Clinical Neurology A Primer by Peter Gates

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This is a clinical neurology book for the student, non neurologist, and those that …

This is a clinical neurology book for the student, non neurologist, and those that
teach them. The book will cover neuroanatomy, history taking and examination and then proceed to discuss the clinical features of common problems as well as some
of the more common rare, neurological disorders, in a way that will demystify a
part of medicine that students find complex and difficult to understand. The book is
accompanied by a DVD explaining concepts, demonstrating techniques of performing
the neurological examination and demonstration of abnormal neurological signs.
The first chapter is devoted to neuroanatomy from a clinical viewpoint. The concept
of localising problems by likening the nervous system to a map grid with vertical
meridians of longitude (the ascending sensory pathways and the descending motor
pathway)and horizontal parallels of latitude (cortical signs, brainstem cranial nerves,
nerve roots and peripheral nerves) of the nervous system is developed. Subsequent
chapters take the reader through the neurological examination and the common
neurological presentations from a symptom oriented approach. Chapter 4 contains
a very simple method of understanding the brainstem, the “rule of 4”. Chapter 6
discusses the approach after the history and examination are completed. The final
chapter is an overview of how to approach information gathering and keeping up-todate
using the complex information streams available.

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube.
    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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  • Purpose >> Teach simple diagnostic techniques for neurological conditions Example: RAAF and “lost in space’ techniques Who is this book for? >> Student & Non-neurologists Key Features >> Frequent case studies and examples >> Review points >> Clinical questions >> Clinical Orientation with comprehensive references Key Focus: The way neurology is taught throughout the text – very difficult concept to understand for medical students Concept of ‘mapping the brain’’ facilitates understanding of the brain C
  • Chapter 1: Clinically Oriented Neuroanatomy This chapter discusses the concept of the nervous system being likened to a map grid with meridians of longitude (the long tracts) and parallels of latitude (dermatomes, myotomes, reflexes, brainstem nuclei and cortical signs) and using this concept to localise the site of the pathology within the nervous system. The chapter will predominantly contain illustrations with brief explanations. Chapter 2: The Neurological History This chapter explains the principles and process of taking a patient’s history, including the concept that the past history, family history and social history are ‘circumstantial evidence’ and should not be used to make the diagnosis. The chapter discusses the mode of onset, duration and progression of symptoms with a view to answering the question ‘what is the likely pathological process?’ and it discusses the nature and distribution of symptoms with a view to answering the question ‘where is the lesion?’
  • The first section of this chapter will describe the anatomy, the techniques for examining the individual cranial nerves and the more common abnormalities encountered. Th e second part will discuss the ‘Rule of 4’ to aid in localising the problem within the brainstem, in particular understanding brainstem vascular syndromes [1] .
  • Chapter 6: After the History and Examination, What Next? Upon completing the history and examination, the next step is determined by the following factors: • diagnostic certainty • the availability of tests to confi rm or exclude certain diagnoses • the potential complications of those tests • the severity and level of urgency in terms of the consequences of a particular illness not being diagnosed and treated promptly • the benefi t versus risk profi le of any potential treatment • the presence of any social factors or past medical history that could infl uence a course of action or treatment in this particular patient. Th is chapter will discuss each of these aspects and how they infl uence the course of action. Chapters 7 – 14 Focuses on the identification of common nuerological occurrences, management strategies and point of differentiation, when you need to call in a Nuerologist The common neurological occurrences explored are: Epilepsy Headace and facial pain Cerebrovascular disease Common neck, arm and upper back problems Common leg problems Tremor and abnormal movements Rarer conditions (including) Hypothyroidism Hypertrophy Paroxysmal Symptoms of MS Orthostatic tremor Th e assessment of patients with intermittent disturbances of neurological function is one of the most interesting and challenging aspects of clinical neurology. One needs to be an amateur detective like Sherlock Holmes, whom Arthur Conan Doyle modelled on Dr Joseph Bell, one of his teachers at the medical school of Edinburgh University. Dr Bell was a master at observation, logic, deduction and diagnosis [1] . Th is chapter discusses the various causes of episodic disturbance of neurological function. Th ere is only a brief discussion of epilepsy and cerebrovascular disease as they are covered in more detail in Chapter 8, ‘Seizures and epilepsy’, and Chapter 