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Neurologic Differential DiagnosisA Case-Based Approach
www.cambridge.org© in this web service Cambridge University Press
Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
www.cambridge.org© in this web service Cambridge University Press
Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
Neurologic DifferentialDiagnosisA Case-Based ApproachEdited byAlan B. Ettinger, MD, MBAEpilepsy Director, Neurological Surgery P.C., Rockville Center, New York;Director of the Epilepsy Wellness Program, Winthrop University Hospital, Mineola, New York;Director of EEG and Epilepsy, Huntington Hospital, Huntington, New York; andProfessor of Clinical Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
Deborah M. Weisbrot, MDAssociate Professor of Clinical Psychiatry and Director, Child & Adolescent Psychiatry, Outpatient Clinic,Department of Psychiatry and Behavioral Sciences, Stony Brook University Medical Center, New York, USA
www.cambridge.org© in this web service Cambridge University Press
Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
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It furthers the University’s mission by disseminating knowledge inthe pursuit of education, learning and research at the highestinternational levels of excellence.
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c© Cambridge University Press 2014
This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place without the writtenpermission of Cambridge University Press.
First published 2014
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ISBN 978-1-107-01455-8 Hardback
Cambridge University Press has no responsibility for the persistenceor accuracy of URLs for external or third-party internet websitesreferred to in this publication, and does not guarantee that anycontent on such websites is, or will remain, accurate or appropriate.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Every effort has been made in preparing this book to provideaccurate and up-to-date information which is in accord with acceptedstandards and practice at the time of publication. Although casehistories are drawn from actual cases, every effort has been made todisguise the identities of the individuals involved. Nevertheless, theauthors, editors and publishers can make no warranties that theinformation contained herein is totally free from error, not leastbecause clinical standards are constantly changing through researchand regulation. The authors, editors and publishers therefore disclaimall liability for direct or consequential damages resulting from the useof material contained in this book. Readers are strongly advised topay careful attention to information provided by the manufacturer ofany drugs or equipment that they plan to use.
3rd printing 2015
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Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
This book is dedicated to our sons, Joshua and Jonathan Ettinger, withlove. They have been our greatest teachers along the journey of life.
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Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
www.cambridge.org© in this web service Cambridge University Press
Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
Contents
List of contributors page xiForeword xxiPreface xxiiiAcknowledgments xxiv
Section 1 – Differential Diagnosisof Abnormal Symptoms and Signs
1 Introduction: localization anddifferential diagnosis in neurology 1Alan B. Ettinger and Deborah M. Weisbrot
2 Agitation 12Angela Scicutella and Durga Roy
3 Agnosias 18Marlene Behrmann and Maxim D. Hammer
4 Anxiety and panic 22Kenneth R. Kaufman
5 Aphasia 34Gad E. Klein and Dragana Micic
6 Apraxia 41Jasvindar Chawla and Noam Epstein
7 Ataxia, acute or subacute 45Jay Elliot Yasen
8 Ataxia, subacute or chronic 55Amanda J. Thompson and S. H. Subramony
9 Attentional problems 61Lenard A. Adler, Thomas M. Boes, David M.Shaw, and Samuel Alperin
10 Autonomic failure or syndromes 70Rajpaul Singh and Joe Colombo
11 Bulbar and pseudobulbar palsy 82Eric R. Eggenberger and David Clark
12 Catatonic-like states 84Edward Firouztale
13 Chorea 89Ruth H. Walker
14 Coma 96Galen V. Henderson and Alan B. Ettinger
15 Dementia 106Howard Crystal and Diana Rojas-Soto
16 Depression 119Yelizaveta Sher and John J. Barry
17 Diplopia 129Deborah I. Friedman
18 Dissociative disorder 135Danielle G. Koby and W. Curt LaFrance, Jr.
19 Dizziness 139Martin Gizzi and Manpreet Multani
20 Drop attacks 145Lourdes Bello-Espinosa
21 Dysarthria 149David B. Rosenfield
22 Dysphagia 152Jessica A. Shields and Anne L. Foundas
23 Dystonia 158Ritesh A. Ramdhani and Steven J. Frucht
24 Eating disorders 164Nina Kirz and Vandana Aspen
25 Eyemovements, abnormal 167Heather E. Moss
26 Falls 170Christyn M. Edmundson and Steven A. Sparr
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Contents
27 Foot drop 178Pinky Agarwal and Ryan J. Zehnder
28 Gait abnormalities 182Michael A. Williams and Scott E. Brown
29 Hallucinations, visual 188Victoria S. Pelak
30 Headache 191Ira M. Turner and Richard B. Lipton
31 Hearing deficit 197David A. Gudis and Michael J. Ruckenstein
32 Hypersomnolence 202Jeffrey S. Durmer and Heidi D. Riney
33 Incontinence 208Cara Tannenbaum and Nelly Faghani
34 Mania and bipolar symptoms 214Christopher P. Kogut and James L. Levenson
35 Medically unexplained symptoms 218Eve G. Spratt and Ryan R. Byrne
36 Memory loss and cognitive decline –acute and subacute amnesia 223Max C. Rudansky, Jacques Winter, AlanMazurek, Fawaz Al-Mufti, and Alan B. Ettinger
