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Color Atlas of Neurology

Reinhard Rohkamm, M.D.

Professor

Neurological Clinic

Nordwest-Krankenhaus Sanderbusch

Sande, Germany

172 illustrations by Manfred Güther

Translation revised by Ethan Taub, M.D.

Thieme

Stuttgart · New York

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 2nd German edition published and copyrighted 2003 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Taschenatlas Neurologie

Original translator: Suzyon O’Neal Wandrey, Berlin, Germany

Translator/editor: Ethan Taub, M.D., Zürich,

Switzerland

Important note: Medicineisanever-chang- ing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers‘ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed.

Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http://www.thieme.com

Cover design: Cyclus, Stuttgart

Typesetting by primustype R. Hurler GmbH, Notzingen

Printed in Germany by Grammlich, Pliezhausen

ISBN 3-13-130931-8 (GTV)
ISBN 1-58890-191-2 (TNY)	1 2 3 4 5

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface

The nervous system and the muscles are the seat of many primary diseases and are affected secondarily by many others.

This pocket atlas is intended as an aid to the detection and diagnosis of the symptoms and signs of neurological disease. The text and illustrations are printed on facing pages, to facilitate learning of the points presented in each.

The book begins with a summary of the fundamentals of neuroanatomy in Chapter 1. Chapter 2 concerns the functions of the nervous system and the commonly encountered syndromes in clinical neurology. Individual neurological diseases are discussed in Chapter 3. The clinical neurological examination is best understood once the material of the first three chapters is mastered; it is therefore presented in the last chapter, Chapter 4.

The choice of topics for discussion is directed toward questions that frequently arise in clinical practice. Some of the illustrations have been reproduced from previous works by other authors, because they seemed to us to be optimal solutions to the problem of visually depicting a difficult subject. In particular, we would like to pay tribute here to the graphic originality of the late Dr. Frank H. Netter.

Many people have lent us a hand in the creation of this book. Our colleagues at the Sanderbusch Neurological Clinic were always ready to help us face the difficult task of getting the book written while meeting the constant demands of patient care. I (R.R.) would particularly like to thank our Oberärzte (Senior Registrars), Drs. Helga Best and Robert Schumann, for their skillful coopera-

tion and support over several years of work. Thanks are also due to the radiologists, Drs. Benno Wördehoff and Ditmar Schönfeld, for providing images to be used in the illustrations. This book would never have come about without the fascination for neurology that was instilled in me in all the stages of my clinical training; I look back with special fondness on the time I spent as a Resident in the Department of Neurology at the University of New Mexico (Albuquerque). Above all, I thank the many patients, past and present, who have entrusted me with their care.

Finally, cordial thanks are due to the publishers, Georg Thieme Verlag, for their benevolent and surefooted assistance throughout the development of this book, and for the outstanding quality of its production. Among the many members of the staff to whom we are grateful, we would like to single out Dr. Thomas Scherb, with whom we were able to develop our initial ideas about the format of the book, as well as Dr. Clifford Bergman and Gabriele Kuhn, who saw this edition through to production with assurance, expertise, and the necessary dose of humor.

We dedicate this book to our families: Christina, Claire, and Ben (R.R.) and Birgit, Jonas, and Lukas (M.G.).

Reinhard Rohkamm, Sande

Manfred Güther, Bermatingen

Autumn 2003

Contents

1 Fundamentals			1
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	2	Central Nervous Sysstem . . . . . . . . . . . . . . .	. 24
Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	4	Anatomical and Functional Organization	. 25
Meninges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	6	Brain Stem . . . . . . . . . . . . . . . . . . . . . . . . . . . .	. 26
Cerebrospinal Fluid . . . . . . . . . . . . . . . . . . . . . .	8	Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . .	. 28
		Spine and Spinal Cord . . . . . . . . . . . . . . . . . .	. 30
Blood Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . .	10
Carotid Arteries . . . . . . . . . . . . . . . . . . . . . . . . .	11	Peripheral Nervous System . . . . . . . . . . . . .	. 32
Anterior Circulation of the Brain . . . . . . . . .	12	Dermatomes and Myotomes . . . . . . . . . . . .	. 33
Vertebral and Basilar Arteries . . . . . . . . . . . .	14	Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . .	. 34
Posterior Circulation of the Brain . . . . . . . .	16	Nerves of the Upper Limb . . . . . . . . . . . . . .	. 35
Intracranial Veins . . . . . . . . . . . . . . . . . . . . . . .	18	Lumbar Plexus . . . . . . . . . . . . . . . . . . . . . . . . .	. 36
Extracranial Veins . . . . . . . . . . . . . . . . . . . . . . .	20	Nerves of the Lower Limb . . . . . . . . . . . . . .	. 37
Spinal Circulation . . . . . . . . . . . . . . . . . . . . . . .	22

