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Contents

Preface xvi

How to UseThis Book xix

Chapter 1 Introductionto ClinicalCasePresentations3Introduction 4

The General History and Physical Exam 4Chief Complaint (CC) 5History of the Present Illness (HPI) 5Past Medical History (PMH) 6Review of Systems (ROS) 6Family History (FHx) 6Social and Environmental History (SocHx/EnvHx) 6

Medications and Allergies 6PhysicalExam 7Laboratory Data 7Assessmentand Plan 7

Neurologic Differential Diagnosis 8

Relationship between the General Physical Examand the Neurologic Exam 9

References 11

Chapter 2 NeuroanatomyOverviewandBasicDefinitions 13Basic Macroscopic Organization of the Nervous

System 14Main Parts of the NervousSystem 14Orientation and Planes of Section 16

Basic Cellular and Neurochemical Organizationof the Nervous System 17

CNSGray Matter and White Matter; PNS Gangliaand Nerves 21

Spinal Cord and Peripheral Nervous System 22

Cerebral Cortex: Basic Organization and PrimarySensory and Motor Areas 24

Lobesof the Cerebral Hemispheres 24Surface Anatomy of the Cerebral Hemispheres in

Detail 25

PrimarySensory and Motor Areas 28

CellLayersand Regional Classificationof the CerebralCortex 29

Motor Systems 32Main Motor Pathways 32Cerebellum and BasalGanglia 34

Somatosensory Systems 34Main Somatosensory Pathways 34Thalamus 35

Stretch Reflex 37

Brainstem and Cranial Nerves 38

Limbic System 41Association Cortex 41

Blood Supply to the Brain and Spinal Cord 44Conclusions 46References 46

Chapter 3 TheNeurologicExamasa Lessonin Neuroanatomy 49Overview of the Neurologic Exam 50neuroexam.com 52

The Neurologic Exam: Examination Techniqueand What Is Being Tested 521. MentalStatus 522. CranialNerves 58

3. Motor Exam '634. Reflexes 645. Coordination and Gait 68

6. Sensory Exam 70The Neurologic Exam as a Flexible Tool 72Coma Exam 73

viii CONTENTS

General PhysicalExam 731. Mental Status 732. Cranial Nerves 75

3. Sensory Exam and 4. Motor Exam 765. Reflexes 776. Coordination and Gait 78

Brain Death 78

Conversion Disorder, Malingering, and RelatedDisorders 78

The Screening Neurologic Exam 80Conclusions 81

References 81

Chapter 4 Introductionto ClinicalNeuroradiology83Introduction 84

Imaging Planes 84

Computerized Tomography 84CTversusMRI 87

Magnetic Resonance Imaging 87

Neuroangiography 93

Functional Neuroimaging 95Conclusions 97

NEURORADIOLOGICALATLAS 98

References 119

Chapter 5 BrainandEnvirons:Cranium,Ventricles,andMeninges 121ANATOMICALAND CLINICALREVIEW 122

Cranial Vault and Meninges 122

Ventricles and Cerebrospinal Fluid 128Blood-Brain Barrier 133KCC5.1 Headache 135

KCC5.2 Intracranial Mass Lesions 137KCC5.3 Elevated Intracranial Pressure 137

KCC5.4 Brain Herniation Syndromes 140KCC5.5 Head Trauma 142

KCC5.6 Intracranial Hemorrhage 143KCC5.7 Hydrocephalus 151KCC5.8 Brain Tumors 152

KCC5.9 Infectious Disorders of the Nervous System 154KCC5.10 Lumbar Puncture 161

KCC5.11 Craniotomy 163CLINICALCASES 164

5.1 An Elderly Man with Headaches and Unsteady Gait164

5.2 Altered Mental Status Following Head Injury 1665.3 Delayed Unresponsiveness after Head Injury 174

5.4 Headache and Progressive Left-Sided Weakness 1765.5 Sudden Coma and Bilateral Posturing during

IntravenousAnticoagulation 1805.6 SevereHeadInjury 1885.7 A Child with Headaches, Nausea, and Diplopia 1895.8 Headaches and Progressive Visual Loss 1965.9 An Elderly Man with Progressive Gait Difficulty,

Cognitive Impairment, and Incontinence 1995.10 A Young Man with Headache, Fever, Confusion, and