37 Mental status change, acute[and delirium] 236G. Bryan Young, Teneille G. Gofton, andAlan B. Ettinger
38 Movement disorders in psychiatricdisorders 242Gregory M. Pontone
39 Movements, facial 247Kevin M. Biglan and Annie Killoran
40 Movements, focal, clonic 250Daniel J. Luciano and Siddhartha Nadkarni
41 Movements, complexmotor activity 253Siddhartha Nadkarni and Daniel J. Luciano
42 Movements during sleep 258Michael J. Thorpy
43 Movements, tonic-clonic type 262Daniel J. Luciano and Siddhartha Nadkarni
44 Mutism 266Gaia Donata Oggioni and Alberto J. Espay
45 Myalgia, cramps 270Gary P. Kaplan and Rina Caprarella
46 Myoclonus 274Venkat Ramani, David Elliott Friedman, andMehri Songhorian
47 Myotonia 282Beth Stein and Steven Herskovitz
48 Nystagmus 287Sarita B. Dave and Patrick J. M. Lavin
49 Ophthalmoparesis, gaze conjugatelateral deficit and conjugate verticaldeficit 299Matthew J. Thurtell
50 Pain, arm 304Robert Duarte
51 Pain, back 308Michael Ronthal
52 Pain, eye 312Mark Beyer and Deepak Grover
53 Pain, face 316Egilius L. H. Spierings
54 Pain, neck 325Louis J. Goodrich and Ajay Berdia
55 Papilledema 332Don C. Bienfang
56 Paresthesias 337George D. Baquis and Anant M. Shenoy
57 Parkinson’s disease and relatedextrapyramidal syndromes 340Oded Gerber, Fawaz Al-Mufti, and Alan B.Ettinger
58 Proptosis [exophthalmos] 346Luis J. Mejico and Laryssa A. Huryn
59 Psychosis, thought disorder 349Ramses Ribot and Andres M. Kanner
60 Ptosis 355Andrew R. Harrison, Ali Mokhtarzadeh, andJuwan Park
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Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
Contents
61 Pupil constriction and Horner’ssyndrome 359Robert C. Sergott and Scott Uretsky
62 Pupil dilation 365Jade S. Schiffman, Rosa Ana Tang, Anastas F.Pass, and L. Anne Hayman
63 Respiratory difficulties, neurologiccauses 375Wan-Tsu W. Chang and Paul A. Nyquist
64 Retardation, mental 380Tal Gilboa, Varda Gross-Tsur, Rolla Nuoman,and Alan B. Ettinger
65 Seizure 387David J. Anschel
66 Sensory deficits and abnormalsensations 395Paul W. Brazis
67 Sensory deficits in the face 405Jeffrey A. Brown and Alan B. Ettinger
68 Smell deficit 408Richard L. Doty and Hakan Tekeli
69 Spasm, hemifacial 412Jagga Rao Alluri
70 Stroke and hemorrhage syndromes 414George C. Newman and Aparna M. Prabhu
71 Stroke in adults, etiologies 432Susan W. Law and Daniel M. Rosenbaum
72 Stroke in the young, etiologies 444Walter J. Molofsky
73 Syncope 450Todd J. Cohen
74 Tinnitus 454Eric E. Smouha and Grace M. Charles
75 Tremor 458Odi Oguh, Esther Baldinger, and Tanya Simuni
76 Vertigo 465Maroun T. Semaan
77 Visual field deficits 477Scott Uretsky
78 Visual loss, acute bilateral 487Robert M. Mallery and Misha L. Pless
79 Visual loss, monocular 494Jeffrey Peterson, Rehan Ahmed, andRod Foroozan
80 Weakness, generalized acute 497Denis Ostrovskiy
81 Weakness, hemiparesis 502Amit M. Shelat, Shicong Ye,and Malcolm H. Gottesman
82 Weakness in the intensive care unit 514John J. Halperin
83 Weakness, monomelic 519Casey A. Chamberlain and Michael Andary
84 Weakness, neck 525Sindhu Ramchandren and Aashit K. Shah
85 Weakness, paraparesis 528Friedhelm Sandbrink
86 Weakness, proximal 537Georgios Manousakis and Glenn Lopate
Section 2 – Differential Diagnosiswithin Specific Localizations
87 Cavernous sinus syndrome 547Vladimir Dadashev, Jonathan L. Brisman,and John Pile-Spellman
88 Facial nerve palsy 549Philip Ragone
89 Fourth nerve palsy 552Kristina Y. Pao and Mark L. Moster
90 Myelopathy 557Amanda R. Bedford and Randall J. Wright
91 Nerve, cranial: multiple deficit 563David Solomon and Jee Bang
92 Neuropathy, axonal versusdemyelinating 573Michael T. Pulley and Alan R. Berger
93 Neuropathy, femoral 580Eva Sahay
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Contents
94 Neuropathy, median and carpal tunnel 583Huiying Yu
95 Neuropathy, radial 587Padmaja Aradhya
96 Neuropathy, sciatic 589Julius Bazan and Pedro J. Torrico
97 Neuropathy, tibial 596Reema Maindiratta
98 Neuropathy, ulnar 601Steven Ender
99 Plexopathy, brachial 612Michael Amoashiy, Prajwal Rajappa, andCaitlin Hoffman
100 Plexopathy, lumbar 623Jean Robert Desrouleaux and Alan B. Ettinger
101 Radiculopathy 631Amtul Farheen and Bashar Katirji
102 Sixth nerve palsy 635Scott Uretsky
103 Third nerve palsy 642Claire A. Sheldon and Jason J. S. Barton
Index 648
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Contributors
Lenard A. Adler, MDProfessor of Psychiatry and Child and AdolescentPsychiatry, NYU School of Medicine, New York, NY,USA
Pinky Agarwal, MDAttending Neurologist, Booth Gardner Parkinson’sCenter at Evergreen Hospital, Kirkland, WA, USA
Rehan Ahmed, MDCullen Eye Institute, Baylor College of Medicine,Houston, TX, USA
Jagga Rao Alluri, MDClinical Neurophysiologist, ABK NeurologicalAssociates, Forest Hills, NY, USA
Fawaz Al-Mufti, MDChief Resident, Department of Neurology, StateUniversity of New York at Stony Brook, Stony BrookUniversity Medical Center, Stony Brook, NY, USA
Samuel Alperin, BSDepartment of Psychiatry, NYU School of Medicine,and Mental Health Research Service, VA NY HarborHealthcare System, New York, NY, USA
Michael Amoashiy, MD, PhDAssistant Professor of Clinical Neurology, WeillCornell Medical College, Brooklyn, NY, USA
Michael Andary, MDProfessor and Residency Program Director, MichiganState University College of Osteopathic MedicineDepartment of Physical Medicine and Rehabilitation,East Lansing, MI, USA
