Netter's Neurology, 2nd Edition

734 Pages·2011·175.88 MB·English

by  Jr., H. Royden Jones, Jayashri Srinivasan, Gregory J. Allam, Richard A. Baker

Netter’s
Neurology
2nd edition
EDITOR-IN-CHIEF
H. ROYDEN JONES, JR., MD
Department of Neurology
Lahey Clinic
Burlington, Massachusetts;
Children’s Hospital Boston
Boston, Massachusetts
EDITORS
JAYASHRI SRINIVASAN, MD, PhD
Department of Neurology
Lahey Clinic
Burlington, Massachusetts
GREGORY J. ALLAM, MD
Department of Neurology
Lahey Clinic
Burlington, Massachusetts
RICHARD A. BAKER, MD
Department of Radiology
Lahey Clinic
Burlington, Massachusetts
Illustrations by Frank H. Netter, MD
CONTRIBUTING ILLUSTRATORS
Carlos A. G. Machado, MD
John A. Craig, MD
James A. Perkins, MS, MFA
Anita Impagliazzo, MA, CMI
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
NETTER’S NEUROLOGY ISBN: 978-1-4377-0273-6
Copyright © 2012 by Saunders, an imprint of Elsevier Inc.
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Dedication
To our dear patients and residents
They taught us so much by providing unforgettable life
experiences in their own special way.
These special encounters continue to bring fond memories, very
poignantly motivating each of us.
To our wonderful families:
spouses, children, and grandchildren
with whom we each share a very extraordinary bond
About the Artists
Frank H. Netter, MD The Netter illustrations are appreciated not only for their
Frank Netter was born in 1906 in New York City. He studied aesthetic qualities, but also, more important, for their intellec-
art at the Art Student’s League and the National Academy of tual content. As Dr. Netter wrote in 1949, “… clarifcation of a
Design before entering medical school at New York University, subject is the aim and goal of illustration. No matter how beauti-
where he received his medical degree in 1931. During his fully painted, how delicately and subtly rendered a subject may
student years, Dr. Netter’s notebook sketches attracted the be, it is of little value as a medical illustration if it does not serve
attention of the medical faculty and other physicians, allowing to make clear some medical point.” Dr. Netter’s planning,
him to augment his income by illustrating articles and text- conception, point of view, and approach are what inform his
books. He continued illustrating as a sideline after establishing paintings and what makes them so intellectually valuable.
a surgical practice in 1933, but he ultimately opted to give up Frank H. Netter, MD, physician and artist, died in 1991.
his practice in favor of a full-time commitment to art. After Learn more about the physician-artist whose work has inspired
service in the United States Army during World War II, Dr. the Netter Reference collection: http://www.netterimages.com/
Netter began his long collaboration with the CIBA Pharmaceu- artist/netter.htm.
tical Company (now Novartis Pharmaceuticals). This 45-year
partnership resulted in the production of the extraordinary col- Carlos A. G. Machado, MD
lection of medical art so familiar to physicians and other medical Carlos Machado was chosen by Novartis to be Dr. Netter’s suc-
professionals worldwide. cessor. He continues to be the main artist who contributes to
In 2005 Elsevier, Inc., purchased the Netter Collection and the Netter collection of medical illustrations.
all publications from Icon Learning Systems. There are now Self-taught in medical illustration, cardiologist Carlos
over 50 publications featuring the art of Dr. Netter available Machado has contributed meticulous updates to some of Dr.
through Elsevier (in the US: www.us.elsevierhealth.com/Netter Netter’s original plates and has created many paintings of his
and outside the US: www.elsevierhealth.com). own in the style of Netter as an extension of the Netter collec-
Dr. Netter’s works are among the fnest examples of the use tion. Dr. Machado’s photorealistic expertise and his keen insight
of illustration in the teaching of medical concepts. The 13-book into the physician-patient relationship informs his vivid and
Netter Collection of Medical Illustrations, which includes the unforgettable visual style. His dedication to researching each
greater part of the more than 20,000 paintings created by Dr. topic and subject he paints places him among the premier
Netter, became and remains one of the most famous medical medical illustrators at work today.
works ever published. The Netter Atlas of Human Anatomy, frst Learn more about his background and see more of his art at:
published in 1989, presents the anatomical paintings from the http://www.netterimages.com/artist/machado.htm
Netter Collection. Now translated into 16 languages, it is the
anatomy atlas of choice among medical and health professions
students the world over.