StiffNeck 203

Additional Cases 204

BRIEFANATOMICAL STUDY GUIDE 205

A Scuba Expedition through the Brain 206References 208

Chapter 6 CorticospinalTractand OtherMotor Pathways 213ANATOMICALAND CLINICALREVIEW 214

Motor Cortex, Sensory Cortex, and SomatotopicOrganization 214

BasicAnatomy of the Spinal Cord 216

Spinal Cord Blood Supply 219

General Organization of the Motor Systems 220Lateral Corticospinal Tract 222

Autonomic Nervous System 228KCC6.1 Upper Motor Neuron versus Lower Motor Neuron

Lesions 231KCC6.2 Terms Used to Describe Weakness 232

KCC6.3 Weakness Patterns and Localization 232

KCC6.4 Detecting Subtle Hemiparesis at the Bedside 239KCC6.5 Unsteady Gait 241

KCC6.6 Multiple Sclerosis 241KCC6.7 Motor Neuron Disease 243

CLINICALCASES 244

6.1 Sudden Onset of Right Hand Weakness 2446.2 Sudden Onset of left Foot Weakness 245

6.3 Sudden Onset of Right Face Weakness 249

CONTENTS ix

6.4 Pure Motor Hemiparesis I 251

6.5 Pure Motor Hemiparesis II 2536.6 Progressive Weakness, Muscle Twitching, and Cramps

256


BRIEFANATOMICALSTUDY GUIDE 258

References 259

Chapter 7 SomatosensoryPathways 263ANATOMICALAND CLINICALREVIEW 264

Main Somatosensory Pathways 264

Posterior Column-Medial Lemniscal Pathway 267

Spinothalamic Tract and Other AnterolateralPathways 268

Somatosensory Cortex 270Central Modulation of Pain 270

The Thalamus 271

Relay Nuclei 273Intralaminar Nuclei 274Reticular Nucleus 275

KCC7.1 Paresthesias 276

KCC7.2 Spinal Cord lesions 276KCC7.3 Sensory loss: Patterns and localization 277

KCC7.4 Spinal Cord Syndromes 279

Chapter 8 SpinalNerveRoots 303ANATOMICAL AND CLINICALREVIEW 304

Segmental Organization of the Nervous System304

Nerve Roots in Relation to Vertebral Bones, Discs,and Ligaments 305

Dermatomes and Myotomes 307KCC8.1 Disorders of Nerve, Muscle, and Neuromuscular

Junction 311

KCC8.2 Back Pain 314

KCC8.3 Radiculopathy 315

Simplification: Three Nerve Roots to Remember inthe Arm 317

Simplification:Three Nerve Roots to Remember inthe Leg 317

KCC8.4 CaudaEquina Syndrome 318KCC8.5 Common Surgical Approaches to the Spine 318CLINICALCASES 319

8.1 Unilateral Neck Painand TinglingNumbnessin theThumb and Index Finger 319

KCC7.5 Anatomy of Bowel, Bladder, and Sexual Function282

CLINICALCASES 285

7.1 SuddenOnset of RightArm Numbness 285

7.2 Sudden Onset of Right Face, Arm, and leg Numbness286

7.3 A Fall Causing Paraplegia and a Sensory level 288

7.4 left leg Weakness and Right leg Numbness 291

7.5 Sensory loss over Both Shoulders 293

7.6 Body Tingling and Unsteady Gait 295

7.7 Hand Weakness, Pinprick Sensory level, and UrinaryRetention 296


BRIEF ANATOMICAL STUDY GUIDE 297

References 300

8.2 Unilateral Occipital and Neck Pain 3208.3 Unilateral Shoulder Pain and Weakness 321

8.4 Blisters, Pain, and Weakness in the left Arm 3238.5 Unilateral Shoulder Pain and Numbness in the Index

and Middle Fingers 324 .