David J. Anschel, MDDirector, Comprehensive Epilepsy of Long Island,St Charles Hospital, Port Jefferson, NY, USA
Padmaja Aradhya, MDNeurologist, Bethpage, NY, USA
Vandana Aspen, PhDPostdoctoral Scholar, Stanford University, Stanford,CA, USA
Esther Baldinger, MDClinical Assistant Professor of Neurology, SUNYDownstate Medical Center, Brooklyn, NY, USA
Jee Bang, MDChief Resident, Department of Neurology, JohnsHopkins Hospital, Baltimore, MD, USA
George D. Baquis, MDHead – Neuromuscular Section, Baystate MedicalCenter and Associate Clinical Professor of Neurology,Tufts University School of Medicine, Springfield,MA, USA
John J. Barry, MDProfessor of NeuroPsychiatry and Behavioral Science,Stanford University Medical Center, Stanford, CA,USA
Jason J. S. Barton, MD, PhD, FRCPCProfessor, Departments of Ophthalmology and VisualSciences, Medicine (Neurology), and Psychology,University of British Columbia, Vancouver, Canada
Julius Bazan, MDNeurologist, Rockville Centre, NY, USA
Amanda R. Bedford, MAUniversity of Houston-Clear Lake, AmericanWashington University College of Law, Houston, TX,USA
Marlene Behrmann, PhDProfessor, Department of Psychology and Center forthe Neural Basis of Cognition, Carnegie MellonUniversity, Pittsburgh, PA, USA
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Cambridge University Press978-1-107-01455-8 - Neurologic Differential Diagnosis: A Case-Based ApproachEdited by Alan B. Ettinger and Deborah M.WeisbrotFrontmatterMore information
List of contributors
Lourdes Bello-Espinosa, MDAssistant Professor of Neurology and Pediatrics,Stony Brook University, Stony Brook, NY, USA
Ajay Berdia, MDNeurologist, Rochester, NY, USA
Alan R. Berger, MDProfessor and Chairman, Department of Neurology,Interim Chairman, Department of Neurosurgery,Associate Dean for Research, University of FloridaCollege of Medicine – Jacksonville, and Director,Neuroscience Institute, Shands Jacksonville, FL, USA
Mark Beyer, DOResident in Ophthalmology, Philadelphia College ofOsteopathic Medicine, Philadelphia, PA
Don C. Bienfang, MDDirector of Neuro-ophthalmology, Brigham andWomen’s Hospital Assistant Professor, HarvardMedical School, Boston, MA, USA
Kevin M. Biglan, MD, MPHAssociate Chair for Clinical Research, AssociateProfessor of Neurology, Director, National ParkinsonFoundation Center of Excellence, Director,Huntington Disease Society of America Center ofExcellence, University of Rochester School ofMedicine and Dentistry, Rochester, NY, USA
Thomas M. Boes, MDDepartment of Psychiatry, NYU School of Medicine,New York, NY, USA
Paul W. Brazis MDProfessor of Neurology and Consultant in Neuro-Ophthalmology and Neurology, Departments ofNeurology and Ophthalmology, Mayo Clinic,Jacksonville, FL, USA
Jonathan L. Brisman, MDNeurological Surgery PC, Rockville Center, NY, USA
Jeffrey A. Brown, MDNeurological Surgery, PC, Great Neck, NY, USARegional Director, TNA-Facial Pain Organization,Neurosurgery Director of the Winthrop-UniversityHospital CyberKnife R© Program and Chief ofNeurosurgery at Mercy Medical Center, RockvilleCentre, New York, NY, USA
Scott E. Brown, MDChief, Department of Physical Medicine andRehabilitation, Sinai Hospital of Baltimore,Baltimore, MD, USA
Ryan R. Byrne, MDAssistant Professor of Psychiatry and BehavioralMedicine, Medical College of Wisconsin (MCW),Milwaukee, WI, USA
Rina Caprarella, MDChief of Neurology, ProHealth, Lake Success,NY, USA
Casey A. Chamberlain, DOPhysiatrist, Michigan State University College ofOsteopathic Medicine, Department of PhysicalMedicine and Rehabilitation, East Lansing, MI, USA
Wan-TsuW. Chang, MDClinical Fellow, Neurosciences Critical Care Division,Department of Anesthesiology and Critical CareMedicine, Johns Hopkins University School ofMedicine, Baltimore, MD, USA
Grace M. Charles, BAMount Sinai School of Medicine, New York, NY, USA
Jasvinder Chawla, MD, MBA, FAANChief, Neurology Service, Edward Hines, Jr. VAHospital, Hines, IL, USA
David Clark, DONeuro-ophthalmology Fellow, Michigan StateUniversity, East Lansing, MI, USA
Todd J. Cohen MD FACC FHRSDirector of ElectrophysiologyDirector of the Pacemaker Arrhythmia Center,Winthrop University Hospital, Mineola, NY, USA
Joe Colombo, PhDMedical Director, Ansar Medical Technologies,Philadelphia, PA, USA
Howard Crystal, MDProfessor of Neurology, Pathology, and Psychiatry,SUNY Downstate Medical Center, Brooklyn, NY,USA
Vladimir Dadashev, MDNeurosurgeon, Neurological Surgery PC, RockvilleCenter, NY, USA
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List of contributors
Sarita B. Dave, MDSenior Resident, Ophthalmology, Vanderbilt EyeInstitute, Nashville, TN, USA
Jean Robert Desrouleaux, MDNeurologist, Hempstead NY, USA
Richard L. Doty, PhDProfessor and Director, Smell and Taste Center,University of Pennsylvania Perelman School ofMedicine, Philadelphia, PA, USA
Robert Duarte, MDDirector, Pain CenterAssistant Professor of Neurology, Hofstra NorthShore-LIJ School of Medicine, Manhasset, NY, USA
Jeffrey S. Durmer, MD, PhDChief Medical Officer, Fusion Health and FusionSleep, Atlanta, GA, USA
Christyn M. EdmundsonMedical Student, Albert Einstein College of Medicine,Bronx, NY, USA
Eric R. Eggenberger, DO, MSEpiProfessor and Vice-Chairman, Michigan StateUniversity Department of Neurology &Ophthalmology, East Lansing, MI, USA
Steven Ender, DOAssistant Clinical Professor of Neurology, AlbertEinstein College of Medicine, Bronx, NY, USA
Noam Epstein, MD, MSStaff Neurologist and Researcher, Edward Hines, Jr.VA Hospital, Hines, IL, USA
