Rapid Neurology and Neurosurgery (eBook)

RAPID Neurology & Neurosurgery
Contents 7
List of Abbreviations 9
Preface 13
Acknowledgements 15
PART I: The basics 17
1 About this book and how to use it 19
2 Basic neuroanatomy 20
Cortical anatomy 20
Brainstem and cranial nerves (CN) 20
Cerebellum 21
Vascular anatomy (cranial) 21
Spinal cord 22
Peripheral nervous system 22
3 Neurological history, examination, signs and localisation 23
‘Where’ 23
‘What’ 23
‘Why’ 23
The neurological history 25
Complaint and history of the presenting complaint (see Part II) 25
Past medical history 26
Medication history 26
Family history 26
Social history 26
Functional history 26
Systems review 26
Neurological examination 27
Suggested order of examination 27
Higher mental function and speech 27
Cranial nerves 27
Upper and lower limbs 32
Sensory 35
Gait and coordination 36
Reference 36
4 Neurological investigations 37
Neurophysiology 37
Electroencephalogram (EEG) 37
Evoked potential studies 37
Nerve conduction studies (NCS) 38
Electromyography (EMG) 38
Neuroradiology 39
Computed tomography (CT) (see CT images throughout the book) 39
Magnetic Resonance Imaging (MRI) 39
Angiography 41
Lumbar puncture and CSF analysis 41
PART II: Complaints: Face-to-face with the patient 45
5 Headache 47
Useful selected questions to ask/facts to establish? 47
Other points to consider 48
Differential diagnoses (see Chapter 12) 48
Basic investigations 48
Basic management 49
6 Blackouts 50
Useful selected questions to ask/facts to establish (syncope versus seizures) 50
Prior to attack 50
During the attack 51
After the attack 51
Differential diagnoses (Table 6.1) 51
Basic investigations 51
Basic management 51
7 Visual disturbances 52
Loss of vision 52
Local eye disease 52
Optic nerve disturbance 52
Optic nerve disturbance causing sudden onset of transient visual loss 53
Optic nerve disturbance causing persistent visual loss 53
Disturbance of the posterior visual pathways 53
Diplopia (double vision) 53
8 Dizziness and vertigo 55
Useful selected questions to ask/facts to establish? 55
Differential diagnoses (Table 8.1) 55
Basic investigations 55
Basic management 55
9 Weak legs 57
Useful selected questions to ask/facts to establish? 57
Differential diagnoses (Table 9.1) 58
Basic investigations 58
Basic management 58
10 Numbness and sensory disturbance 60
Useful selected questions to ask/facts to establish? 60
Differential diagnoses (Table 10.1) 61
Basic investigations 61
Basic management 61
11 Gait assessment and disturbance 62
Useful selected questions to ask/facts to establish (during gait assessment) 62
Differential diagnoses 62
Basic investigations 63
Basic management 63
PART III: Conditions: Applying the basics 65
12 Headache 67
DEFINITION/DESCRIPTION 67
Migraine 67
EPIDEMIOLOGY 67
AETIOLOGY 67
HISTORY 67
Migraine without aura 67
Migraine with aura 67
INVESTIGATIONS 67
MANAGEMENT 67
Tension-type headache 68
HISTORY 68
MANAGEMENT 68
Cluster headache 69
EPIDEMIOLOGY 69
HISTORY 69
INVESTIGATIONS 69
MANAGEMENT 69
