnosis, 200 dopamine transporter scan, 201 drug-induced, 208 examination bradykinesia, 198 eye movements, 199 gait, 198–199 mental status examination, 199 orthostasis, 200 rigidity, 197–198 speech, 199 tremor, 198 family history, 197 gait dysfunction and falls, 196 history, 195 left-right symmetry, 196 medications and toxins, 197 pace of onset, 195 presence of tremor, 196 vascular, 208–209 Paroxysmal hemicrania, 299 Partial seizure GTCS, 309 ictal semiology, 310 Patchy spinal cord lesions, 376 PD See Parkinson disease (PD) Pentobarbital coma, 333 Perfusion-weighted imaging (PWI), 352 Perilymph fistula, 144 Perimenstrual migraines, 297 Peripheral nervous system, 177 Peripheral vestibulopathy, 348 Periscapular weakness long thoracic neuropathy, 173–174 spinal accessory neuropathy, 174 Peroneal neuropathy, 177–178 Persistent vegetative state (PVS), 37–38 Phalen sign, 254 Pharyngeal exudate, 184 Pharyngeal phase dysphagia extrapyramidal lesions, 131 glossopharyngeal and vagus nerves, 129–130 myopathic lesions, 130–131 neuromuscular junction lesions, 130 supranuclear lesions, 129 Phenytoin, 325 Phonemic fluency, 57 Phosphocreatine, 155 Physiologic myoclonus, 218 Pinprick examination, 230–232 Pituitary apoplexy, 292 Plantar fasciitis, 241 Plaques, 378, 379 Plasmapheresis, 188 PML See Progressive multifocal leukoencephalopathy (PML) Polar artery, thalamic strokes, 343 Poliomyelitis, acute paralysis, 191 Polymerase chain reaction (PCR), 17 Polymyositis, 159 Polyneuropathy acute paralysis, 190–191 B12 deficiency, 236 CMT disease, 238 diabetes mellitus, 236 428 Polyneuropathy (cont.) EMG, 235 ethanol, 238 HIV, 238 idiopathic, 239 laboratory screening, 234–235 length-dependent, 233 medication, 239 monoclonal gammopathy, 237 NCS, 235 nerve biopsy, 235 non-length-dependent, 234 screening panel, 234 thyroid dysfunction, 238–239 vasculitis, 237 Pontine lesions, 124–125, 376 Postconcussion syndrome, 76, 145 Posterior cerebral artery (PCA) infarction, 91, 342 Posterior choroidal artery, thalamic strokes, 343 Posterior circulation ischemic strokes, 340–341 cerebellar strokes, 343–344 mid-basilar artery occlusion, 342 mid-basilar penetrating branch occlusion, 342 PCA infarction, 342 rostral basilar occlusion, 342 thalamic strokes, 343 Wallenberg syndrome, 341 Posterior cortical atrophy, 71–72 Posterior reversible encephalopathy syndrome (PRES), 19–20, 92, 295 Postherpetic neuralgia, 306 Post-lumbar puncture headache, 300 Postpartum leg weakness, 179–180 Postsynaptic neuromuscular junction dysfunction, 186 Posttraumatic dizziness, 145 Posttraumatic seizures, 318 Postural orthostatic tachycardia syndrome (POTS), 135 PPA See Primary progressive aphasia (PPA) Praxis, 54 Preeclampsia, 320 Pregnancy, headache, 303 PRES See Posterior reversible encephalopathy syndrome (PRES) Presynaptic neuromuscular junction dysfunction, 186 Primary central nervous system lymphoma (PCNSL), 404, 408 Primary progressive aphasia (PPA), 71 Primary progressive MS (PPMS), 391 Primitive reflexes, 61 Index Progressive multifocal leukoencephalopathy (PML), 384, 389 Progressive supranuclear palsy (PSP) clinical features, 206–207 gait, 281 Prolonged neuromuscular junction blockade, 193 Prominent gait instability, 206 Prophylactic agents, 297 Prophylaxis, 143 Proprioceptive sensations, 230 Prosopagnosia, 93 Prothrombin complex concentrate (PCC), 367 Provoked