10, ‘Cerebrovascular disease’, respectively. Vertigo is discussed in this chapter as most often it is an episodic disturbance, but mainly because it seemed to fi t better in this chapter than in any other. Patients are rarely seen by the neurologist during the episode. Th erefore, the diagnosis of intermittent disturbances of neurological function is almost entirely dependent on the history. As the symptoms are episodic, these patients rarely if ever have any abnormal neurological signs and investigations only rarely yield a diagnosis. Sometimes it is not possible to diagnose the problem when the patient fi rst presents. A very useful technique is to send the patient away with a list of things to observe and record. Th is will often enable a diagnosis to be made at a subsequent consultation. However, this technique can only be employed if the episodes are likely to be benign and the patient is advised to avoid activities that could result in harm should an event recur during that activity. For example, where there is a suspicion of epilepsy patients should be advised not to drive, go swimming, have a bath alone etc. Chapter 7: Epilepsy This chapter describes the clinical features of the more common seizure types such as tonic-clonic, myoclonic, absence, simple-partial and complex-partial seizures. It discusses the principles of investigation and management without discussing any particular mode of imaging or specific therapy, as these change frequently. Instead, links to relevant reliable websites will be provided which will enable readers to access current information. Chapter 8: Headache and Facial Pain This chapter describes the clinical features of the common causes of headache and facial pain. The clinical characteristics of conditions such as dental pain, trigeminal neuralgia and atypical facial pain, tension headache, chronic daily headache, migraine, cluster headache, benign sex and benign exertional headache will be described. Once again principles of management will be discussed rather than specific therapies. Chapter 9: Cerebrovascular Disease This chapter consists of a clinically oriented approach to the patient with cerebrovascular disease. Concepts such as small versus large vessel territory ischaemia, carotid versus posterior circulation or vertebro-basilar insufficiency (VBI) will be described. Principles of management will be discussed. Chapter 10: Common Neck, Arm and Upper Back Problems This chapter describes the clinical features of the common problems encountered in clinical practice affecting the neck, arm and upper back. The clinical features and examination findings that differentiate the various causes of arm pain, weakness and sensory disturbance will be described. Conditions such as carpal tunnel syndrome, tardy ulnar palsy, cervical radiculopathy, brachial neuritis and radial nerve lesions will be discussed.   Chapter 11: Common Leg Problems with or without Difficulty Walking   This chapter describes the clinical features of the common clinical problems affecting the legs. The chapter includes conditions that do not result in difficulty walking such as restless legs, burning feet, tarsal tunnel syndrome, meralgia paraesthetica, as well as the common causes of difficulty walking such as atalgic gait disorders, lumbar canal stenosis and apraxia of gait. Chapter 12: Tremor and Abnormal Movements This chapter describes the clinical features of the more common causes of tremor and how to differentiate them. The more common movement disorders encountered in clinical practice will be discussed. The various causes of Parkinson’s syndrome and in particular Parkinson’s disease will be discussed. Principles of management will be discussed. The chapter will discuss the clinical features used to differentiate the various types of tremo Chapter 13: The ‘More Common’ Rare Neurological Conditions This chapter describes the clinical features of the more frequently encountered rare neurological disorders. These include hypothyroidism and muscle hypertrophy, paroxysmal symptoms of multiple sclerosis, orthostatic tremor, superior oblique myokymia and paroxysmal kinesogenic choreoathetosis to mention just a few.  
  • Videos Chapter 1. None Chapter 2. 2.1 Video presentation of principles of the neurological history. 2.2 Video of Lord Walton taking a history Chapter 3. 3.1 Video of Author demonstration technique of examining the upper and the lower limbs. Chapter 4. 4.1 Video presentation explaining the rule of 4 of the brainstem. 4.2 Video of Author demonstrating technique of examining the cranial nerves. 4.3 Video of patient with lateral brainstem syndrome Chapter 5. 5.1 Video presentation explaining the concepts in this chapter. Chapter 6. None Chapter 7. 7.1. Video of author taking history from patient with recurrent seizures. 7.2 Video of author taking history from patient with recurrent headaches. Chapter 8. None Chapter 9. None Chapter 10. None Chapter 11. 11.1 Video of how to examine upper arm and then hand and forearm problems. Chapter 12. 12.1 Video of author showing how to examine lower leg problems. Chapter 13. 13.1 Video of patients with difficulty walking with spasticity Chapter 14. None Chapter 15. None   Additional Video   Video demonstrating upper motor neuron signs Video demonstrating lower motor neuron signs   Photo Library **Eleanor and Sabrina have discussed the idea of putting all the colour images onto the DVD – if there is sufficient space after uploading all the videos etc.