Alberto J. Espay, MD, MSc, FAANAssociate Professor of Neurology and Director ofClinical Research, UC Neuroscience Institute,Department of Neurology, Gardner Family Center forParkinson’s Disease and Movement Disorders,University of Cincinnati, Cincinnati, OH, USA
Alan B. Ettinger, MD, MBAEpilepsy Director, Neurological Surgery P.C.,Rockville Center; Director of the Epilepsy WellnessProgram, Winthrop University Hospital, Mineola;Director of EEG and Epilepsy, Huntington Hospital,Huntington; and Professor of Clinical Neurology,Albert Einstein College of Medicine, Bronx, NY, USA
Niloofar (Nelly) Faghani, PTPhysiotherapist/Clinical Director/Owner, AuroraPrime Physiotherapy and Sports RehabilitationCentre, Richmond Hill, ON, Canada
Amtul Farheen, MDNeuromuscular Center, Neurological Institute,University Hospitals Case Medical Center, CaseWestern Reserve University, School of Medicine,Cleveland, OH, USA
Edward Firouztale, DEngSc, DOSouth Shore Neurologic Associates, Patchogue, NY,USA
Rod Foroozan, MDAssociate Professor of Ophthalmology, Cullen EyeInstitute, Baylor College of Medicine, Houston, TX,USA
Anne L. Foundas, MDProfessor and Chair, Department of Neurology andCognitive Neuroscience, University ofMissouri-Kansas City School of Medicine, KansasCity, MO, USA
David Elliot Friedman, MDMedical Director, Winthrop Comprehensive EpilepsyCenter, Mineola, NY, USA
Deborah I. Friedman, MD, MPHProfessor, Departments of Neurology andOphthalmology, University of Texas SouthwesternMedical Center, Dallas, TX, USA
Steven J. Frucht, MDProfessor of Neurology and Director, MovementDisorders Division, Mount Sinai School of Medicine,New York, NY, USA
Oded Gerber, MDAssociate Professor, Department of Neurology atStony Brook University Hospital, Stony Brook,NY, USA
Tal Gilboa, MDPediatric Epilepsy Clinic Director, Shaare-ZedekMedical Center, Jerusalem, Israel
Martin Gizzi, MD, PhDProfessor and Chairman, NJ Neuroscience Institute,Seton Hall University JFK Medical Center, Edison,NJ, USA
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Teneille G. Gofton, MD, MSc, FRCPCDepartment of Clinical Neurological Sciences,London Health Sciences Centre – UniversityHospital, The University of Western Ontario, London,ON, Canada
Louis J. GoodrichMedical Student, Nova Southwestern University,Davie, FL, USA
Malcolm H. Gottesman, MD, FACP, FAANProfessor of Clinical Neurology, Stony BrookUniversity School of MedicineChief, Division of Neurology, Winthrop-UniversityHospital, Mineola, NY, USA
Varda Gross-Tsur, MDAssociate Professor, Pediatrics (Neurology), Facultyof Medicine, Hebrew UniversityDirector, Neurodevelopment Unit, Shaare ZedekMedical Center, Jerusalem, Israel
Deepak Grover, DOOphthalmologist, Philadelphia, PA, USA
David A. Gudis, MDResident Physician, Department ofOtorhinolaryngology: Head and Neck Surgery,University of Pennsylvania Health System,Philadelphia, PA, USA
John J. Halperin, MD, FAAN, FACP, FRCP(E)Professor of Neurology & Medicine, Mount SinaiSchool of Medicine Chair; Department ofNeurosciences, Overlook Medical Center, Summit,NJ, USA
Maxim D. Hammer, MDAssistant Professor of Neurology, University ofPittsburgh Medical Center, Pittsburgh, PA, USA
Andrew R. Harrison, MDDepartments of Ophthalmology & VisualNeurosciences and OtolaryngologyDirector, Ophthalmic Plastic and ReconstructiveSurgery Service Co-Director, Center for Thyroid EyeDisease, Associate Professor, University ofMinnesota, Minneapolis, MN, USA
L. Anne Hayman, MDClinical Director Neuro-Radiology, Anatom-eInformation Systems, Ltd., Houston, TX, USA
Galen V. Henderson, MDDirector of Neuro ICU, Brigham andWomen’sHospital, Boston, MA, USA
Steven Herskovitz, MDProfessor of Clinical Neurology and Director of theNeuromuscular Division and EMG Lab, MontefioreMedical Center, Albert Einstein College of Medicine,Bronx, NY, USA
Caitlin Hoffman, MDDepartment of Neurological Surgery, Weill CornellMedical College, New York Presbyterian Hospital,New York, NY, USA
Laryssa A. Huryn, MDResident in Ophthalmology, Department ofOphthalmology, Syracuse, NY, USA
Andres M. Kanner, MDProfessor of Clinical Neurology, Director,Comprehensive Epilepsy Center and Chief, EpilepsySection, University of Miami Miller School ofMedicine, Miami, FL, USA
Gary P. Kaplan, MD, PhDClinical Associate Professor of Neurology, HofstraNorth Shore-LIJ School of Medicine, Hempstead,NY, USA
Bashar Katirji, MDDirector, Neuromuscular Center and EMGLaboratory, University Hospitals Case Medical CenterProgram Director, Neuromuscular Medicine,University Hospitals Case Medical CenterProfessor, Neurology, Case Western ReserveUniversity School of Medicine, Cleveland, OH, USA
Kenneth R. Kaufman, MD, MRCPsychProfessor of Psychiatry, Neurology, andAnesthesiology, Departments of Psychiatry,Neurology, and Anesthesiology, Rutgers – RobertWood Johnson Medical School, New Brunswick, NJ,USA
Annie Killoran, MDMScAssistant Professor of Neurology, Director of theWVUMovement Disorders Clinic, Robert C. ByrdHealth Sciences Center, West Virginia University,Morgantown, WV, USA
Nina Kirz, MDClinical Instructor, Child and Adolescent Psychiatry,Stanford University, Stanford, CA, USA
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Gad E. Klein, PhDNeurological Surgery PC, Lake Success, New York,USA
Danielle G. Koby, PhDStaff Psychologist, Division of Health Psychology,The Institute of Living, Departments of Neurologyand Neurosurgery, Comprehensive Epilepsy Center,Hartford Hospital, Hartford, CT, USA
Christopher P. Kogut, MDAssistant Professor, Department of Psychiatry,Virginia Commonwealth University, Richmond, VA,USA