seizures, 322 Proximal weakness CIDP, 166–168 CNS dysfunction, 168 exercise testing, 153–154 features, 153 gait, 154 history, 151–153 inflammatory myopathies dermatomyositis, 159–160 IBM, 160 overlap myopathies, 160 polymyositis, 159 laboratory testing aldolase, 156 creatine kinase, 155, 156 EMG, 156 forearm exercise testing, 158 muscle biopsy, 156–157 myositis-associated antibodies, 157–158 NCS, 156 muscle bulk, 153 muscle strength, 153 muscular dystrophies DMD, 160 LGMD, 161 myasthenia gravis, 163–166 reflexes, 154 sensory examination, 154 signs and symptoms, 155 thyroid myopathies, 161 toxic and iatrogenic myopathies, 161–162 Pseudoseizures, 327, 328 Pseudotumor cerebri, 294–295 Psychiatric disorders, 314 Psychogenic gait, 282 Psychogenic tremor, 216 Psychosis, 7, 205 Ptosis, 155 fluctuating extraocular weakness, 184 muscle lesions, 113–114 429 Index nerve lesions facial nerve, 112 oculomotor nerve, 111 oculosympathetic nerves, 112 neuromuscular junction lesions, 112–113 soft tissue lesions, 114 supranuclear lesions, 111 treatment, 114 Pupil-sparing third nerve lesions, 104 PVS See Persistent vegetative state (PVS) Q Quadrantanopsia, 85 R Radial neuropathy, 176 Radiation-induced brachial plexopathy, 249 Radiation-induced pseudoprogression, gliomas, 402 Radiation necrosis, gliomas, 403 Radiculopathies back pain (see Back pain) inflammatory, 271–273 Radiculopathy C5, 173, 248 C6, 173, 250 C8, 251 C8–T1, 175 L2 and L3, 176–177, 255 L5, 178 Radiofrequency ablation (RFA), 304 Radiologically isolated syndrome, 377 RAPD See Relative afferent pupillary defect (RAPD) Rapid eye movement (REM), 54 Rapidly progressive weakness axonal neuropathy, 186 blood, urine, and stool examination, 187 CSF analysis, 187 demyelinating neuropathy, 185–186 diagnostic studies EMG, 185–187 NCS, 185–187 neuroimaging studies, 185 initial pattern, 183–184 myopathy, 186 neurologic examination, 184 neuromuscular respiratory failure, 183 neuropathies, 191 postsynaptic neuromuscular junction dysfunction, 186 presynaptic neuromuscular junction dysfunction, 186 Raynaud phenomenon, 243 Rebound, vertigo, 137 Red flags, 264 Reflexes proximal weakness, 154 sympathetic dystrophy, 259 Refractory epilepsy, 326–332 Refractory symptoms, 143, 392 Rehabilitation program, 366 Relapsing-remitting MS (RRMS) contrast-enhanced MRI, 388 dimethyl fumarate, 390 fingolimod, 390 glatiramer acetate, 388–389 interferon β, 388, 389 natalizumab, 389–390 teriflunomide, 390 treatment of MS flares, 388 Relative afferent pupillary defect (RAPD), 83–84, 375, 378 Renal dysfunction, 323 Repetitive nerve stimulation (RNS), 163, 164 Restless legs syndrome (RLS), 242–243 Retinal ischemia, 89 Retroperitoneal hematoma, 256 Reversible cerebral vasoconstriction syndrome (RCVS), 292 Right hemispheric syndrome, Rigidity axial, 207 parkinsonism, 197–198 Rivastigmine, 66 Romberg sign, 233, 279 Rostral basilar occlusion, 342 Rotator cuff tendonitis, 250 S Sacroiliac joint dysfunction, 274 Scapular winging long thoracic neuropathy, 173–174 spinal accessory neuropathy, 174 Sciatic neuropathy, 178 Secondary prevention, stroke, 360 anticoagulation, 361–362 antiplatelet therapy, 362 blood pressure control, 360 carotid stenosis, 362–363 CEA, 362–363 diabetes mellitus, 361 hyperlipidemia, 361 interventions, 364 lifestyle recommendations, 361 Secondary progressive MS (SPMS), 391 Secondary tremor, 