8.6 Unilateral Neck Pain, Hand Weakness, and Numbnessin the Ringand little Fingers 325

8.7 Painand Numbnessin the MedialArm 326

8.8 low Back Pain Radiating to the Sole of the Foot andthe Small Toe 327

8.9 Unilateral Thigh Weakness with Pain Radiating tothe AnteriorShin 328

8.10 low BackPain,Radiatingto the BigToe 3298.11 Saddle Anesthesia with loss of Sphincteric and

ErectileFunction 332Additional Cases 335


References 336

X CONTENTS

Chapter 9 MajorPlexusesandPeripheralNerves 339ANATOMICAL AND CLINICALREVIEW 340Brachial Plexus and Lumbosacral Plexus 340Simplification: Five Nerves to Remember

in the Arm 342

Simplification:Three Nerves Acting onthe Thumb 344

Intrinsic and Extrinsic Hand Muscles 344Simplification: Five Nerves to Remember

in the Leg 345KCC9.1 CommonPlexus and Nerve Syndromes 346KCC9.2 Electromyography (EMG)and Nerve Conduction

Studies 349

CLINICALCASES 351

9.1 Complete Paralysis and Lossof Sensationin One Arm 351

9.2 A Newborn with Weakness in One Arm 353

9.3 A Blow to the Medial Arm Causing Hand Weaknessand Numbness 353

9.4 Nocturnal Pain and Tingling in the Thumb, Pointer,and Middle Finger 355

9.5 Hand and Wrist Weakness after a Fall 355

9.6 Numbness and Tingling in the Pinkyand Ring Finger 356

9.7 Unilateral Thigh Pain, Weakness, and Numbness in aDiabetic 357

9.8 Tingling and Paralysis of the Foot after a Fall 358

9.9 A leg Injury Resulting in Foot Drop 3599.10 lateral Thigh Pain and Numbness after

Pregnancy 3619.11 Dysarthria, Ptosis, and Decreased Exercise

Tolerance 362

Additional Cases 363BRIEFANATOMICAL STUDY GUIDE 363References 363

Chapter 10 CerebralHemispheresand VascularSupply 367ANATOMICAL AND CLINICALREVIEW 368Review of Main Functional Areas of Cerebral

Cortex 368

Circle of Willis: Anterior and Posterior Circulations369

Anatomy and Vascular Territories of the ThreeMain Cerebral Arteries 371

Vascular Territories of the Superficial CerebralStructures 371

Vascular Territories of the Deep Cerebral Structures373

KCC10.1 ClinicalSyndromes of the Three Main CerebralArteries 376

KCC10.2 Watershed Infarcts 378

KCC10.3 Transient Ischemic Attack and Other TransientNeurologic Episodes 379

KCC10.4 Ischemic Stroke: Mechanisms and Treatment380

KCC10.5 Carotid Stenosis 384

KCC10.6 Dissection of the Carotid or Vertebral Arteries385

Venous Drainage of the Cerebral Hemispheres386

KCC10.7 Sagittal Sinus Thrombosis 387

CLINICAL.CASES 38810.1 Sudden-Onset Worst Headache of life 388

10.2 left leg Weakness and left Alien Hand Syndrome389

10.3 Decreased Vision on One Side 390

10.4 Transient Episodes of left Eye Blurriness or RightHand Weakness 398

10.5 Nonfluent Aphasia with Right Face and ArmWeakness 399

10.6 Talking Ragtime 403

10.7 Dysarthria and Hemiparesis 404

10.8 Global Aphasia, Right Hemiplegia, and Hemianopia405

10.9 left Face and Arm Weakness 408

10.10 left Hemineglect 411

10.11 left Hemineglect, Hemiplegia, and Hemianopia413

10.12 Unilateral Proximal Arm and leg Weakness 41510.13 Right Frontal Headache and left Arm Numbness in a

Woman with Gastric Carcinoma 419


BRIEFANATOMICAL STUDY GUIDE 421References 424

Chapter 11 VisualSystem 427ANATOMICAL AND CLINICAL REVIEW 428

Eyes and Retina 428

Optic Nerves, Optic Chiasm, and Optic Tracts 431

Lateral Geniculate Nucleus and ExtrageniculatePathways 432

Optic Radiations to Primary Visual Cortex 433

Visual Processing in the Neocortex 435

Parallel Channels for Analyzing Motion, Form, andColor 435

Ocular Dominance Columns and OrientationColumns 437

KCC11.1 Assessment of Visual Disturbances 438

KCC11.2 Localization of Visual Field Defects 440

KCC11.3 Blood Supply and Ischemia in the VisualPathways 443

CONTENTS xi

KCC11.4 Optic Neuritis 445

CLINICAL CASES 446

11.1 A Dark Spot Seen with One Eye 446

11.2 Vision Lossin One Eye 447

11.3 Menstrual Irregularity and BitemporalHemianopia 448

11.4 Hemianopia after Treatment for a Temporal LobeTumor 449

11.5 Visual Changes Caused by Migraine Headaches? 451



References 456

Chapter 12 BrainstemI: SurfaceAnatomy and CranialNerves 459ANATOMICALAND CLINICALREVIEW 460Surface Features of the Brainstem 461Skull Foramina and Cranial Nerve Exit Points 464