About the Editors
H. Royden Jones, Jr., MD, was raised in semi-rural New Jersey Electrodiagnostic Medicine in 2007 and the Frank Lahey award
but also frequently visited his grandmother, who lived a few of the Lahey Clinic Staff Association of 2010.
blocks from the Atlantic Ocean. He graduated from Tufts In his free time Royden is a photographer and an amateur
College and Northwestern University Medical School, where sea and landscape artist. He particularly enjoys opportunities to
during his frst year he was intrigued by the introductory neu- photograph his family, as well as record the magnifcence of
roanatomy course, which was particularly enhanced by his use nature at the 40-mile long Moosehead Lake lying within the
of the frst Netter Nervous System atlas and his teacher’s presenta- mountains of northwestern Maine. Here he spends part of his
tion of active patients. Years later as Chair of the Alumni summer on remote Deer Island with his wife, four children,
Advisory Board he received their Outstanding Service award. and fve grandchildren. His daughter is a former prosecutor in
After interning at the Philadelphia General Hospital, Royden Manhattan, and one of his sons is a college professor at the
began an internal medicine residency at the Mayo Clinic. He University of Rochester. His other two sons are physicians; one
completed two years of internal medicine and took his last practices emergency medicine at a community hospital in sub-
required rotation, neurology. This unexpectedly rekindled urban Boston, and his youngest son is the A. Bernard Ackerman
interests that began as a medical student, leading him to make Professor of the Culture of Medicine conjointly at Harvard
a career shift from cardiology to neurology. One year later he College and Harvard Medical School. Their family particularly
volunteered for active duty, as a neurologist, with the United enjoys skiing, kayaking, and hiking together.
States Army Medical Corps, serving from 1966 to 1970 at the
5th General Hospital, Bad Cannstatt, Germany. Returning to Jayashri Srinivasan, MD, PhD, grew up in Chennai, India,
Mayo, Royden completed his neurologic and clinical neuro- where she graduated from Stanley Medical College. She initially
physiology training. pursued her postgraduate training in Cardiff, Wales, where she
In 1972 he joined the Lahey Clinic Neurology department, received a doctorate in neurophysiology, as well as completing
subsequently becoming their Chair and later the Chair of the a residency in internal medicine and becoming a Fellow of the
Division of Medicine and Medical Specialties. Dr. Jones contin- Royal College of Physicians (FRCP), United Kingdom. Jayashri
ues to practice at Lahey, where he holds the Jaime Ortiz-Patino moved to Boston to train at the Tufts neurology program; sub-
chair in neurology. Currently his efforts are entirely dedicated sequently she completed a fellowship in neuromuscular disor-
to patient care and educational /clinical research pursuits. ders at Brigham & Women’s Hospital and Harvard Medical
Royden is renowned for his astute clinical acumen and his com- School. She briefy returned to the Tufts faculty at Tufts Medical
passionate care of patients. His wisdom is highly sought after Center but soon thereafter moved to the Lahey Clinic in 2003.
by other physicians at Lahey, the surrounding community, as Jayashri is an associate professor of neurology at Tufts Univer-
well as nationally. He is recognized as an exceptional teacher sity School of Medicine.
and has mentored numerous residents and fellows. His former At Lahey Dr. Srinivasan specializes in neuromuscular medi-
students practice adult and pediatric neurology across the world. cine, where she is a very skilful clinical neurophysiologist with
Dr. Jones developed the Lahey neurophysiology fellowship. A particular interests in electromyography and autonomic disor-
number of directors of EMG labs and several department chairs ders. She is director of the clinic’s electromyography laboratory,
have been trained by Royden. the Lahey neuromuscular fellowship, as well as director of their
After having joined the Children’s Hospital Boston neurol- Muscular Dystrophy Association clinic. Dr. Srinivasan has pre-
ogy department, Royden was asked to develop their clinical sented a number of papers at major North American neurologic
electromyography laboratory in 1978. This presented an inter- societies and has written signifcantly within the neuromuscular
esting challenge, since there was little written in the feld of feld. When she is not practicing neurology, Jayashri devotes
pediatric electromyography. Keeping careful prospective fles of almost all of her free time to her family—her husband Bala, a
every patient studied there, Dr. Jones subsequently co-authored nephrologist at Tufts, and their 2 children, a daughter in college
and edited three major texts of childhood clinical neurophysiol- at MIT, and a son in high school.
ogy and neuromuscular disorders.