W. Curt LaFrance Jr, MD, MPHAssistant Professor of Psychiatry and Neurology(Research), Alpert Medical School, Brown University,Director of Neuropsychiatry and BehavioralNeurology, Rhode Island Hospital, Providence,RI, USA
Patrick J.M. Lavin, MDProfessor of Neurology and Ophthalmology,Vanderbilt University Medical Center, Nashville, TN,USA
SusanW. Law, DONeurology Resident, SUNY Downstate MedicalCenter Long Island College Hospital, Brooklyn, NY,USA
James L. Levenson, MDVice Chair, Department of Psychiatry, Chair, Divisionof Consultation-Liason Psychiatry and Professor ofPsychiatry, Medicine and Surgery, VirginiaCommonwealth University School of Medicine,Richmond, VA, USA
Richard B. Lipton, MDEdwin S. Lowe Professor and Vice Chair ofNeurology, Professor of Epidemiology andPopulation Health and Professor of Psychiatry andBehavioral Sciences, Albert Einstein College ofMedicine, Bronx, NY, USA
Glenn Lopate, MDAssociate Professor, Department of Neurology,Division of Neuromuscular Diseases, WashingtonUniversity School of Medicine; Consulting Staff,Department of Neurology, Barnes-Jewish Hospital,St. Louis, MO, USA
Daniel J. Luciano, MDDirector of the Clinical Epilepsy Program at the NYUComprehensive Epilepsy Center and Director of theOut Patient EEG Epilepsy Service, NYU School ofMedicine, NY, USA
ReemaMaindiratta, MDNeurologist, Babylon, NY, USA
Robert M. Mallery, MDResident in Neurology, Harvard Medical School,Massachusetts General Hospital, and Brigham andWomen’s Hospital, Boston, MA, USA
Georgios Manousakis, MDAssistant Professor, University of Minnesota,Minneapolis, MN, USA
Alan Mazurek, MDAssistant Clinical Professor of Neurology at Mt. SinaiMedical Center and Director of Rockville CenterNeurology, Rockville Centre, NY, USA
Luis J. Mejico, MDAssociate Professor of Neurology andOphthalmology, SUNY Upstate Medical University,Syracuse, NY, USA
Dragana Micic, MA, PhDDepartment of Psychology, Queens College, The CityUniversity of New York, NY, USA
Ali Mokhtarzadeh, MDFellow, Oculoplastic and Orbital SurgeryUniversity of Minnesota Minneapolis, MN, USA
Walter J. Molofsky, MDAssociate Professor of Neurology, Albert EinsteinCollege of Medicine, Chief, Pediatric Neurology, BethIsrael Medical Center, New York, NY, USA
Heather E. Moss, MD, PhDAssistant Professor in Ophthalmology, Department ofOphthalmology & Visual Sciences, University ofIllinois at Chicago, Chicago, IL, USA
Mark L. Moster, MDProfessor of Neurology and Ophthalmology,Neuro-Ophthalmology Service, Wills Eye Institute,Thomas Jefferson University School of Medicine,Philadelphia, PA, USA
Manpreet Multani, MDNJ Neuroscience Institute, Seton Hall University,Edison, NJ, USA
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Siddhartha Nadkarni, MDAssistant Professor of Neurology, Director of theEpilepsy HOS Clinic and Epilepsy FellowshipProgram, NYU School of Medicine, New York,NY, USA
George C. Newman, MD, PhDProfessor and Chairman, Neurosurgery Sciences,Director, Stroke Program, Albert Einstein MedicalCenter, Philadelphia, PA, USA
Rolla Nuoman, MDPediatric Resident, Woodhull Medical Center, NewYork University, Brooklyn, NY, USA
Paul A. Nyquist, MD, MPHAssociate Professor, Department of Neurology,Anesthesiology and Critical Care Medicine,Neurosurgery, Johns Hopkins University School ofMedicine, Baltimore, MD, USA
Gaia Donata Oggioni, MDUC Neuroscience Institute, Department ofNeurology, Gardner Family Center for Parkinson’sDisease and Movement Disorders, University ofCincinnati, Cincinnati, OH, USADepartment of Neurology, Universita del PiemonteOrientale A. Avogadro, Novara, Italy
Odi Oguh, MDUniversity of Florida Jacksonville Assistant Professor,Department of Neurology Jacksonville FL, USA
Denis Ostrovskiy, MDAssistant Clinical Professor of Neurology, HofstraNorth Shore-LIJ School of Medicine, HempsteadAssistant Clinical Professor of Neurology, MountSinai School of Medicine, New York, NY, USA
Kristina Y. Pao, MDOphthalmology Resident, Wills Eye Institute atThomas Jefferson University, Philadelphia, PA, USA
Juwen ParkOculoplastic Surgeon, Republic of Korea
Anastas F. Pass, OD, MS, JDUniversity of Houston – University Eye Institute,Co-Director: Neuro-Ophthlamology Service, OcularDiagnostic and Medical Eye Service, University ofHouston – University Eye Institute, Houston, TX,USA
Victoria S. Pelak, MDAssociate Professor of Neurology andOphthalmology, University of Colorado School ofMedicine, Aurora, CO, USA
Jeffrey Peterson, MD, PhDCullen Eye Institute, Baylor College of Medicine,Houston, TX, USA
John Pile-Spellman, MDNeurological Surgery PC, Rockville Center, NY, USA
Misha L. Pless, MDChief, Divisions of General Neurology andNeuro-ophthalmology Neurology Department,Massachusetts General Hospital Associate Professor,Harvard Medical School, Neuro-ophthalmology,Multiple Sclerosis and General Neurology, Boston,MA, USA
Gregory M. Pontone, MDAssistant Professor and Director, MovementDisorders Psychiatry Clinic, John Hopkins UniversitySchool of Medicine, Baltimore, MD, USA
Aparna M. Prabhu, MDAttending Neurologist, Albert Einstein MedicalCenter, Philadelphia, PA, USA
Michael T. Pulley, MD, PhDClinical Associate Professor of Neurology, DirectorEM6 Laboratory, University of Florida, Jacksonville,FL, USA
Philip Ragone, MDNeurologist, Great Neck, NY, USA
Prajwal Rajappa, MDFellow, Department of Neurological Surgery, WeillCornell Medical College, New York PresbyterianHospital, New York, NY, USA
Venkat Ramani, MDProfessor of Neurology at New York Medical CollegeChief of Section of Epilepsy and ClinicalNeurophysiology Laboratory at Westchester MedicalCenter, Valhalla, NY, USA