Sensory and Motor Organization of the CranialNerves 466

Functions and Course of the Cranial Nerves 469

CN I: Olfactory Nerve 471KCC12.1Anosmia(CNI) 472CN II: Optic Nerve 472CN III, IV,and VI: Oculomotor, Trochlear, and

Abducens Nerves 472

CN V: Trigeminal Nerve 474KCC12.2 Trigeminal Nerve Disorders (CN V) 478CN VII: Facial Nerve 479

KCC12.3 Facial Nerve Lesions (CN VII) 482KCC12.4 Corneal Reflex and Jaw Jerk Reflex (CN V, VII)

484

CN VIII: Vestibulocochlear Nerve 484

Auditory Pathways 485

Vestibular Pathways 489

KCC12.5 Hearing Loss(CN VIII) 491KCC12.6 Dizziness and Vertigo (CN VIII) 492

CN IX: Glossopharyngeal Nerve 495

CN X: Vagus Nerve 496CN XI: Spinal Accessory Nerve 499CN XII:Hypoglossal Nerve 499KCC12.7 Disorders of CNIX,X, XI,and XII 500KCC12.8 Hoarseness, Dysarthria, Dysphagia, and

Pseudobulbar Affect 500Review: Cranial Nerve Combinations 502

CLINICAL CASES 504

12.1Anosmiaand VisualImpairment 50412.2 CheekNumbnessand a BulgingEye 50512.3 Jaw Numbnessand Episodesof Lossof Consciousness

50812.4 IsolatedFacialWeakness 50912.5 Hearing Lossand Dizziness 51212.6 Hoarse Voice Following Cervical DiscSurgery 51612.7 Hoarseness, with Unilateral Wasting of the Neck and

Tongue Muscles 51712.8 Uncontrollable Laughter, Dysarthria, Dysphagia, and

Left-Sided Weakness 521Additional Cases 522


References 526

xii CONTENTS

Chapter 13 BrainstemII:EyeMovementsandPupillaryControl 529

Chapter 14 BrainstemIII:InternalStructuresandVascularSupply576576

ANATOMICAL AND CLINICAL REVIEW 530

Extraocular Muscles, Nerves, and Nuclei 530

Extraocular Muscles 530

Extraocular Nerves and Nuclei 532

KCC13.1 Diplopia 535

KCC13.2 Oculomotor Palsy (CN III) 536

KCC13.3 Trochlear Palsy(CN IV) 538

KCC13.4 Abducens Palsy (CN VI) 539

The Pupils and Other Ocular Autonomic Pathways540

KCC13.5 Pupillary Abnormalities 543KCC13.6 Ptosis 546

Cavernous Sinus and Orbital Apex 546

KCC13.7 Cavernous Sinus Syndrome (CN III, IV, VI, V,) andOrbital Apex Syndrome (CN II, III, IV,VI, V,) 547

Supranuclear Control of Eye Movements 548

Brainstem Circuits for Horizontal Eye Movements 548

KCC13.8 Brainstem lesions Affecting Horizontal Gaze 549

ANATOMICALAND CLINICALREVIEW

Main Components of the BrainstemBrainstem Sections 577

Cranial Nerve Nuclei and Related Structures 584

Long Tracts 586KCC14.1locked-in Syndrome 587Cerebellar Circuitry 587Reticular Formation and Related Structures 588

Widespread Projection Systems of Brainstem andForebrain: Consciousness,Attention, andOther Functions 589

Brainstem Reticular Formation and Thalamus 590

Identified Neurotransmitter Systems 592Anatomy of the Sleep-Wake Cycle 598KCC14.2 Comaand RelatedDisorders 601Reticular Formation Motor, Reflex, and