Dr. Jones is a Clinical Professor of Neurology at Harvard Gregory J. Allam, MD, has a dad and brother who are also
Medical School and a Lecturer at Tufts University School of physicians. Greg received his medical degree from the American
Medicine. He served as a Director of the American Board of University of Beirut before coming to Boston to pursue his
Psychiatry and Neurology from 1997 to 2004 and concomi- neurology training though the Tufts University program, with
tantly was a member of the Residency Review Council of the additional training in EMG/neuromuscular disease and acute
Accreditation Council for Graduate Medical Education. He has care neurology at the Saint Elizabeth’s Medical Center in
served on the editorial boards of Neurology Continuum and Boston. Greg joined the Lahey Clinic neurology department
Muscle and Nerve and is a reviewer for many neurologic journals. in 1997 as a member of the neurovascular team with interests
Dr. Jones was the recipient of the Distinguished Physician in critical care neurology, as well as a skillful electromyographer.
Award of the American Association of Neuromuscular and While at Lahey Greg was recognized as an astute and caring
viii About the Editors
physician, especially by his many challenging patients whom he another year of radiology followed by a fellowship in neuro-
followed for their spasticity where his very careful Botox min- radiology there and at the Children’s Hospital Boston. After
istrations were often very successful. completion of his training, Dr. Baker joined the staff of the
Dr. Allam recently joined the Brigham and Woman’s Peter Bent Brigham Hospital and Harvard Medical School. The
Hospital in Boston and is director of stroke care at the South Lahey Clinic recruited him as their frst neuroradiologist in
Shore Hospital in South Weymouth, Massachusetts. He is a 1978. Dick helped to develop this section and later became
clinical instructor at the Harvard Medical School and lives radiology department chairman, as well as president of the
in the Suburban Boston area with his wife Christina, an endo- Lahey medical staff. He is currently an Associate Professor of
crinologist at Children’s Hospital Boston, and their two young Radiology at Tufts University School of Medicine.
children. His wisdom and clinical acumen are greatly appreciated and
highly sought after at Lahey. Dick was a major force in the
Richard A. Baker, MD, was raised in rural Ohio and graduated development of the frst volume of Netter’s Nervous System, Part
from the College of Wooster and the Case Western Reserve II, Neurologic and Neuromuscular Disorders published in 1986 and
Medical School in Cleveland. He interned at King County the frst edition of Netter’s Neurology, published in 2005.
Hospital, Seattle, Washington, and began an internal medicine Dick has two children, one who followed in the footsteps of
residency there. This was interrupted by service as a physician her mother as an infectious disease physician at Massachusetts
in the US Air Force. During his military tour Dick was stationed General Hospital and Harvard, and a son who is working on his
in Greenland, where in addition to his service responsibilities doctorate. Dr. Baker is a master gardener and a skilled wood-
he also volunteered to care for the native Inuits. He then pursued worker, something he is pursuing with vigor now that he is
a residency in radiology, initially at the University of Rochester, working part time. He also enjoys a variety of outdoor activities
and then later at the Peter Bent Brigham Hospital in Boston for with his wife, including skiing and hiking.
Acknowledgments
First and foremost I must thank Jaime Ortiz-Patino, my dear completion. My many Lahey Clinic colleagues, in particular
friend who underwrote the Jaime Ortiz-Patino Chair in Neuro- Paul T. Gross, MD, our department chairman, have been
logy at Lahey. This funding has provided me time to devote to most gracious in their enthusiastic support of this project. The
this project. Equally important once again, my wonderful wife, Elsevier team, including Marybeth Thiel, John Casey, Elyse
Mary, has put up with my very frequent weekend and evening O’Grady, and Carolyn Kruse, has always been very responsive
presence behind a laptop computer in our family room. and gracious in working with us. We are most appreciative of
Similarly, Jayashri, Greg, and Dick acknowledge the support their expertise and support.
and understanding of their families in bringing this project to
Foreword
Neurologic problems are among the most frequent encountered the features characterizing the typical course of a particular
in medicine. The trainee in neurology, whether a medical disorder, the investigative approach to clarify the likely diagno­
student or resident, often has diffculty in fully grasping the sis, and the optimal management plan. These vignettes focus
subject, in part because of the complexities of the anatomy and the attention of readers on details that might otherwise be over­
physiology involved and in part also because of the mystery that looked and help to make the volume clinically relevant, a feature
still enshrouds the brain. The amazing advances made in the that medical students will fnd particularly appealing. The
neurosciences over the past quarter century have, on the one artwork, too, has been updated, beneftting from the advances
hand, helped the clinician in the management of individual in neuroimaging in recent years. The illustrations, and particu­
patients and, on the other hand, increased wonder about the larly the rich color plates that made Frank Netter the premier
elegance of cerebral function. The current edition is intended medical artist of his time, help to convey to the reader an under­
as a resource to aid students endeavoring to understand neuro­ standing of clinical neurology and its scientifc underpinnings
logy and to keep up with advances in the feld. that it is hard to obtain with such facility elsewhere.