Sindhu Ramchandren, MD, MSAssistant Professor of Neurology, Director of thePediatric and Adult CMT and MDA Clinic,University of Michigan, Ann Arbor, MI, USA
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Ritesh A. Ramdhani, MDFellow, Movement Disorders Division, Department ofNeurology, Mount Sinai School of Medicine, NewYork, NY, USA
Ramses Ribot, MDFellow in Clinical Neurophysiology, Department ofNeurological Sciences, Rush Medical College at RushUniversity and Rush University Medical Center,Chicago, IL, USA
Heidi D. Riney, MD, D. ABPNSleep Medicine Medical Director, Fusion Sleep,Atlanta, GA, USA
Diana Rojas-Soto, MDStroke Fellow, Department of Neurology SUNYDownstate Medical Center, Brooklyn, NY, USA
Michael Ronthal, MDProfessor of Neurology, Harvard Medical School,Boston, MA, USA
Daniel M. Rosenbaum, MDProfessor and Chairman, Department of Neurology,SUNY Downstate Medical Center, SUNY DownstateStroke Center, Brooklyn, NY, USA
David B. Rosenfield, MDDirector, Speech and Language Center,Director, EMG and Motor Control Laboratory,Neurological Institute, The Methodist HospitalProfessor, Weill Medical College of CornellUniversity, Houston, TX, USA
Durga Roy, MDAssistant Professor Department of Psychiatry andBehavioral Sciences, Johns Hopkins UniversitySchool of Medicine Baltimore, MD, USA
Michael J. Ruckenstein, MDProfessor and Vice Chairman, Department ofOtorhinolaryngology: Head and Neck Surgery,University of Pennsylvania Health System,Philadelphia, PA, USA
Max C. Rudansky, MD, FACPClinical Assistant Professor of Neurology, HofstraNorth Shore-LIJ School of MedicineEmeritus Chief and Director of Stroke Unit,Huntington Hospital, Huntington, NY, USA
Eva Sahay, MDConsultant Neurology and Neurophysiology, SahayMedical Group PC, Garden City, NY, USA
Friedhelm Sandbrink, MDAssistant Clinical Professor of Neurology,Georgetown University, Washington, DC;Director EMG Laboratory and Chief Pain Clinic,Department of Neurology, Washington VAMedicalCenter, Washington, DC, USA
Jade S. Schiffman, MD, FAAO, FAANProfessor of Ophthalmology and Neuro-Oncology,Director of Neuro-Ophthalmology, Head & NeckSurgery, Section of Ophthalmology, and Co-Directorof MS EyeCARE, The University of Texas MDAnderson Cancer Center, Houston, TX, USA
Angela Scicutella, MD, PhDAttending Neuropsychiatrist, Clinical AssociateProfessor in Psychiatry, Hofstra North Shore – LongIsland Jewish School of Medicine at HofstraUniversity, Hempstead, NY, USA
Maroun T. Semaan, MDClinical Assistant Professor of Otolaryngology atUniversity Hospitals Case Medical Center and theLouis Stokes Cleveland Department of VeteranAffairs Medical Center, Case Western ReserveUniversity, Cleveland, OH, USA
Robert C. Sergott, MDDirector, Neuro-Ophthalmology Wills Eye Hospital;Professor of Ophthalmology, Neurology, andNeurosurgery, Thomas Jefferson University,Philadelphia, PA, USA
Aashit K. Shah, MD, FAAN, FANAProfessor and Associate Chair Wayne State UniversityDepartment of Neurology; Director, ComprehensiveEpilepsy Program Director, Clinical NeurophysiologyFellowship, Wayne State University Detroit; MedicalCenter Chief of Neurology, Harper UniversityHospital
David M. Shaw, BADepartment of Psychiatry, NYU School of Medicine,New York, NY Department of Psychology, FordhamUniversity, Bronx, NY, USA
Amit M. Shelat, DO, MPA, FACPAssistant Professor of Clinical Neurology, StonyBrook University School of Medicine and AttendingNeurologist, Winthrop-University Hospital, Mineola,NY, USA
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Claire A. Sheldon, MD, PhD, FRCSCDepartment of Ophthalmology and Visual Sciences,University of British Columbia, VC, Canada
Anant M. Shenoy, MDNeurology Attending, Baystate Medical Center andAssistant Professor of Neurology, Tufts UniversitySchool of Medicine, Springfield, MA, USA
Yelizaveta Sher, MDInstructor, Psychosomatic Medicine, StanfordUniversity Medical Center Stanford, CA, USA
Jessica A. Shields, PhDBrain & Behavior Program, Department ofNeurology, Cell Biology & Anatomy, Louisiana StateUniversity Health Sciences Center, New Orleans, LA,USA
Tanya Simuni, MDArthur C. Nielson Professor of Neurology, Director,Parkinson’s Disease and Movement Disorders Center,Northwestern University Feinberg School ofMedicine, Chicago, IL, USA
Rajpaul Singh, MDNeurology, Hollis, NY, USA
Eric E. Smouha, MDAssociate Professor and Director of Otology-Neurotology, Department of Otolaryngology,Mount Sinai School of Medicine, New York,NY, USA
David Solomon, MD, PhDAssistant Professor of Neurology and OtolaryngologyHead and Neck Surgery, CSF Disorders Program,Johns Hopkins Hospital, Baltimore, MD, USA
Mehri Songhorian, MDNeurologist, Great Neck, NY, USA
Steven A. Sparr, MD, FAANProfessor of Clinical Neurology and AssistantProfessor of Rehabilitation Medicine, Albert EinsteinCollege of Medicine, Bronx, NY, USA
Egilius L. H. Spierings, MD, PhDAssociate Clinical Professor of Neurology, BrighamandWomen’s Hospital, Harvard Medical School;Associate Clinical Professor of Craniofacial Pain,Tufts University School of Dental Medicine; Director,Headache and Face Pain Program, Tufts MedicalCenter, Boston, MA, USA
Eve G. Spratt, MDProfessor of Psychiatry, Medical University of SouthCarolina, Mount Pleasant, SC, USA
Beth Stein, MDAssistant Professor of Neurology, Montefiore MedicalCenter, Albert Einstein College of Medicine, Bronx,NY, USA
S.H. Subramony, MDProfessor, Department of Neurology, University ofFlorida College of Medicine, Gainesville, FL, USA
