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LectureNotes:Neurology i Tomychildren Amelia,TobyandConnie andinmemoryoftheirmother AndreaMargueriteCobon ii Lecture Notes Neurology Lionel Ginsberg BSc,MB,BS,PhD,FRCP ConsultantNeurologist,RoyalFreeHospital,London; HonoraryConsultantPhysician,NationalHospitalfor NeurologyandNeurosurgery,QueenSquare,London; ClinicalSub-DeanandWelfareTutor,RoyalFreeCampus, UniversityCollegeLondonMedicalSchool,London Ninth Edition A John Wiley & Sons, Ltd., Publication iii Thiseditionfirstpublished2010,(cid:1)C by2010LionelGinsberg Previouseditions:1965,1968,1970,1974,1980,1985,1999,2005 BlackwellPublishingwasacquiredbyJohnWiley&SonsinFebruary2007.Blackwell’spublishingprogramhasbeen mergedwithWiley’sglobalScientific,TechnicalandMedicalbusinesstoformWiley-Blackwell. 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Designationsusedbycompaniestodistinguishtheirproductsareoftenclaimedastrademarks.Allbrandnamesand productnamesusedinthisbookaretradenames,servicemarks,trademarksorregisteredtrademarksoftheir respectiveowners.Thepublisherisnotassociatedwithanyproductorvendormentionedinthisbook.This publicationisdesignedtoprovideaccurateandauthoritativeinformationinregardtothesubjectmattercovered.Itis soldontheunderstandingthatthepublisherisnotengagedinrenderingprofessionalservices.Ifprofessionaladvice orotherexpertassistanceisrequired,theservicesofacompetentprofessionalshouldbesought. LibraryofCongressCataloging-in-PublicationData Ginsberg,Lionel. Lecturenotes.Neurology/LionelGinsberg.–9thed. p.;cm. Includesbibliographicalreferencesandindex. ISBN978-1-4051-7722-1 1.Neurology. I.Title. II.Title:Neurology. [DNLM:1.NervousSystemDiseases.WL140G493L2010] RC346.G562005 616.8–dc22 2009038758 ISBN:9781405177221 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Setin8/12ptStoneSerifbyAptara(cid:1)R Inc.,NewDelhi,India PrintedinSingapore 1 2010 iv Contents Prefacetotheninthedition,vi 11 Stroke,81 Prefacetotheseventhedition,vii 12 Parkinson’sdiseaseandothermovement Acknowledgements,viii disorders,91 13 Neurosurgicaltopics:headinjuryandbrain tumour,102 Part1: TheNeurologicalApproach 14 Neurologicalinfections,111 1 Neurologicalhistory-taking,3 15 Spinalconditions,121 2 Consciousness,7 16 Multiplesclerosis,129 3 Cognitivefunction,11 17 Nerveandmuscle,137 4 Visionandothercranialnerves,17 18 Developmentanddegeneration,147 5 Motorfunction,35 19 Neurologyandothermedicalspecialties,161 6 Sensation,45 20 Neurologicalemergencies,173 7 Autonomicfunction,49 21 Neurorehabilitation,177 8 Investigatingthepatient,52 Multiplechoicequestions,182 Answerstomultiplechoicequestions,187 Part2: NeurologicalDisorders Index,189 9 Headacheandfacialpain,63 10 Epilepsy,72 v Preface to the ninth edition The seventh edition of Lecture Notes on Neurology ● The text has been fully updated to reflect the involvedacompleterevisionofthetext,anoppor- continuing rapid advances in neurological man- tunityaffordedbythechangeofauthor.Withthe agement. eighthandnintheditions,therehavebeenfurther Tony Wilson and Charlie Davie, Consultant refinementsasfollows: Neurologists,kindlyreadandcommentedonthe ● Selectedcasehistories,drawnfromlife,aregiven casehistoriesandexaminationquestions,respec- attheendofeachchapterinPart2ofthebook,so tively. Susan Huson, Consultant Clinical Geneti- that important clinical points made in the main cist, commented on Table 18.3. Editorial staff at textcanbeillustratedandexpanded. Wiley-Blackwell,notablyLauraMurphyandKaren ● A series of sample examination questions Moore,werepatientandtolerantasalways.Final and answers is given at the end of the vol- thanksmustagaingotoSue,mywife,forheren- ume. Desmond Kidd, Consultant Neurologist, couragementandsupport. and Thomas Solbach, Consultant Neuroradiolo- gist, kindly provided figures to accompany some LionelGinsberg ofthesequestions. ● Someofthefiguresinthemaintexthavebeen replacedandafewnewonesadded. vi Preface to the seventh edition Morethanadecadehaspassedsincethesixthedi- trates