2 Normal and Abnormal Function of the Nervous System			39

Motor Function . . . . . . . . . . . . . . . . . . . . . . . . . 40

Reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Motor Control . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Motor Execution . . . . . . . . . . . . . . . . . . . . . . . . 44

Central Paralysis . . . . . . . . . . . . . . . . . . . . . . . . 46

Peripheral Paralysis . . . . . . . . . . . . . . . . . . . . . 50

Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Vestibular System . . . . . . . . . . . . . . . . . . . . . . . 56

Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Gait Disturbances . . . . . . . . . . . . . . . . . . . . . . . 60

Tremor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Dystonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Chorea, Ballism, Dyskinesia, Myoclonus . . 66

Myoclonus, Tics . . . . . . . . . . . . . . . . . . . . . . . . . 68

Brain Stem Syndromes . . . . . . . . . . . . . . . . . . 70

Midbrain Syndromes . . . . . . . . . . . . . . . . . . . . 71

Pontine Syndromes . . . . . . . . . . . . . . . . . . . . . 72

Medullary Syndromes . . . . . . . . . . . . . . . . . . . 73

Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Skull Base Syndromes . . . . . . . . . . . . . . . . . . . 75 Smell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Visual pathway . . . . . . . . . . . . . . . . . . . . . . . . . 80 Visual Field Defects . . . . . . . . . . . . . . . . . . . . . 82 Oculomotor Function . . . . . . . . . . . . . . . . . . . . 84 Oculomotor Disturbances . . . . . . . . . . . . . . . . 86 Nystagmus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Pupillomotor Function . . . . . . . . . . . . . . . . . . 90 Pupillary Dysfunction . . . . . . . . . . . . . . . . . . . 92 Trigeminal Nerve . . . . . . . . . . . . . . . . . . . . . . . 94 Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Facial Nerve Lesions . . . . . . . . . . . . . . . . . . . . . 98 Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Disturbances of Deglutition . . . . . . . . . . . . . . 102

Sensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Sensory Disturbances . . . . . . . . . . . . . . . . . . . 106

Contents

Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Normal Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 114

Disturbances of Consciousness . . . . . . . . . . . 116

Acute Disturbances of Consciousness . . . . . 116

Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Comalike Syndromes, Death . . . . . . . . . . . . . 120

Behavioral Manifestations of Neurological

Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Agraphia, Alexia, Acalculia, Apraxia . . . . . . 128

Speech Disorders . . . . . . . . . . . . . . . . . . . . . . . 130

3 Neurological Syndromes

Central Nervous System . . . . . . . . . . . . . . . . . 166

Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Epilepsy: Seizure Types . . . . . . . . . . . . . . . . . 192

Epilepsy: Classification . . . . . . . . . . . . . . . . . . 196

Epilepsy: Pathogenesis and Treatment . . . 198

Nonepileptic Seizures . . . . . . . . . . . . . . . . . . . 200

Parkinson Disease: Clinical Features . . . . . . 206

Parkinson Disease: Pathogenesis . . . . . . . . . 210

Parkinson Disease: Treatment . . . . . . . . . . . 212

Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . 214

CNS Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Disturbances of Orientation . . . . . . . . . . . . . . 132

Disturbances of Memory . . . . . . . . . . . . . . . . 134

Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Pseudo-neurological Disorders . . . . . . . . . . . 138

Autonomic Nervous System (ANS) . . . . . . . . 140

Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Hypothalamus . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Limbic System and Peripheral ANS . . . . . . . 144

Heart and Circulation . . . . . . . . . . . . . . . . . . . 148

Respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Thermoregulation . . . . . . . . . . . . . . . . . . . . . . . 152

Gastrointestinal Function . . . . . . . . . . . . . . . . 154

Bladder Function, Sexual Function . . . . . . . 156

Intracranial Pressure . . . . . . . . . . . . . . . . . . . . 158

165

Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Cerebellar Diseases . . . . . . . . . . . . . . . . . . . . . . 276

Myelopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

Malformations and Developmental

Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Neurodegenerative Diseases . . . . . . . . . . . . . 296

Encephalopathies . . . . . . . . . . . . . . . . . . . . . . . 306

Peripheral Nerve and Muscle . . . . . . . . . . . . . 316

Peripheral Neuropathies . . . . . . . . . . . . . . . . . 316

Myopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Neuromuscular Disorders . . . . . . . . . . . . . . . . 346

4 Diagnostic Evaluation

Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . 350 History and Physical Examination . . . . . . . . 350 Neurophysiological and Neuro-

psychological Tests . . . . . . . . . . . . . . . . . . . . . . 352

349

Cerebrovascular Ultrasonography,

Diagnostic Imaging, and Biopsy

Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

5 Appendix		355
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	409 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	. 415

1Fundamentals

!Anatomy

!Physiology

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