Netter’s Neurology was frst published in 2005 and met with Dr. H. Royden Jones, the editor, is joined by three co­editors
immediate acceptance. Edited by H. Royden Jones, Jr., a clinical for this new edition. The authors of the individual chapters are
professor of neurology at Harvard Medical School, holder of drawn from the current or former staff of the Lahey Clinic, and
the Jaime Ortiz­Patino chair in neurology at the Lahey Clinic, many are former trainees of the senior editor. They are rich in
and one of the outstanding clinical neurologists of his genera­ clinical experience, and this is refected in the text, where a
tion, the book presented a concise account of the subject, illus­ practical approach to the evaluation and management of neuro­
trated by the renowned medical artwork of Frank Netter and logic disorders is described with enviable clarity.
others. Rapid advances in the feld have underscored the need Readers will beneft greatly from this account of clinical
for a second edition of the book, however, and it is with especial neurology with its clear, fowing prose, amplifed by the remark­
pleasure that I welcome its publication. ably beautiful artwork contained within the volume. Together,
The new edition is broader in scope than the earlier one, but the text and artwork will give students a frm grasp of the fun­
improved design and an alteration in trim size have reduced the damentals of the subject. I congratulate the editors on their
overall number of pages. Every chapter has been updated and achievement in producing such an important addition to the
many have been rewritten almost completely to incorporate the medical literature.
accumulated wisdom of recent years and provide more details Michael J. Aminoff, MD, DSc, FRCP
on treatment. They contain numerous clinical vignettes exem­ Distinguished Professor of Neurology
plifying important points, such as clues to the site of the lesion, University of California, San Francisco
Preface
The second edition of Netter’s Neurology speaks to the perpetuity esteemed clinical neuroradiologist, has provided the neurora-
of Frank Netter’s incomparable artistic genius and educational diologic images for both of our earlier Netter texts. Concomi-
vision. During my frst year at Northwestern University Medical tantly I recruited two outstanding younger Lahey colleagues,
School we were forewarned as to how diffcult the introductory Jayashri Srinivasan and Gregory Allam, as our other co-editors.
neuroanatomy course was going to be, “the toughest one” that Both are master clinicians who are highly respected for their
we would face. A few upperclassmen told me to purchase the clinical acumen and teaching abilities. It has been an honor to
Netter Atlas of Neurosciences and it would all fall into place. work with both of them for more than a decade. As with the
Indeed it did, and I became interested in a career in neurology. frst edition of Netter’s Neurology all of the authors have a Lahey
However, in 1960 when I discussed the possibility of a neuro- Clinic heritage either as a current staff member, a former
logic career with Northwestern’s chairman of their combined fellow, or former staff. This seemingly parochial approach has
psychiatry and neurology department, he told me that one could allowed us to minimize duplication and, more important, ensure
not make a living as a neurologist; instead I would need to the reader that what is discussed herein represents the latest
eventually primarily practice Freudian psychiatry while just dab- approach to the patient with a clinical neurologic problem.
bling in neurology! That was not for me. A few years later my As Frank Netter often stated to me “a picture is worth a
internal medicine residency at Mayo required 3 months of neu- thousand words.” Indeed they are, and his magnifcent plates
rology; this was so interesting and intellectually challenging that provide the foundation for this monograph. However, when
I switched my career plans to neurology and gave up plans to conceiving the overall format for the frst edition of Netter’s
become a cardiologist. Neurology it was very important for me not only to include an
Having continued to be impressed with Dr. Netter’s skillful overview of a neurologic condition but also to use clinical case
renditions of many medical subjects, as presented in his semi- vignettes, particularly since these are my most effective means
monthly Ciba Symposia, some years later I enquired at an AMA of teaching. Case-based methodologies are currently used at a
meeting, where these were on display, as to whether he might number of medical schools; we have aimed this volume to com-
have interest in illustrating the various mononeuropathies. plement such for both the undergraduate medical student as
Never did I think this suggestion would be transmitted directly well as residents. My frst neuroscience teachers at Northwest-
to Dr. Netter. However, less than a year later, in 1982, I received ern very effectively used patient presentations to bring life to
a letter from him asking me to elaborate my ideas. I soon found the complexities of basic neurologic anatomy and physiology.
myself visiting Dr. Netter at his new studio in Palm Beach. This This didactic approach was very well received by the beginning
was an undreamed of opportunity, especially as one of my student and resident alike in the frst edition of Netter’s Neurol-
hobbies includes rather amateur attempts at oil and water color ogy. We also think that the practicing clinical neurologist will
painting. After a few visits with Frank, who was a very gracious fnd this combination of basic anatomy and clinical neurology
and kind gentleman, he asked me to help him revise his Neuro- to be a refreshing alternative to the various forms of clinical
logic and Neuromuscular Disorders of his two-volume Netter review now available for our required recertifcation process.