Rosa Ana Tang, MD, MPH, MBADirector, Neuro-Ophthalmology Service andCo-Director, MS EyeCARE, University of Houston –University Eye Institute, Houston, TX, USA
Cara Tannenbaum, MD, MScAssociate Professor of Medicine, Institut universitairede geriatrie, Universite de Montreal, QC, Canada
Hakan Tekeli, MDNeurology Department, Kasimpasa Military Hospital,Istanbul, Turkey
Amanda J. Thompson, MDAdjunct Clinical Post-Doctoral Fellow, University ofFlorida Center for Movement Disorders andNeurorestoration, Gainesville, FL, USA
Michael J. Thorpy, MDDirector, Sleep-Wake Disorders Center, MontefioreMedical Center, Albert Einstein College of Medicine,Bronx, NY, USA
Matthew J. Thurtell, BSc(Med), MBBS,MSc(Med), FRACPAssistant Professor of Ophthalmology and Neurology,Department of Ophthalmology and Visual Sciences,University of Iowa, Iowa City, IA, USA
Pedro J. Torrico, MDDepartment of Neurology, North Shore MedicalGroup of the Mount Sinai School of Medicine,Huntington, NY, USA
Ira M. Turner, MDThe Center for Headache Care and Research, IslandNeurological Associates PC, Plainview, NY, USA
Scott Uretsky, MDDirector, Neuro-Ophthalmology Division,Neurological Surgery PC, Lake Success, NY, USA
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Ruth H. Walker, MB, ChB, ASS, PhDDepartment of Neurology, James J. Peters VeteransAffairs Medical Center, Bronx, NY and Mount SinaiSchool of Medicine, New York City, NY, USA
Deborah M. Weisbrot, MDAssociate Professor of Clinical Psychiatry andDirector, Child & Adolescent Psychiatry OutpatientClinic, Department of Psychiatry and BehavioralSciences, Stony Brook University Medical Center,New York, USA
Michael A. Williams, MD, FAANMedical Director, The Sandra and Malcolm BermanBrain & Spine InstituteDirector, Adult Hydrocephalus Center, Sinai Hospitalof Baltimore, Baltimore, MD, USA
Jacques Winter, MDNeurologist Huntington, New York, NY, USA
Randall J. Wright, MDClinical Assistant Professor, UT Health, Departmentof Neurosurgery, Mischer Neuroscience Associates,Houston, TX, USA
Jay Elliot Yasen, MDDirector Stroke Service, Associate Professor ofClinical Neurology, School of Medicine, StateUniversity of New York at Stony Brook, NY, USA
Shicong Ye, MDAssistant Professor of Clinical Neurology, StonyBrook University School of Medicine, and AttendingNeurologist, Winthrop-University Hospital, Mineola,NY, USA
G. Bryan Young, MD, FRCPCDepartment of Clinical Neurological Sciences,London Health Sciences Centre – UniversityHospital, The University of Western Ontario, London,ON, Canada
Huiying Yu, MDDirector of Neurodiagnostic Laboratory, WinthropUniversity Hospital, Mineola, NY, USA
Ryan J. Zehnder, MDPhysical Medicine and Rehabilitation, EvergreenRehabilitation, Kirkland, WA, USA
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Foreword
There is an apocryphal story of an eminent neurol-ogy professor who was asked to provide a differen-tial diagnosis. He allegedly quipped: “I can’t give youa differential diagnosis. If you wish I will give you alist of wrong diagnoses followed by the right diagno-sis.” Sadly, this sort of arrogance pervaded our field,particularly in the era before there were accurate diag-nostic methods and effective treatments of neurologi-cal diseases. Fortunately, this sort of pomposity is nowrelegated to the past and remains only as an antiquereminder of a type of hubris that precluded discoveryand progress in diseases of the nervous system.
Fortunately, the era of therapeutic nihilism in neu-rology is over, but now we are faced with a differ-ent problem. There is simply too much informationfor any one person to accommodate. In the twenti-eth century, internalmedicine responded to this explo-sion of knowledge by differentiating itself into an arrayof subspecialties, such as cardiology, endocrinology,nephrology, hematology, oncology, gastroenterology,infectious diseases, pulmonology, andmanymore.Theinternist of the 1950s took care of patients with car-diological and hematological problems. In the year2000, no one can imagine a hematologist performinga cardiac catheterization or a nephrologist managinghepatitis C. Similarly, in the twenty-first century neu-rology now is a group of fields, such as stroke, move-ment disorders, epilepsy, cancer neurology, neuromus-cular disease, headache, multiple sclerosis, cognitiveand behavioral neurology, neuroophthalmology andmany more. Just as, in internal medicine, the Parkin-son’s disease expert cannot be expected to undertakethe treatment of brain tumors or complex epilepsy.
But because of the changes in the way medical careis delivered, neurology, as internal medicine, has expe-rienced a renaissance of the generalist in the formof divisions of general and hospital neurology. Afterall, someone must decode the non-specific neurologi-cal complaint, such as dizziness, headache, and confu-sion, and determine the nature of the problem so the
evaluation and treatment can be undertaken in aneffective and efficientmanner.Obtaining an unfocusedarray of neurodiagnostic tests is not only inordinatelyexpensive, but it is potentially dangerous, as it maydisclose an incidentaloma, the irrelevant finding on ablood test or image that can lead to unnecessary andeven life-threatening interventions. Also the availabil-ity of an enormous amount of medical informationto the lay public, some of which is useful but mostof which is misleading and often terrifying for thepatient, greatly complicates the care of patients whomay come to the doctor with a strongly held theory oftheir own problem.