Brief notes on other conditions causing headache 69
Giant cell arteritis (GCA) 69
Idiopathic intracranial hypertension (IIH) 70
Trigeminal neuralgia (TN) 70
13 Transient ischaemic attacks (TIAs) 71
DEFINITION 71
EPIDEMIOLOGY 71
AETIOLOGY AND PREVENTION 71
ASSOCIATIONS/RISK FACTORS 71
CLINICAL FEATURES (HISTORY/EXAMINATION) 71
INVESTIGATIONS 71
MANAGEMENT 72
Early assessment 72
Medical management 72
Surgical management: Carotid endarterectomy and stenting 73
Lifestyle modifications 73
DIFFERENTIAL DIAGNOSES 74
14 Stroke I: Thromboembolic stroke and syndromes 75
DEFINITION 75
EPIDEMIOLOGY 75
AETIOLOGY 75
ASSOCIATIONS/RISK FACTORS 76
Clinical syndromes 76
HISTORY/EXAMINATION 76
INVESTIGATIONS 77
MANAGEMENT 77
Stroke units 77
Thrombolysis 77
Aspirin 77
MEDICAL MANAGEME N T : SECONDARY PREVENTION 78
Nutrition and feeding 78
Thromboprophylaxis 78
Carotid endarterectomy and stenting 79
COMPLICATIONS 79
Note on rehabilitation 79
15 Stroke II: Intracerebral haemorrhage 81
DEFINITION 81
EPIDEMIOLOGY 81
AETIOLOGY 81
ASSOCIATIONS/ RISK FACTORS 81
PATHOLOGY/PATHOGENESIS 81
HISTORY 81
EXAMINATION 81
INVESTIGATIONS 82
MANAGEMENT 83
Non-surgical 83
Surgical 83
COMPL ICATIONS 83
PROGNOSIS 83
DIFFERENTIAL DIAGNOSES 83
16 Stroke III: Subarachnoid haemorrhage 84
DEFINITION 84
EPIDEMIOLOGY 84
AETIOLOGY 84
ASSOCIATIONS/RISK FACTORS 84
PATHOLOGY/PATHOGENESIS 84
HISTORY 84
Headache 84
Loss of consciousness 85
Meningism 85
Warning headache 85
Other symptoms 85
EXAMINATION 85
Depressed level of consciousness/coma 85
Focal neurological deficits 85
Meningism 86
Ocular haemorrhage 86
Fever 86
Cardiovascular signs 86
INVESTIGATIONS 86
CT head 86
Lumbar puncture 86
MRI head 87
Digital subtraction four-vessel angiography 87
CT cerebral angiogram 87
MANAGEMENT 87
Initial measures 88
Treatment of the aneurysm 88
Prevention and treatment of cerebral vasospasm 88
COMPLICATIONS 89
Stroke 89
Hydrocephalus 89
Rebleeding 89
Epilepsy 89
Hyponatraemia 89
Cardiac complications 90
PROGNOSIS 90
DIFFERENTIAL DIAGNOSES 90
17 Epilepsy 91
DEFINITION 91
EPIDEMIOLOGY 91
AETIOLOGY 91
CLASSIFICATION AND CHARACTERISTICS 91
Primary generalised seizures (40% of all seizures) 91
Partial seizures (around 50–60% of seizures) 91
ASSOCIATIONS/RISK FACTORS 92
PATHOLOGY/PATHOGENESIS 92
HISTORY 92
EXAMINATION 92
INVESTIGATIONS 93
MANAGEMENT 93
PROGNOSIS 94
DIFFERENTIAL DIAGNOSES 94
MANAGEMENT OF STATUS EPILEPTICUS 95
18 Multiple sclerosis 96
DEFINITION 96
EPIDEMIOLOGY 96
AETIOLOGY 96
ASSOCIATIONS/RISK FACTORS 96
PATHOLOGY/PATHOGENESI S 96
HISTORY 96
EXAMINATION 97
INVESTIGATIONS 97
MANAGEMENT 98
COMPLICATIONS 98
PROGNOSIS 98
DIFFERENTIAL DIAGNOSES 98
19 Parkinson’s disease and other related syndromes 100
DEFINITION 100
EPIDEMIOLOGY 100
AETIOLGY 100
Sporadic 100
Genetic 100
PATHOLOGY 100
HISTORY 100
EXAMINATION 101
INVESTIGATIONS 101
MANAGEMENT 101
Medical 101
Surgical 103
Supportive 103
COMPLICATIONS 103
PROGNOSIS 103
DIFFERNTIAL DIAGNOSES 103
20 Other movement disorders 104
DEFINITION 104
AETIOLOGY 104
Tremor 104
Essential (familial) tremor 104
DEFINITION 104