Autonomic Systems 605

Brainstem Vascular Supply 607

KCC13.9 Parinaud's Syndrome 551

KCC13.10 Right-Way Eyesand Wrong-Way Eyes 552

CLINICAL CASES 554

13.1 Double Vision and Unilateral Eye Pain 554

13.2 A Diabetic with Horizontal Diplopia 555

13.3 Vertical Diplopia 557

13.4 left Eye Pain and Horizontal Diplopia 558

13.5 Unilateral Headache, Ophthalmoplegia, andForehead Numbness 559

13.6 Ptosis, Miosis, and Anhidrosis 560

13.7 Wrong-Way Eyes 562

13.8 Horizontal Diplopia in a Patient with MultipleSclerosis 563

13.9 Headaches and Impaired Upgaze 567Additional Cases 568


References 572

575KCC14.3 Vertebrobasilar Vascular Disease 612

CLINICALCASES 620

14.1 Faceand Contralateral Body Numbness, Hoarseness,Horner's Syndrome, and Ataxia 620

14.2 Hemiparesis Sparing the Face 622

14.3 Dysarthria and Hemiparesis 626

14.4 Unilateral FaceNumbness, Hearing loss, and Ataxia626

14.5 locked In 629

14.6 Wrong-Way Eyes,limited Upgaze, DecreasedResponsiveness,and Hemiparesis with an AmazingRecovery 632

14.7 Diplopia and Unilateral Ataxia 639

14.8 Intermittent Memory loss, Diplopia, Sparkling lights,and Somnolence 641

14.9 Intractable Hiccups 644



References 650

Chapter 15 Cerebellum653ANATOMICALAND CLINICALREVIEW 654

Cerebellar lobes, Peduncles, and Deep Nuclei654

Microscopic Circuitry of the Cerebellum 658

Cerebellar Output Pathways 660

Cerebellar Input Pathways 664

Vascular Supply to the Cerebellum 668

KCC15.1CerebellarArtery Infarctsand CerebellarHemorrhage 669

KCC15.2ClinicalFindingsand Localizationof CerebellarLesions 670

Chapter 16 BasalGanglia 689ANATOMICALAND CLINICALREVIEW 690

BasicThree-Dimensional Anatomy of the BasalGanglia 690

Input, Output, and Intrinsic Connections of theBasal Ganglia 698

Inputs to the Basal Ganglia 698Outputs from the Basal Ganglia 699Intrinsic Basal Ganglia Connections 699Hyperkinetic and Hypokinetic Movement Disorders

701

Parallel Basal Ganglia Pathways for Movement,Eye Movement, Cognition, and Emotion 702

Ansa lenticularis, lenticular Fasciculus,and theFields of Forel 704

KCC16.1 Movement Disorders 705

CONTENTS xiii

KCC15.3 Differential Diagnosis of Ataxia 675

CLINICAL CASES 67615.1 Sudden Onset of Unilateral Ataxia 676

15.2 Walking Like a Drunkard 67715.3 A Boy with Headaches, Nausea, Slurred Speech, and

Ataxia 680

15.4 Nausea, Progressive Unilateral Ataxia, and Right FaceNumbness 682



References 687

KCC16.2Parkinson'sDiseaseand RelatedDisorders 712

KCC16.3 Huntington'sDisease 716KCC16.4 Stereotactic Surgery for Movement Disorders and

