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a LANGE medical book
Clinical Neurology
T E N T H E D I T I O N
Roger P. Simon, MD
Professor of Medicine (Neurology) and Neurobiology
Morehouse School of Medicine
Clinical Professor of Neurology
Emory University
Atlanta, Georgia
Michael J. Aminoff, MD, DSc, FRCP
Distinguished Professor
Department of Neurology
School of Medicine
University of California
San Francisco, California
David A. Greenberg, MD, PhD
Professor Emeritus
Buck Institute for Research on Aging
Novato, California
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
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Clinical Neurology, Tenth Edition
Copyright © 2018 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Except as
permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in
any form or by any means, or stored in a database or retrieval system, without prior written permission of the publisher.
Copyright © 2015, 2012, 2009, 2005, 2002 by The McGraw-Hill Companies, Inc.
Previous editions copyright © 1999, 1996, 1993, 1989 by Appleton & Lange.
1 2 3 4 5 6 7 8 9 LCR 22 21 20 19 18 17
ISBN 978-1-259-86172-7
MHID 1-259-86172-4
ISSN 1522-6875
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in
treatment and drug therapy are required. The authors and the publisher of this work have checked with sources
believed to be reliable in their efforts to provide information that is complete and generally in accord with the
standards accepted at the time of publication. However, in view of the possibility of human error changes in medical
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To our families, as well as to our patients and students over the years.
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Contents
Preface vii
1. Neurologic History & Examination 1 11. Movement Disorders 311
2. Investigative Studies 27 12. Seizures & Syncope 344
3. Coma 46 13. Stroke 369
4. Confusional States 65 Appendix: Clinical Examination of
Common Isolated Peripheral
Nerve Disorders 407
5. Dementia & Amnestic Disorders 106
Index 415
6. Headache & Facial Pain 139
7. Neuro-Ophthalmic Disorders 166
8. Disorders of Equilibrium 190
9. Motor Disorders 219
10. Sensory Disorders 278
v
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Preface
Forty years ago, as clinical teachers at the UCSF School of Medicine, we decided that there was a need for a new teaching
text that combined the basic and clinical aspects of neurology. Following a lunch meeting, Jack Lange of Lange Medical
Publications agreed to the addition of a clinical neurology textbook to the Lange textbook series. He smiled when one of
us (RPS) offered to provide the text in two years, noting that no one had produced a textbook in that time. With two
coauthors (MJA and DAG) and after some ten years, the text of Clinical Neurology was finally completed and in 1989 the
first edition was published. With the publication of the 10th edition and translations in eight languages, our text will have
provided nearly 30 consecutive years of neurology teaching material to medical students in the United States and around
the world via the print volume (purchased or rented), e-book edition, and AccessMedicine website.
As in each new edition, we have retained and refined the core didactic material relating to the function of the nervous
system in health and disease and added new and evolving diagnostic and therapeutic material. Full-color figures illustrate
key concepts. Over the years, the book has encompassed the evolution of therapeutics in neurology, particularly for
epilepsy and headache and most recently for demyelinating disease. This edition continues to document the expansion of
diagnostic and therapeutic approaches to nervous system disease. To those who still believe that there are limited therapeutic
options in neurology, we hope that the present volume will help to convince them otherwise. Within just the last year,
advances in molecular biology and immunology have led to the approval of new drugs for the treatment of multiple sclerosis
(alemtuzumab), spinal muscular atrophy (nusinersen), amyotrophic lateral sclerosis (edaravone), and Huntington’s disease
(deutetrabenazine). These and other therapeutic advances are included in this new edition.
Over the years, many colleagues have suggested revisions, contributed figures and radiographic material, and read over
portions of the book. In this regard, we thank the members of the faculty of UCSF, the University of Pittsburgh, the Oregon
Health and Sciences University, and Emory University who helped us, as well as the current and past staff of our publisher,
McGraw-Hill, and particularly Andrew Moyer and Christie Naglieri for their assistance with this latest edition. Special
thanks are due to Martha Johnson, PhD, for her careful copy-editing of the entire 10th edition and to McGraw-Hill for
providing a new index to optimize accessibility.
Roger P. Simon
Michael J. Aminoff
David A. Greenberg
vii
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Neurologic History &
Examination
History/ 1 Neurologic Examination/ 7
Age/ 1 Mental Status/ 7
Chief Complaint/ 1 Cranial Nerves/ 1O
History of Present Illness/ 2 Motor Function / 17
Past Medical History/ 3 Sensory Function/ 19
Family History/ 3 Coordination/ 20
Social History/ 3 Reflexes/ 21
Review of Systems/ 4 Stance & Gait/ 21
Summary/ 4 Neurologic Examination in Special
General Physical Examination/ 4 Settings/ 23
Vital Signs/ 4 Coma/ 23
Skin/ 5 "Screening" Neurologic Examination/ 23
Head, Eyes, Ears, & Neck/ 5 Diagnostic Formulation/ 23
Chest & Cardiovascular/ 6
Principles of Diagnosis/ 23
Abdomen/ 7
Anatomic Diagnosis: Where Is the Lesion?/ 23
Extremities & Back/ 7
Etiologic Diagnosis: What Is the Lesion?/ 24
Rectal & Pelvic/ 7
Laboratory Investigations/ 26
HISTORY from-the correct diagnosis. The goal is for the patient to
describe the nature of the problem in a word or phrase.
Taking a history from a patient with a neurologic com
Common neurologic complaints include confusion,
plaint is fundamentally the same as taking any history.
dizziness, weakness, shaking, numbness, blurred vision,
(cid:141) and spells. Each of these terms means different things to
Age different people, so it is critical to clarify what the patient
is trying to convey.
Age can be a clue to the cause of a neurologic problem.
Epilepsy, multiple sclerosis, and Huntington disease usu A. Confusion
ally have their onset by middle age, whereas Alzheimer
disease, Parkinson disease, brain tumors, and stroke pre Confusion may be reported by the patient or by family
dominantly affect older individuals. members. Symptoms can include memory impairment,
(cid:141) getting lost, difficulty understanding or producing spoken
or written language, problems with numbers, faulty judg
Chief Complaint
ment, personality change, or combinations thereof. Symp
The chief complaint should be defined as clearly as possi toms of confusion may be difficult to characterize, so
ble, because it will guide evaluation toward-or away specific examples should be sought.
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