214 430 Segmental myoclonus, 218 Seizures AED, 322–323 alcohol withdrawal, 318 arteriovenous malformations, 320 autoimmune and paraneoplastic epilepsy, 321 counseling after, 323–325 differential diagnosis, 327 migraine, 312–313 movement disorders, 313 narcolepsy, 314 psychiatric disorders, 314 sensory symptoms, 313 syncope, 312 transient ischemic attack, 312–313 eclampsia, 320–321 EEG, 316 electroencephalography, 315–317 electrolyte abnormalities, 317 encephalitis, 318 etiology, 314–315 evaluation, 309–325 glucose imbalance, 317 hemorrhagic stroke, 319 hepatic encephalopathy, 317 ictal semiology absence seizures, 311 atonic seizures, 312 CPS, 311 GTCS, 309–310 myoclonus, 312 partial seizures, 310 SPS, 310–311 idiopathic, 321 JME, 320 laboratory testing, 315 medication, 318, 327 meningitis, 318 neoplasms, 319 neurocysticercosis, 319 neurodegenerative diseases, 320 neuroimaging, 315 noncontrast head CT, 315 posttraumatic, 318 provoked, 322 recurrence chance, 322 stroke, 319–320 and syncope, 313 toxins, 318 uremia and dialysis dysequilibrium, 317 Selective serotonin reuptake inhibitors (SSRIs), 204 Sellar region, intracranial mass, 406–407 Index Semantic dementia, 71 Semantic fluency, 57 Sensory examination, 154 Sensory innervation, 251 Sensory loss, 149, 176, 261, 262 Sensory seizures, 311, 313 Sensory symptoms anatomy, 230 CIS, 376 cortical sensory modalities, 232–233 cramps, 242 morton neuroma, 242 MS, 393 neuropathic treatment, 239–241 overview, 229–230 pinprick and temperature sensation, 230–232 plantar fasciitis, 241 Raynaud phenomenon, 243 RLS, 242–243 spine disease, 241 tarsal tunnel syndrome, 241–242 vibratory and joint position perception, 232 Short-acting anxiolytics, 392 Shortlasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT), 299 Shoulder and proximal arm pain brachial plexopathy, 248 cancer, 249 idiopathic brachial neuritis, 249 trauma, 248–249 C5 radiculopathy, 248 rotator cuff tendonitis, 250 Shoulder weakness brachial plexopathy, 173 C5–6 radiculopathy, 173 Simple partial seizures (SPS) behavioral and psychic seizures, 311 motor seizures, 310 sensory seizures, 311 Sinus headache, 305 Skin-nerve biopsy, 235 SMI See Subjective memory impairment (SMI) Somatosensory deficits, 313 Somatosensory neglect, Somnolence, Spasmodic dysphonia, 127 Spastic dysarthria, 126, 199, 206 Spastic gait, 280 Spasticity multiple sclerosis, 391 weakness, 151 Speech, examination, 199 Index Spetzler–Martin AVM grading scale, 405 Spinal accessory neuropathy, 174 Spinal cord cross-sectional diagram, 263 infarction, 269–270 insults, acute paralysis, 191 stroke, treatment, 270, 344 Spinal fluid pleocytosis, 11 Spinal fractures, 273–274 Spinal stenosis conservative therapy, 267 L2–3 radiculopathy, 176 manifestation, 266 Spine MRI, MS, 381 Spontaneous intracranial hypotension (SIH), 300, 301 Spontaneous speech, 44 Statin-induced myopathy, 161–162 Status epilepticus abort seizures, 332–334 AEDs, 333 burst-suppression, 334 cause, 335 convulsive vs nonconvulsive, 332 definition, 332 etiology, 334 life support, 332 pentobarbital coma, 333 Status migrainosus acute pain control, 302 antiemetic agents, 301 migraine abortive agents, 302 steroids, 302 supportive care, 301 Steppage gait, 281–282 Steroids myopathy, 162 status migrainosus, 302 Steroid-sparing agent, 159 Stiff person syndrome, 223 Stocking-glove sensory loss, 233 