It was in this context that Alan Ettinger andDeborah Weisbrot conceived of the idea of a practi-cal, easily accessible source for the clinician to gen-erate a rapid differential diagnosis when faced withthe most common neurological complaints. This is abold and ambitious endeavor as the number of suchcomplaints is enormous. Entire textbooks have beenwritten about virtually all of the major subjects anda huge literature lurks in the background for everyproblem. Rather than try to create simply another text-book, Drs Ettinger andWeisbrot have disciplined theirlarge array of authors to follow a strict format. Foreach chapter, there is a brief description of the symp-tom, sign, or condition, followed by a summary ofthe relevant anatomy, physiology, and pathophysiol-ogy. The heart of each chapter is a differential diag-nosis table, which is consistent throughout the book.For each item, the differential diagnosis is dividedby the basic nature of the problem, followed by spe-cific types, etiologies, and clinical features. For exam-ple, for the dilated pupil, the several major categoriesof the table are toxic, pressure, degenerative, vascu-lar, traumatic, inflammatory, ictal, and congenital. Fortoxic types, anticholinergic and adrenergic are listedas the subtypes. For anticholinergic, scopolamine, cos-metics, glaucoma treatments are listed as etiologiesand for scopolamine, special clinical features such as
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Foreword
accidental instillation into the eye of an agent beingused for the prevention of motion sickness. Followingthe table, there is an illustrative clinical vignette. Forthe dilated pupil, a case of amalewhowas using scopo-lamine to prevent sea sickness is recounted.
Using this stereotyped method the reader canknow exactly how to look up a particular symp-tom (e.g. dizziness) or sign (e.g. the dilated pupil)and quickly obtain a reasonable differential diagnosiswhich will aid in ordering studies, starting treatment,and referring to the appropriate specialist. The bookwill be valuable to multiple different types of readersdepending on their specific needs and level of sophisti-cation.The studentwill use the book to begin to under-stand the assessment of the patient with a neurolog-ical complaint. The non-neurologist, including otherspecialists and physician extenders, will be aided in
approaching such patients and referring those whoneed it to the appropriate specialist. The general neu-rologist will use it to refresh memory of the many dif-ferent subspecialties of the field and the subspecialistwill find it invaluable to deal with problems outsidetheir area of special competence. Those taking certi-fying examinations can use it as a study guide for themajor neurological problems faced in the practice ofmedicine, whether it be in the office, the hospital, orthe emergency department.
Ettinger and Weisbrot’s Neurologic DifferentialDiagnosis: ACase-BasedApproach is likely to become amust-have for any doctor or other healthcare providerwho must assess neurologic symptoms and signs, andthat is just about everyone.
Martin A. Samuels, M.D.
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Preface
There is certainly no paucity of general and specialtyneurology textbooks, so why produce yet anotherone? This book was inspired by our experiences asneurology and psychiatry residents many years ago,and has been reinforced decades later as senior clin-icians. Nowadays, in the era of managed care, clin-icians are expected to see increasing numbers ofpatients in shorter amounts of time; how can theclinician ensure that important diagnoses are notmissed?
It seems to us that it is unlikely that the busy neu-rologist or neurology resident will have the time orinclination to pore through voluminous textbooks inthe office or emergency room, looking for clarificationof differential diagnosis. A smaller collection of text-books specifically devoted to differential diagnosis isavailable; however, many of these are essentially bare-bone lists of diagnoses while others seem too basic orsuperficial.
What we seek to provide in Neurologic Differen-tial Diagnosis: A Case-Based Approach, is a highlyaccessible and pragmatic guide to the vast array ofpotential etiologies for neurologic and psychiatricsymptoms. Clinicians can readily find, in the alphabet-ized arrangement of topics, immediate references thatremind the clinician of items to check for when facedwith complaints of “dizziness,” “mental status change,”“diplopia,” or “psychosis.” Instead of simple lists ofpotentially responsible causes for symptoms, eachdiagnostic possibility is linked to reminders of key ele-ments that will help the clinician decide whether the
specific patient’s presentation fits with each possibleetiology. In addition, each chapter includes case stud-ies that exemplify a systematic approach to differentialdiagnosis of each symptom.
Who will find the book useful? Both experiencedand junior neurologists should find the content writ-ten by the expert authors to be invaluable. The non-neurologist such as the internist or general or fam-ily practitioner, emergency room physician, physicianassistant, and nurse practitioner who finds the subjectof neurology to be esoteric and difficult to conceptu-alize, will find the organized tables in each chapter tobe readily comprehensible. Many chapters are devotedto psychiatric symptoms and will find good use in thehands of the psychiatrist performing the essential taskof ruling out compelling medical diagnoses present-ing as psychiatric conditions. Neurologists and psychi-atrists preparing for their board examinations will alsofind Neurologic Differential Diagnosis to be invaluable,particularly because of the inclusion of case examplesand the discussion of the organized approach to diag-nosing each symptom.
As academic clinicians teaching residents in neu-rology and psychiatry, we have had the opportunity topilot the use of numerous chapters as teaching guidesfor physicians-in-training. We have been very grati-fied by the enthusiastic and positive feedback that wehave received from our student physicians as well asour colleagues. We sincerely hope that this book willfind an important place on the shelves of clinicianseverywhere.
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Acknowledgments
This ambitious project would not have been possiblewithout the kind and dedicated efforts of numerousindividuals. We would like to acknowledge the manyauthors who, in spite of daily clinical and academicdemands, contributed invaluable chapters to this book.We extend our special thanks toDr. Bashar Katirji whoprovided additional assistance in reviewing the chap-ters related to peripheral nerve disease. We also thankDr. Richard Libman for his helpful comments.
We would also like to thank the many colleagueswho provided administrative assistance or helped pro-cure medical articles utilized in formulating this book.These include Rosemary Valdez, Chaomei Wu, GildaDavis, Kathy Grzymala, Anna Dushenkov, Erica Jalal,Susan Simpson, Debra Rand, Shifra Atik, BarbaraSacks, and Rita Feigenberg.
We would also like to acknowledge individualswho have played special roles in our lives. First, DaveJones, LCSW, for sharing his extraordinary wisdom
and insight. Second, our friend John Mangione, forproviding musical diversion during the long processof preparing this book and for his generous spirit rais-ing funds to help children with devastating neurolog-ical disorders. Finally, Omri Adut, for bringing thegreat joy of horseback riding into Deborah’s life andenabling her to fulfill her most treasured childhooddream.
We extend our special thanks to Nicholas Dunton,Jane Seakins, Sarah Payne, Lesley Bennun, andArindam Bose at Cambridge University Press, whowere very helpful throughout the publication process.
Finally, we thank our patients, who shared theirlives and struggles with us and taught us the true valueof patiently taking a thorough history when generatingthe differential diagnosis.
Alan B. Ettinger, MD, MBADeborah M. Weisbrot, MD
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