  • 1. Clinical Neurology: A Primer Peter Gates MBBS FRACP Associate Professor of Neurology, University of Melbourne Associate Professor of Neurology, Deakin University Director of Stroke, Director of Neuroscience & Director of Physician Training, Barwon Health Geelong
  • 2. About the book... A comprehensive guide. Equips medical students and doctors with knowledge and techniques to diagnose common neurological conditions Learning Tools to facilitate easy understanding of neurological anatomy > ‘Meridian of longitude’ and ‘parallels of latitude’ > Rule of Four > Principles & processes o f patient History taking & examination > How to diagnose the more common neurological diseases Key Knowledge & Techniques:
  • 3. Learning tool #1: Understanding Neuroanatomy ‘ meridians of longitude’ and ‘parallels of latitude’ Figure 1.1 This unique concept was designed by the author to help simplify neuroanatomy
  • 4. Learning tool #2: Cranial Nerves & the Brainstem The Rule of 4 The ‘Rule of 4’ was designed to facilitate easy localisation of a problem within the brainstem, in particular understanding brainstem vascular syndromes
  • 5. Overview of Chapters The chapters are grouped as follows: Chapters 1 & 2 & 3: Neurology, Anatomy, Patient History & Examination Focus of these chapter are to provide underpinning knowledge for neurology: > How to identify the anatomy > Process of gathering the patient history > How to perform the examination
  • 6. Chapter 4: Understanding the Brainstem > Anatomy and techniques for examining individual cranial nerves > Common abnormalities encountered > ‘Rule of 4’ Chapter 5: Higher Cognitive Function > How to perform a simplistic assessment of language disturbances and very basic higher cortical functions
  • 7. Chapter 6: What Next? After the History & Examination Details the steps that you need to undertake after the patient history is taken and the examination performed Chapter 7 – 14: Assessment & Management Strategies The common neurological occurrences are detailed in regards to their assessment and possible management strategies: > Epilepsy > Headache and facial pain > Cerebrovascular disease > Common neck, arm and upper back problems > Common leg problems > Tremor and abnormal movements
  • 8. About the DVD... Includes video demonstrations & explanations of: > Upper & lower limb examination > Taking patient history > Patient with difficultly walking with spasticity > Explanation of ‘rule of 4’ > Cranial nerve examination > ... and more!
  • 9. Why choose this book? > Local, internationally acclaimed author > Benefit from Peter Gates’ years of experience and research > The most current book on the market > Two unique learning tools > Comprehensive - provides all underpinning knowledge necessary for the ‘non-neurologist’ > A comprehensive DVD which provides ‘real life’ examples and explanations of the clinical examples as discussed in the book
  • 10. Foreword: Professor Edward Byrne AO “ In this book he [Peter Gates] sets out the lessons of a lifetime spent in clinical neurology and distils some of the principles which have led him to become a master diagnostician.... ... I would recommend it to senior medical students , to young doctors at all stages and also to those beginning their neurological training. ... ... It is the best introduction to the diagnosis and treatment of nervous system disorders that I have seen for many years and contains a font of wisdom about a speciality often perceived as difficult by the non-expert. Professor Edward Byrne AO Vice Chancellor & President Monash University, Melbourne, Australia
  • 11. **Two groups of reviewers engaged. Group 1 - 3 rd /4 th year Medical Students, ANU & Group 2 – JMOs & Neurologists with academic appointments What the reviewers said.... **This text is appropriate for the senior medical student or the doctor not specialising in neurology. It introduces concepts to neurology that I wish were taught in medical school ** All you need to know at your fingertips at a glance ... It isn’t too complicated so as to confuse the junior medical officer, but yet in-depth enough that the right diagnosis is made. **The clinical examples are great – is a good way to see how history taking forms a major part of the diagnostic process **It’s main strength is the basic approach to the topics of localisation and pathophysiological process which will lead to accurate clinical diagnosis.
  • 12. ... Available for purchase June 2010!! Purchase this text online @ and save!! RRP: AU$ 90.00 Online Price: AU$ 81.00 Title: Clinical Neurology Author: Peter Gates ISBN: 9780729539357
  • 13. As always, for more information, contact your local ANZ Elsevier representative: NSW/ACT/NT: Lucinda Frumar [email_address] NSW/WA: Alana Brittain [email_address] VIC/TAS: Carolyn Crowther [email_address] VIC/SA: Lou Thorn [email_address] QLD: Carolyn Crowther [email_address] NZ: Gopal Ramanathan [email_address]