Straight leg raise test, 261 Strains and sprains, 273 Strategic infarct dementia, 69 Stress gait, 279 Stroke acute confusional state, 345 anterior circulation ischemic strokes ACA syndrome, 339 ICA, 339–340 MCA syndromes, 337–339 antiplatelet agents, 363 Bell palsy, 348 blood tests, 359–360 431 cardiac evaluation, 358–359 causes of, 360 cerebral venous thrombosis, 344 convexal subarachnoid hemorrhage, 347 DWI, 350–351 focal neuropathies, 345 funduscopic examination, 349 hyperacute ischemic stroke cerebellar infarction, 358 intra-arterial tPA, 356–357 intravenous rt-PA, 354–356 malignant MCA syndrome, 358 hyperglycemia, 347 hypoglycemia, 347 ICH, 344 acute life support, 366 blood pressure treatment, 368 etiology, 368–369 heparin, 367 intraparenchymal hemorrhage, 368 prognosis, 369 restarting anticoagulation, 369–370 surgical hematoma evacuation, 368 warfarin, 367 laboratory studies, 349 lacunar, 344 MICROS, 345 migraine aura, 346 noncontrast head CT, 349–351 peripheral vestibulopathy, 348 physical examination, 349 posterior circulation ischemic strokes cerebellar strokes, 343–344 mid-basilar artery occlusion, 342 mid-basilar penetrating branch occlusion, 342 PCA infarction, 342 rostral basilar occlusion, 342 thalamic strokes, 343 Wallenberg syndrome, 341 psychogenic disorders, 348 PWI, 352 SDH, 346–347 secondary prevention, 360 anticoagulation, 361–362 antiplatelet therapy, 362 blood pressure control, 360 carotid stenosis, 362–363 CEA, 362–363 diabetes mellitus, 361 hyperlipidemia, 361 interventions, 364 lifestyle recommendations, 361 432 Stroke (cont.) seizures, 319–320 spinal cord, 344 supportive care aspiration prevention, 365 assessing aspiration risk, 365 DVT prophylaxis, 365–366 hyperglycemia, 365 hyperthermia and infection, 364–365 maintaining adequate nutrition, 365 preventing falls, 366 rehabilitation program, 366 susceptibility imaging, 351–352 TGA, 346 Todd paralysis, 346 vascular evaluation, 359 vascular imaging studies, 352 wrist and finger drop, 175, 176 Stroop test, 60 Subarachnoid hemorrhage (SAH) convexal, 347, 348 headache, 289–290 non-contrast head CT, 289, 290 Subcortical aphasias, 49 Subcortical dementia, 393 Subcortical white matter disease, 69 Subdural hematoma (SDH) diagnosis, 346 non-contrast head CT, 347 Subjective memory impairment (SMI), 73–74 Suboccipital decompressive craniectomy, 358 Subthalamic nucleus (STN), 203 Sumatriptan, 296, 297 SUNCT See Shortlasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT) Superior rectus, 103 Super-refractory status epileptus, 334 Supranuclear dysfunction, 199 Supranuclear gaze palsy, 207 Supranuclear lesions facial weakness, 124 dysphagia, 129 Supratentorial masses abscesses, 406 arteriovenous malformations, 404–406 gliomas, 401–402 deterioration, 402 meningiomas, 403–404 radiation necrosis, 403 radiation-induced pseudoprogression, 402 recurrence, 402 Index metastatic tumors, 399–401 PCNSL, 404 tumefactive MS, 406 Swallowing See Dysphagia Syncope, 312, 313 Synkinesis, 126 T T1 black holes, 379–381 T1 radiculopathy, 175 Taenia solium, 319 Tandem gait, 279 Tangier disease, 234 Tardive dyskinesia (TD), 226 Tarsal tunnel syndrome, 241–242 Task-specific dystonias, 222–223 Task-specific tremor, 216 TCMA See Transcortical motor aphasia (TCMA) TD See Tardive dyskinesia (TD) Temozolomide, 402 Temperature sensation, 230–232 Temporal arteritis headache, 