Nervous System atlas, the very one that had so impressed me Concomitantly my co-editors and I hope that the internal
during my frst-year neuroanatomy course. We spent many medical resident and the general internist will fnd the blending
3-day weekends together as he listened to my ideas as to how of Netter paintings with clinical medicine to be similarly
best illustrate each subject. The typical Netter day began in his useful.
studio at 7 AM … Frank always had a cigar going, and in self- Every chapter in this second edition has been carefully
defense I kept a pipe well stoked. With much help from some reviewed and in most instances signifcantly rewritten. The total
dear colleagues, this was published in 1986. number of chapters was reduced, as we combined some subjects
We planned to update this text every 6 to 8 years; however, into one broader area. Many new vignettes have been added,
with Frank’s death in 1991 and Ciba Pharmaceutical’s merging and in a number of instances we replaced some of those in the
into Novartis, ongoing revisions seemed to be relegated to the frst edition. The plates have a number of new MR images, and
publishing tundra. Much to my delight in 2000 Icon Publishers some are reedited in their entirety. New plates have also been
contacted me after they had purchased the rights to use the added. Elsevier has changed the overall format to a standard text
Netter paintings. Their vision led to the development of a size that provides a slimmer volume. As in the frst edition this
number of more traditional, specialty oriented textbooks, and is not a source for specifc pharmacologic dosing, as such is an
I had the honor of editing the frst neurology edition in this ever evolving standard. We are excited to be able to present this
more classic format. volume and are particularly pleased to be able to take advantage
Now 52 years after my introduction to Dr. Netter’s artwork, of the many publishing attributes that the Elsevier/Saunders
we are fnishing my third text utilizing his magnifcent paintings staff brings to the table.
and are already proceeding to a new edition of his Neurosciences
atlas. On this occasion I have asked three colleagues to co-edit H. Royden Jones, Jr., MD
this volume with me. My dear friend, Richard Baker, a highly June 5, 2011
Contributors
Lloyd M. Alderson, MD G. Rees Cosgrove, MD
Department of Neurosurgery Professor and Chairman
Lahey Clinic Department of Neurosurgery
Burlington, Massachusetts Brown University Medical School
Providence, Rhode Island
Timothy D. Anderson, MD
Department of Otolaryngology Donald E. Craven, MD
Lahey Clinic Chairman, Department of Infectious Diseases
Burlington, Massachusetts Lahey Clinic
Burlington, Massachusetts;
Diana Apetauerova, MD Professor of Medicine
Department of Neurology Tufts University School of Medicine
Lahey Clinic Boston, Massachusetts
Burlington, Massachusetts
Carlos A. David, MD
Jefrey E. Arle, MD, PhD Department of Neurosurgery
Department of Neurosurgery Lahey Clinic
Lahey Clinic Burlington, Massachusetts
Burlington, Massachusetts
Peter K. Dempsey, MD
Ritu Bagla Department of Neurosurgery
Department of Neurology Lahey Clinic
Lahey Clinic Burlington, Massachusetts
Burlington, Massachusetts
Robert A. Duncan, MD
Ted M. Burns, MD Department of Infectious Diseases
University of Virginia Health Sciences Lahey Clinic
Department of Neurology Burlington, Massachusetts
Charlottesville, Virginia
Stephen R. Freidberg, MD
Ann Camac, MD Department of Neurosurgery
Department of Neurology Lahey Clinic
Lahey Clinic Burlington, Massachusetts
Lexington, Massachusetts
Paul T. Gross, MD
Peter J. Catalano, MD Chairman, Department of Neurology
Department of Otolaryngology Lahey Clinic
Lahey Clinic Burlington, Massachusetts
Burlington, Massachusetts
Jose A. Gutrecht
Claudia J. Chaves, MD Department of Neurology
Department of Neurology Lahey Clinic
Lahey Clinic Burlington, Massachusetts
Lexington, Massachusetts
Gisela Held, MD
Ellen Choi, MD Department of Neurology
Attending Anesthesiologist Lahey Clinic Northshore
Santa Clara Valley Medical Center Peabody, Massachusetts
San Jose, California
Doreen Ho
Department of Neurology
Lahey Clinic
Burlington, Massachusetts