Baehr, Duus' Topical Diagnosis in Neurology PDF

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I Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license. III Duus’ Topical Diagnosis in Neurology Anatomy · Physiology · Signs · Symptoms 4th completely revised edition Mathias Baehr, M.D. Professor of Neurology and Chair...

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I

Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

III

Duus’

Topical Diagnosis in Neurology Anatomy · Physiology · Signs · Symptoms 4th completely revised edition

Mathias Baehr, M.D. Professor of Neurology and Chairman Department of Neurology University of Goettingen Goettingen, Germany

Michael Frotscher, M.D. Professor of Anatomy and Chairman Department of Anatomy and Cell Biology University of Freiburg Freiburg, Germany With contributions by Wilhelm Kueker Founding author Peter Duus

Translated by Ethan Taub, M.D. 400 illustrations, most in color, by Professor Gerhard Spitzer and Barbara Gay

Thieme Stuttgart · New York Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

IV

Library of Congress Cataloging-in-Publication Data Baehr, Mathias. [Duus’ neurologisch-topische Diagnostik. English] Duus’ topical diagnosis in neurology : anatomy, physiology, signs, symptoms/Mathias Baehr, Michael Frotscher ; with contributions by Wilhelm Kueker ; translated by Ethan Taub ; illustrated by Gerhard Spitzer. ­ 4th, rev. ed. p. ; cm. Rev. translation of the 8th German ed. c2003. Includes index. ISBN 3­13-612804­4 (GTV : alk. paper) ­ ISBN 1­58890-215­3 (TNY : alk. paper) 1. Nervous system­Diseases­Diagnosis. 2. Neuroanatomy. 3. Anatomy, Pathological. 4. Nervous system­Pathophysiology. I. Frotscher, M. (Michael), 1947- . II. Duus, Peter, 1908-. Topical diagnosis in neurology. III. Title. IV. Title: Topical diagnosis in neurology. [DNLM: 1. Nervous System Diseases­diagnosis. 2. Nervous System­anatomy & histology. 3. Nervous System­physiopathology. WL 141 B139d 2005a] RC347.D8813 2005 616.8’04754­dc22 2005013120 1st Brazilian 1st Greek edition 1992 (Portuguese) edition 1985 1st Indonesian 2nd Brazilian edition 1996 (Portuguese) edition 1990 1st Italian edition 1987 1st Chinese edition 1996 1st Japanese edition 1982 1st English edition 1983 2nd Japanese edition 1984 2nd English edition 1989 3rd Japanese edition 1988 3rd English edition 1998 4th Japanese edition 1999 1st French edition 1998 1st Korean edition 1990 1st German edition 1976 1st Polish edition 1990 2nd German edition 1980 3rd German edition 1983 1st Russian edition 1996 4th German edition 1987 1st Spanish edition 1985 5th German edition 1990 6th German edition 1995 1st Turkish edition 2001 7th German edition 2001 8th German edition 2003

© 2005 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http://www.thieme.com Cover design: Cyclus, Stuttgart Typesetting by primustype Hurler, Notzingen Printed in Germany by Appl, Wemding

ISBN 3­13-612804­4 (GTV) ISBN 1­58890-215­3 (TNY)

1 2 3 4 5

Important note: Medicine is an ever-changing 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.

This book is an authorized and revised translation of the 8th German edition published and copyrighted 2003 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Duus’ Neurologischtopische Diagnostik Contributor: Wilhem Küker, M.D., Radiological Clinic, Department of Neuroradiology, University Hospital Tübingen, Germany Translator: Ethan Taub, M.D., Klinik im Park, Zurich, Switzerland Illustrators: Gerhard Spitzer, Frankfurt/M; Barbara Gay, Stuttgart

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.

Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

V

Preface This is the first complete revision of Duus’ textbook of topical diagnosis in neurology since the death of its original author, Professor Peter Duus, in 1994. As is well known, the intervening time has witnessed major developments, both in the clinical neurosciences and in basic research. In particular, modern imaging techniques such as magnetic resonance imaging and positron emission tomography on the one hand, and the new molecular biological understanding of the development, plasticity, and pathology of the nervous system on the other, have brought about substantial progress in our knowledge in the field of neuroscience. Yet, despite all of the advances in ancillary diagnostic techniques, topical neurological diagnosis—the correct attribution of symptoms or syndromes to lesions at specific sites in the nervous system—remains today the primary task of the clinical neurologist. In this entirely new, thoroughly revised edition of “Duus,” we have tried to preserve the remarkably effective didactic conception of the book while bringing it up to date. We have replaced older case studies based mainly on history by new ones more closely reflecting current practice, provided multicolored illustrations to ease and enhance comprehension, and added state-of-the-art neuroradiological images to demonstrate the correlation of structure and function in nervous system lesions. We have also newly color-coded the section headings to enable readers to distinguish at a glance between neuroanatomical (blue) and clinical (green) material, without having to disrupt the thematic continuity of the text. Welcome changes in the undergraduate medical curriculum over the past two decades have vastly increased the exposure of medical students in the socalled “preclinical” years to clinical case material. To make the book more accessible to these students, we have written a new first chapter entitled “Elements of the Nervous System,” and we have also added a brief summary of basic concepts at the beginning of each of the other chapters. The authors thank Georg Thieme Verlag and Dr. Kundmueller for their diligence and for many constructive discussions, as well as Mrs. Gay for her outstanding work on the illustrations. We hope that this “new Duus,” like the earlier editions, will merit the appreciation of its audience, and we look forward to receiving readers’ comments in any form that they choose.