293 risk for, 289 symptoms, 287 Temporal crescent defects, 86 Temporomandibular joint (TMJ) disease, 305–306 Tension headache, 286, 297–298 Teriflunomide, 390 TGA See Transient global amnesia (TGA) Thalamic strokes, 343 Thalamogeniculate artery, thalamic strokes, 343 Thigh and hip pain lumbosacral plexopathy, 256 cancer, 257 diabetic amyotrophy, 257 idiopathic lumbosacral plexitis, 257 retroperitoneal hematoma, 256 trauma, 256 L2 and L3 radiculopathy, 255 meralgia paresthetica, 256 osteoarthritis, 258 trochanteric bursitis, 257 Thoracic spine, 272 Thyroid dysfunction, 238–239 Thyroid myopathies, 161 Tics, 219 Tinel sign, 253 Todd paralysis, 310, 346 Tolosa–Hunt syndrome, 105–106 Tongue weakness, 128 433 Index Tonic spasms, 394 Torsional nystagmus, 138 Toxic myopathies, 161 alcohol-related myopathies, 162 statin-induced myopathy, 161–162 steroid myopathy, 162 Toxoplasmosis, 408 Transcortical motor aphasia (TCMA), 48 Transcortical sensory aphasia, 48–49 Transesophageal echocardiography (TEE), 359 Transient global amnesia (TGA), 6, 346 Transient ischemic attack (TIA), 312–313, 337 Transtentorial herniation, 40 Transthoracic echocardiography (TTE), 359 Transverse cord infarction, 269 Transverse myelitis back pain, 269 MS, 375 Trauma brachial plexopathy, 248–249 carotid artery dissection, 291 lumbosacral plexopathy, 256 Traumatic brain injury (TBI), 76 Tremor CBD, 208 cerebellar outflow tremor, 215 dystonic tremor, 215 enhanced physiologic tremor, 213 essential tremor, 212 examination, 198 medications producing, 214 multiple sclerosis, 393 neuropathic tremor, 215 palatal tremor, 215 parkinsonian tremor, 214–215 parkinsonism, 196 psychogenic tremor, 216 secondary tremor, 214 task-specific tremor, 216 Wilson disease, 212–213 Trendelenburg gait, 154–155 Trendelenburg sign, 278 Tricyclic antidepressants, 204 Trigeminal autonomic cephalalgias (TACs) cluster headache, 298 paroxysmal hemicrania headaches, 299 SUNCT, 299 Trigeminal nerve lesions, dysphagia, 128 Trigeminal neuralgia, 376, 393 cause of, 304 facial pain, 303–304 Triptans side effects, 296 symptomatic treatment, 297 Trochanteric bursitis, 257 Trochlear nerve palsy, 101 Tropical spastic paraparesis, 270 Truncal ataxia, vertigo, 137 Tuberculoma, 410 Tuberculous meningitis, 17 Tumefactive multiple sclerosis, 406 U Ulnar neuropathy, 174, 250–251 Upbeating nystagmus, 138 Upper quadrantanopsia, 85 Upper trunk brachial plexopathy, 173 Uremic seizures, 317 Urinary dysfunction, 391–392 V Vagus nerves, dysphagia, 129–130 Vagus nerve stimulator (VNS), 331 Valacyclovir, 125 Valproate, status epilepticus, 333 Vascular claudication, 267 Vascular dementia, 65, 68 Vascular evaluation, 359 Vascular imaging, stroke, 352 Vascular parkinsonism, 208–209 Vascular syndromes, 343 Vasculitic mononeuropathy multiplex, 181 Vasculitic neuropathies, 237 Vasogenic edema, 399, 400 Ventilator, difficulty weaning from CIM, 192–193 CIP, 192 prolonged neuromuscular junction blockade, 192–193 Ventralis intermedius (VIM), 393 Vertebrobasilar disease, 140 Vertebroplasty, 274 Vertigo BPPV, 141–142 cerebellar signs, 136 finger-to-nose test, 136 heel–knee–shin test, 137 overshoot, 137 rebound, 137 truncal ataxia, 137 cervicogenic dizziness, 145 chronic undifferentiated dizziness, 145 CPA tumors, 145 CT scan, 140 Dix–Hallpike maneuver, 139–140 dizziness of psychological origin, 146 434 Vertigo (cont.) epileptic dizziness, 144 episodic ataxia, 146 head-thrust test, 139 imaging, 140 medication toxicity, 144 Meniere disease, 142–143 migraine, 143–144 MRI, 140 multiple sclerosis, 146 nystagmus, 137–138 paraneoplastic cerebellar degeneration, 146 perilymph fistula, 144 postconcussion syndrome and posttraumatic dizziness, 145 vertebrobasilar ischemia and infarction, 140 vestibular neuritis, 141 Vestibular schwannomas, 407 Vestibulotoxic medications, 144 Vibratory perception, 232 Vibratory sensations, 230 Viral encephalitis, 14–16 Viral meningitis, 14–16 Viral prodrome, 145 Visual apperceptive agnosia, 93 Visual evoked potentials (VEPs), 382 Visual loss alexia without agraphia, 91 bitemporal hemianopsia, 90 CIS, 375 cortical blindness bilateral occipital lobe infarction, 91 PRES, 92 functional visual loss, 92 history, 82 homonymous upper quadrantanopsia, 90–91 junctional scotoma, 90 PCA infarctions, 91 Visual neglect, 4–6 Visual object agnosia, 93 Visual strain headache, 299 Visual system angle closure glaucoma, 90 examination central visual fields, 84 color discrimination, 84 funduscopic examination, 86 peripheral visual fields, 84–86 pupillary reactions, 83 RAPD, 83–84 visual acuity, 82 inherited optic neuropathies, 89 migraine aura, 89–90 Index monocular visual loss, 86 NAION, 88 neuroanatomy, 82 neuroanatomy of, 81–82 optic neuritis, 86–87 retinal ischemia and infarction, 89 structural optic neuropathies, 88 temporal arteritis, 87–88 toxic and nutritional optic neuropathies, 88 Vitamin B12 deficiency, 269 Vitamin K, 367 W Waddling gait, 281 Wallenberg syndrome, 341 Watershed infarction, 340 Weakness definition, 149 flaccidity, 150 gradual-onset patterns, 150 history, 150 mimics, 149 muscle bulk, 150–151 paratonia, 151 power, 151 proximal aldolase, 156 CIDP, 166–168 CNS dysfunction, 168 creatine kinase, 155, 156 exercise testing, 153–154 features, 153 forearm exercise testing, 158 gait, 154 genetic test, 158 history, 151–153 inflammatory myopathies, 158–160 muscle biopsy, 156–157 muscle bulk, 153 muscle strength, 153 muscular dystrophies, 160, 161 myasthenia gravis, 163–166 myositis-associated antibodies, 157–158 NCS, 156 reflexes, 154 sensory examination, 154 signs and symptoms, 155 thyroid myopathies, 161 toxic and iatrogenic myopathies, 161–162 435 Index rigidity, 151 shoulder (see Shoulder weakness) spasticity, 151 tested movements, 152 Wernicke aphasia, 47 Wernicke encephalopathy, 10–11, 104–105 Willis–Ekbom disease See Restless legs syndrome (RLS) Wilson disease, 197, 212–213 Word-finding difficulties, 54 Wrist and finger drop radial neuropathy, 176 stroke, 175, 176 [...]... pathognomonic for hepatic encephalopathy Advanced hepatic encephalopathy is characterized by seizures and more severe cognitive dysfunction which may progress to coma and death Fulminant hepatic encephalopathy with massive transaminitis, often due to intoxication with acetaminophen, may produce malignant cerebral edema and increased intracranial pressure (Chap 2) While a high serum ammonia level may... seconds later Differential Diagnosis There are several conditions that are often “confused with confusion.” Most prominent among these are aphasia, neglect, transient global amnesia, psychosis, and Charles Bonnet syndrome Aphasia Aphasia is an acquired disorder of language resulting from brain damage (Chap 3) It may be difficult