EPIDEMIOLOGY 104
AETIOLOGY 104
HISTORY 104
INVESTIGATIONS 105
MANAGEMENT 105
Chorea 105
DEFINITION 105
AETIOLOGY 105
Huntington’s disease (HD) 105
DEFINITION 105
EPIDEMIOLOGY 105
HISTORY 105
INVESTIGATIONS 105
MANAGEMENT 105
Wilson’s disease 105
DEFINITION 105
EPIDEMIOLOGY 105
AETIOLOGY 105
HISTORY AND EXAMINATION 105
INVESTIGATIONS 106
MANAGEMENT 106
Dystonia 106
DEFINITION 106
AETIOLOGY 106
INVESTIGATIONS 106
MANAGEMENT 106
21 Central nervous system infections: Meningitis 107
DEFINITION 107
EPIDEMIOLOGY 107
AETIOLOGY 107
PATHOLOGY/PATHOGENESIS 107
HISTORY 107
EXAMINATION 107
INVESTIGATIONS (TYPICAL F INDINGS- BACTERIAL MENING I T I S ) 107
MANAGEMENT 108
COMPLICATIONS 108
PROGNOSIS 108
DIFFERENTIAL DIAGNOSES 108
Note on CSF shunt infections 109
22 Central nervous system infections: Cerebral abscess 110
DEFINITION 110
EPIDEMIOLOGY 110
AETIOLOGY 110
PATHOLOGY/PATHOGENESIS 110
HISTORY 110
EXAMINATION 110
INVESTIGATIONS 110
MANAGEMENT 111
COMPLICATIONS 112
DIFFERENTIAL DIAGNOSES 112
23 Radiculopathy and disc herniation 113
DEFINITION 113
AETIOLOGY 113
ASSOCIATIONS/RISK FACTORS 113
PATHOLOGY/PATHOGENESIS 113
HISTORY 113
Lumbar discs 113
Cervical discs 113
EXAMINATION 113
Lumbosacral spine 113
Cervical spine 113
INVESTIGATIONS 114
Lumbosacral spine 114
Cervical spine 115
MANAGEMENT 115
Lumbosacral spine 115
Cervical Spine 115
COMPLICATIONS 115
Cauda equina syndrome 115
Note on Red Flag Signs for Imaging 115
24 Peripheral neuropathies’ syndromes 116
DEFINITION/INTRODUCTION 116
EPIDEMIOLOGY 116
HISTORY 116
EXAMINATION 117
INVESTIGATIONS 117
MANAGEMENT 118
DIFFERENTIAL DIAGNOSES 118
Guillain–Barré syndrome 118
DEFINITION 118
EPIDEMIOLOGY 118
AETIOLOGY 118
PATHOLOGY/PATHOGENESIS 118
HISTORY 118
EXAMINATION 118
INVESTIGATIONS 118
MANAGEMENT 119
Note on Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) 119
25 Common peripheral nerve lesions: Mononeuropathies 120
DEFINITION 120
EPIDEMIOLOGY 120
AETIOLOGY 120
Median nerve palsy 120
Ulnar nerve palsy 120
Radial nerve palsy 120
Common peroneal nerve palsy 120
PATHOLOGY/PATHOGENESIS 121
HISTORY/EXAMINATION 121
Special tests 121
INVESTIGATIONS AND DIAGNOSIS 123
MANAGEMENT 123
26 Motor neurone disease (MND) 124
DEFINITION 124
EPIDEMIOLOGY 124
AETIOLOGY 124
ASSOCIATIONS/RISK FACTORS 124
PATHOLOGY/PATHOGENESI S 124
HISTORY 124
EXAMINATION 125
INVESTIGATIONS 125
MANAGEMENT 125
COMPLICATIONS 126
PROGNOSIS 126
DIFFERENTIAL DIAGNOSES 126
27 Myasthenia gravis and Lambert–Eaton myasthenic syndrome 127
DEFINITION 127
EPIDEMIOLOGY 127
AETIOLOGY 127
ASSOCIATIONS/RISK FACTORS 127
PATHOLOGY/PATHOGENESIS 127
HISTORY 127
EXAMINATION 127
INVESTIGATIONS 128
MANAGEMENT 128
COMPLICATIONS 128
PROGNOSIS 129
DIFFERENTIAL DIAGNOSES 129
28 Diseases of the muscle 130
INTRODUCTION 130
APPROACH TO D IAGNOS IS 130
The treatable inflammatory Mmyopathies 130
DEFINITION 130
EPIDEMIOLOGY 131
AETIOLOGY 131
ASSOCIATIONS/RISK FACTORS 131
PATHOLOGY/PATHOGENESIS 131
HISTORY 131
EXAMINATION 131
INVESTIGATIONS 131
MANAGEMENT 132
COMPLICATIONS 132
PROGNOSIS 132
DIFFERENTIAL DIAGNOSES 132