Professor M. Baehr

Professor M. Frotscher

Associate Professor W. Küker

Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

VII

Contents 1

Elements of the Nervous System

....................

2

Information Flow in the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

Neurons and Synapses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Synapses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 3 7

Neurotransmitters and Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

Functional Groups of Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Glial Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

Development of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

2

18

Somatosensory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Peripheral Components of the Somatosensory System and Peripheral Regulatory Circuits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Receptor Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peripheral Nerve, Dorsal Root Ganglion, Posterior Root . . . . . . . . . . . . . . . . Peripheral Regulatory Circuits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18 18 21 30

Central Components of the Somatosensory System . . . . . . . . . . . . . . . . . . Posterior and Anterior Spinocerebellar Tracts . . . . . . . . . . . . . . . . . . . . . . . . . Posterior Columns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anterior Spinothalamic Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lateral Spinothalamic Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Afferent Tracts of the Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39 39 41 47 47 49

Central Processing of Somatosensory Information . . . . . . . . . . . . . . . . . .

50

Somatosensory Deficits due to Lesions at Specific Sites along the Somatosensory Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51

3

56

Motor System

...........................................

Central Components of the Motor System and Clinical Syndromes of Lesions Affecting Them . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

57

VIII · Contents

Motor Cortical Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corticospinal Tract (Pyramidal Tract) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corticonuclear (Corticobulbar) Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Central Components of the Motor System . . . . . . . . . . . . . . . . . . . . . . . Lesions of Central Motor Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

57 59 59 61 64

Peripheral Components of the Motor System and Clinical Syndromes of Lesions Affecting Them . . . . . . . . . . . . . . . . . . . . . . Clinical Syndromes of Motor Unit Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

67 69

Complex Clinical Syndromes due to Lesions of Specific Components of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Spinal Cord Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Vascular Spinal Cord Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Nerve Root Syndromes (Radicular Syndromes) . . . . . . . . . . . . . . . . . . . . . . . . 91 Plexus Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Peripheral Nerve Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Syndromes of the Neuromuscular Junction and Muscle . . . . . . . . . . . . . . . . 113

4

Brainstem

................................................

116

Surface Anatomy of the Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medulla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Midbrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

117 117 119 120

Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Origin, Components, and Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Olfactory System (CN I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Visual System (CN II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eye Movements (CN III, IV, and VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trigeminal Nerve (CN V) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Facial Nerve (CN VII) and Nervus Intermedius . . . . . . . . . . . . . . . . . . . . . . . . . Vestibulocochlear Nerve (CN VIII)—Cochlear Component and the Organ of Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vestibulocochlear Nerve (CN VIII)—Vestibular Component and Vestibular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vagal System (CN IX, X, and the Cranial Portion of XI) . . . . . . . . . . . . . . . . . Hypoglossal Nerve (CN XII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

120 120 128 130 137 160 167 175 184 194 204

Topographical Anatomy of the Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Internal Structure of the Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

Contents · IX

Brainstem Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Ischemic Brainstem Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

5

Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

240

Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Internal Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cerebellar Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cerebellar Nuclei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Afferent and Efferent Projections of the Cerebellar Cortex and Nuclei . . .

243 243 245 245

Connections of the Cerebellum with Other Parts of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Cerebellar Function and Cerebellar Syndromes . . . . . . . . . . . . . . . . . . . . . . Vestibulocerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spinocerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cerebrocerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

251 252 253 254

Cerebellar Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Cerebellar Ischemia and Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Cerebellar Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

6

Diencephalon and Autonomic Nervous System

..

260

Location and Components of the Diencephalon . . . . . . . . . . . . . . . . . . . . . 261 Thalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nuclei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Position of the Thalamic Nuclei in Ascending and Descending Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functions of the Thalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Syndromes of Thalamic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thalamic Vascular Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

263 263 264 269 270 272

Epithalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Subthalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Hypothalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Location and Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Hypothalamic Nuclei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Baehr, Duus' Topical Diagnosis in Neurology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license.

X · Contents

Afferent and Efferent Projections of the Hypothalamus . . . . . . . . . . . . . . . . 276 Functions of the Hypothalamus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Peripheral Autonomic Nervous System . . . . . . . . . . . . . . . . . . ...