to distinguish some patients with aphasia, particularly those with fluent varieties,... learning how to approach and care for patients with neurological illness Massachusetts General Hospital Harvard Medical School Boston, MA, USA Bart Chwalisz, M.D Preface to the Second Edition In 2010, I began the preface of the first edition of Neurology: A Clinician’s Approach by asking whether the world needed another introductory neurology textbook I was uncertain about the answer then, and the availability... animals, or animated objects Usually the hallucinations are not threatening to the patient, but in some instances can be disturbing and lead to agitation The symptoms may come on suddenly and may wax and wane Unfortunately, effective treatments are lacking because the visual loss is severe and uncorrectable Reassurance that the hallucinations do not represent serious psychiatric illness may help patients... finding an elevated serum ethanol level Ethanol Withdrawal Withdrawal symptoms may develop as soon as 6 h after stopping heavy alcohol intake The most common manifestation of ethanol withdrawal is tremulousness When ethanol withdrawal causes a confusional state, it most frequently takes the form of agitated delirium, including auditory and visual hallucinations These typically peak between 24 and 36... demonstrate a variety of other mental status examination abnormalities including problems with language, memory, and praxis (Chaps 3 and 4) Careful testing, however, shows that the main problem is inattention Asterixis Asterixis accompanies most metabolic and some structural encephalopathies, and is not pathognomonic for hepatic encephalopathy To test for asterixis, ask the patient to elevate their pronated... who have trained me and those whom I have had the privilege of training Drs Clif Saper, Mike Ronthal, Frank Drislane, and Penny Greenstein remain towering influences in my approach to neurology Neurology: A Clinician’s Approach persists as a tribute to their expertise as neurologists and to the personalized attention that they gave me during my residency training at Beth Israel Deaconess Medical Center... specifically Moderate hepatic encephalopathy produces more prominent inattention and somnolence Asterixis, the most well-known sign of hepatic encephalopathy, is usually present at this stage Other features of moderate hepatic encephalopathy include pyramidal and extrapyramidal signs such as dysarthria, tremor, rigidity, and bradykinesia Patients may have EEG recordings which show triphasic waves, though... Toxic and Metabolic Encephalopathies Medical diseases and intoxications are the most common causes of the acute confusional state While essentially any medical disturbance may lead to confusion, commonly identified precipitants include urinary tract infections, pneumonia, hyponatremia, uremia, hepatic dysfunction, hypoxia, and hypercarbia (Table 1.1) In many elderly patients, subtle rather than overt... Limbic Encephalitis Limbic encephalitis is an immune-mediated neurological syndrome characterized by confusion, memory loss, and seizures It classically occurs as a paraneoplastic syndrome, in many cases presenting before a cancer diagnosis, but also occurs as a nonneoplastic, autoimmune process The various encephalitides are named for associated autoantibodies, though in many cases the antibody is