29 Alzheimer’s disease and other dementia syndromes 134
DEFINITION 134
EPIDEMIOLOGY 134
AETIOLOGY 134
ASSOCIATIONS/RISK FACTORS 134
PATHOLOGY/PATHOGENESI S 134
HISTORY 134
EXAMINATION 135
INVESTIGATIONS 135
MANAGEMENT 135
COMPLICATIONS 136
PROGNOSIS 136
DIFFERENTIAL DIAGNOSES 136
30 Raised intracranial pressure and herniation syndromes 138
DEFINITION 138
AETIOLOGY OF RAISED ICP 138
Intracranial mass lesion 138
Increase in CSF volume 138
Increase in cerebral blood volume 138
Cerebral oedema 138
Prevention of normal skull growth (children) 139
PATHOLOGY/PATHOGENESIS 139
Monro–Kellie doctrine 139
HISTORY 139
EXAMINATION 140
IN VESTIGATIONS 140
MANAGEMENT 140
Reducing ICP 140
Cerebral protection 141
COMPLICATIONS 141
Cerebral herniation 141
PROGNOSIS 142
Notes on differential diagnoses 142
31 Coma and brainstem death 143
DEFINITION 143
AETIOLOGY 143
ASSOCIATIONS/RISK FACTORS 143
PATHOLOGY/PATHOGENESIS 143
HISTORY 143
EXAMINATION 143
INVESTIGATIONS 144
MANAGEMENT 144
COMPLICATIONS 144
PROGNOSIS 145
Criteria for diagnosis of brainstem death 145
DIFFERENTIAL DIAGNOSES 145
32 Head injury: General approach and management 146
DEFINITIONS 146
EPIDEMIOLOGY 146
AETIOLOGY 146
ASSOCIATIONS/RISK FACTORS 146
PATHOLOGY/PATHOGENESIS 147
IMMEDIATE CLINCAL MANAGEMENT 147
HISTORY 147
EXAMINATION 147
INVESTIGATIONS 147
MANAGEMENT 148
COMPLICATIONS 149
PROGNOSIS 150
Note on differential diagnoses 150
33 Head injury: Subdural haematoma, skull fractures and contusions 151
DEFINITION 151
EPIDEMIOLOGY 151
AETIOLOGY 151
ASSOCIATIONS/ RISK FACTORS 151
PATHOLOGY/PATHOGENESIS 151
HISTORY 151
EXAMINATION 152
INVESTIGATIONS 153
MANAGEMENT 154
COMPLICATIONS 154
PROGNOSIS 154
DIFFERENTIAL DIAGNOSIS 154
Other Conditions of note 155
34 Head injury: Extradural haematoma 157
DEFINITION 157
EPIDEMIOLOGY 157
AETIOLOGY 157
ASSOCIATIONS/RISK FACTORS 157
PATHOLOGY/PATHOGENESIS 157
HISTORY 157
EXAMINATION 157
INVESTIGATION 158
MANAGEMENT 159
COMPLICATIONS 159
PROGNOSIS 159
DIFFERENTIAL DIAGNOSES 159
35 Spinal injuries and spinal cord syndromes 160
DEFINITION 160
EPIDEMIOLOGY 160
AETIOLOGY 160
ASSOCIATIONS/RISK FACTORS 160
PATHOLOGY/PATHOGENESIS 161
HISTORY 161
EXAMINATION 161
INVESTIGATIONS 162
MANAGEMENT 162
COMPLICATIONS 162
PROGNOSIS 163
DIFFERENTIAL DIAGNOSES 164
Notes on common cervical spine fractures 164
36 CNS neoplasia 167
PATHOLOGY 167
HISTORY AND EXAMINATION 167
INVESTIGATIONS 167
MANAGEMENT 169
COMPLICATIONS 169
PROGNOSIS 169
DIFFERENTIAL DIAGNOSES 169
37 Hydrocephalus 171
DEFINITION 171
EPIDEMIOLOGY 171
AETIOLOGY 171
ASSOCIATIONS/RISK FACTORS 171
PATHOLOGY/PATHOGENESIS 171
HISTORY 172
EXAMINATION 172
INVESTIGATIONS 173
MANAGEMENT 174
Medical Treatment 174
Surgical Treatment 174
COMPLICATIONS 175
Shunts 175
ETV 175
PROGNOSIS 175
DIFFERENTIAL DIAGNOSI S 176
Appendices 177
Appendix 1: Management of status epilepticus (SE) 179
Appendix 2: Glasgow Coma Scale (GCS) 180
Appendix 3: Primary neuroepithelial tumours of the central nervous system 182
Appendix 4: Other tumours affecting the central nervous system 189
Index 197