Other Conditions 717

CLINICALCASES 719

16.1 Unilateral Flappingand Flinging 71916.2 IrregularJerking Movementsand MaritalProblems

720

16.3 Asymmetrical Resting Tremor, Rigidity,Bradykinesia,and Gait Difficulties 723

16.4 Bilateral Bradykinesia, Rigidity, and Gait Instabilitywith NoTremor 726



References 733

Chapter 17 PituitaryandHypothalamus737ANATOMICALAND CLINICALREVIEW 738

Overall Anatomy of the Pituitary andHypothalamus 738

Important Hypothalamic Nuclei and Pathways740

Major Hypothalamic Nuclei 740Hypothalamic Control of the Autonomic Nervous

System 741

Hypothalamic-Limbic Pathways 742Other Regionalized Functions of the Hypothalamus

742

Endocrine Functions of the Pituitary andHypothalamus 743

KCC17.1 Pituitary Adenoma and Related Disorders 746

KCC17.2 Diabetes Insipidus and SIADH 749

KCC17.3 Panhypopituitarism 750

CLINICAL CASES 751

17.1 Moon Facies,Acne, Amenorrhea, and Hypertension751

17.2 Impotence, Anorexia, Polyuria, Blurred Vision,Headaches, and Hearing Loss 754



References 759

xiv CONTENTS

Chapter 18 LimbicSystem:Homeostasis,Olfaction,Memory,andEmotion 761

ANATOMICAL AND CLINICALREVIEW 762Overview of Limbic Structures 763

Olfactory System 770

Hippocampal Formation and Other Memory-Related Structures 771

Hippocampal Formation and Parahippocampal Gyrus772

Intrinsic Circuitry of the Hippocampal Formation776

Input and Output Connections of the MedialTemporal Lobe Memory System 777

The Fornix and Medial Diencephalic MemoryPathways 778

KCC18.1 MemoryDisorders 780The Amygdala: Emotions, Drives, and Other

Functions 787

Other Limbic Pathways 789

KCC18.2 Seizures and Epilepsy 790

KCC18.3 Anatomical and Neuropharmacological BasisofPsychiatricDisorders 798

CLINICAL CASES 800

Case 18.1 Sudden Memory Lossafter a Mild Head Injury800

Case 18.2 Progressive Severe Memory Loss,with MildConfabulation 802

Case18.3 TransientDiplopia,Lethargy,and Hemiparesis,Followedby a SustainedMemoryDeficit 804

Case18.4 Episodesof Panic,OlfactoryHallucinations,andLossof Awareness 806

Case18.5 Episodesof Staring,LipSmacking,and UnilateralSemipurposefulMovements 809

BRIEFANATOMICAL STUDY GUIDE 816Additional Cases 817

References 817

Chapter 19 Higher-OrderCerebralFunction 821ANATOMICAL AND CLINICALREVIEW 822KCC19.1 The Mental Status Exam 822Unimodal and Heteromodal Association Cortex

823

Principles of Cerebral Localization andLateralization 825

The Dominant Hemisphere: Language Processingand Related Functions 827

KCC19.2 Differential Diagnosis of Language Disorders 829KCC19.3 Bedside Language Exam 830KCC19.4 Broca's Aphasia 831KCC19.5 Wernicke's Aphasia 832KCC19.6 Simplified Aphasia Classification Scheme 833KCC19.7 Other Syndromes Related to Aphasia 835KCC19.8 Disconnection Syndromes 838The Nondominant Hemisphere: Mechanisms of

Attention and Spatial Processing 839LateralizedAspects of Attention 839Spatial Analysisand Integration 840

KCC19.9 Hemineglect Syndrome 841KCC19.10 Other Clinical Features of Nondominant

HemisphereLesions 846

The Frontal Lobes: Anatomy and Functions of anEnigmatic Brain Region 847

Regional Anatomy of the Frontal Lobes 847Connections of the Prefrontal Cortex 848Functions of the Frontal Lobes 849

KCC19.11FrontalLobeDisorders 850

Visual Association Cortex: Higher-Order VisualProcessing 854

KCC19.12Disordersof Higher-OrderVisualProcessing 855KCC19.13 Auditory Hallucinations 858Attention, Awareness, and Other General Network

Functions of The Brain 859General Mechanismsof Attention 859

Awareness of Self and Environment 862KCC19.14 Attentional Disorders 864KCC19.15Deliriumand Other Acute Mental Status

Disorders 865KCC19.16Dementiaand Other ChronicMental Status

Disorders 868

CLINICAL CASES 876

19.1 AcuteSevereAphasia,with Improvement 87619.2 Nonsensical Speech 879

19.3 Aphasia with Preserved Repetition 88119.4 Impaired Repetition 88219.5 Inability to Read, with Preserved Writing Skills 88319.6 Left Hemineglect 88819.7 Abulia 89119.8 Blindness without Awareness of Deficit 894

19.9 Sudden Inability to Recognize Faces 898

CONTENTS XV

19.10 Musical Hallucinations 899

19.11 Progressive Dementia, Beginning with MemoryProblems 901



References 906

Epilogue: A SimpleWorkingModelof the Mind 911CASEINDEX 915

SUBJECTINDEX 924

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