on common diseases. The book falls natu- tionofDrIvanDraper’sLectureNotesonNeurology. rally into two parts. The first section, ‘The Neu- This seventh edition has been prepared with the rological Approach’, is concerned with history- dual aims of reflecting advances in neurology in takingandexamination,wherepossiblelinkedto theinterveningperiodandchangesintheunder- relevantanatomyandphysiology.Afinalchapter graduatemedicalcurriculum. inthispartoutlinestheexpandingrangeofneu- There have been dramatic developments in rologicalinvestigations.Thesecondsection,‘Neu- neurological practice in recent years, parallel- rologicalDisorders’,isasystematicaccountofthe ing achievements in basic neuroscience research. commonconditions,raritiesbeingrelegatedtothe These include new imaging techniques, which tables, or to a brief thumbnail sketch. There are have greatly refined diagnostic accuracy and also chapters on neurological emergencies, neu- spared patients the discomfort of previous inves- rorehabilitationandtheinterfacebetweenneurol- tigativeapproaches.Noveltherapiesarebeginning ogyandotherspecialties.Theseparationofgeneral toappearforconditionsonceconsidereduntreat- from systematic is incomplete. For convenience, able.Moleculargeneticresearchhascastnewlight some disorders are discussed in the first part of ondiseasepathogenesisandshouldultimatelypay thebookandsomeprinciplesappearforthefirst dividendsinthetreatment,aswellasdiagnosis,of timeinthesecond.Theauthoralsoapologizesfor inheriteddisorders. occasions where his enthusiasm has allowed dis- Despite these advances, neurology remains par cussion of a few topics that might be considered excellence a clinical discipline. Contrary to popu- beyondtherangeofa‘corecurriculum’.Theirin- lar opinion outside the specialty, it is not a ster- clusion may, it is hoped, be justified on grounds ile and obscure diagnostic exercise. Neurological ofcontinuityandinterest,particularlywherethey disorders are common, permeating the whole of reflectgrowingareasofneurologicalresearchand general medicine and surgery. Their diagnosis is practice. basedonaccuratehistory-takingandphysicalex- This new edition of Lecture Notes on Neurology amination,coupledwiththeapplicationoflogical shouldfunctionasaportablecompanionduringa rules derived from knowledge of the underlying student’sneurologyclinicalattachment,andalso anatomy,physiologyandpathology. seniormedicalclerkships.Itmayserveasarevision Thisvolumeisintendedtoemphasizethesegen- aid,andcontainsagroundingforearlypostgradu- eral principles. In line with the concept of an ateworkingeneralmedicine. undergraduate ‘core curriculum’, it also concen- LionelGinsberg vii Acknowledgements Thisworkwouldnothavebeencompletedwithout Robinson, have been embodiments of patience the secretarial assistance of Barbara Parker, who andtolerance. uncomplaininglycopedwithnumerousdraftsand Mostoftheradiologicalfigureswerekindlypro- corrections. Many colleagues read selected chap- vided by Alan Valentine, Consultant Neuroradi- ters. I am grateful to Bob Bradford, Consultant ologist. Figure 10.1 was from the Department of Neurosurgeon, Heather Angus-Leppan, Jeremy Clinical Neurophysiology at the Royal Free Hos- Gibbs, John Hodges, Gareth Llewelyn, Gordon pital. Pathological plates were prepared by Jim Plant,TonySchapira,NeilScolding,TomWarner McLaughlin, Consultant Neuropathologist. The and Tony Wilson, Consultant Neurologists, for Department of Medical Illustration at the Royal their comments. The responsibility for any re- FreeHospitalhelpedprovidemostoftheclinical mainingerrorsis,ofcourse,myown.Severalstu- photographs. Several other figures were prepared dentreviewersatBlackwellPublishingalsomade byKieranPrice.Finally,Ithankmywife,Sue,who helpfulsuggestions,whichhavebeenincorporated encouraged and supported me, and drafted most whereverpossible.TheeditorialstaffatBlackwell ofthelinedrawings. Publishing, particularly Mike Stein and Andrew LionelGinsberg viii