Neurologic Pearls

I am appreciative to Dr. Karen Roos, Editor in Chief of Seminars in Neurology, for inviting me to edit this volume on “Neurologic Pearls” based on a course I have directed at the American Academy of Neurology annual meeting for the past 3 years. This issue contains a diverse array of clinical topics presented by experts who were eager to share their knowledge and wisdom.

The first article, on brain tumors, by Drs. Craig Nolan and Igor Gavrilovic, reflects their expertise from Sloan-Kettering, one of the world’s centers of neurooncology. It emphasizes that despite advances in imaging, the diagnostic assessment and clinical-radiologic correlation of patients with brain tumors still relies heavily on bedside skills and clinical judgment. The next two articles are on movement disorders. Dr. Eric Ahlskog has few peers as a clinician and expert on Parkinson’s disease (PD) and his pearls come from many years of caring for people with PD in a thoughtful and critical way. His two outstanding books on PD—one for patients: The Parkinson's Disease Treatment Book: Partnering with Your Doctor to Get the Most from Your Medications and another for physicians: Parkinson's Disease Treatment Guide for Physicians—are recommended highly as natural follow-ups to his article. Turning from parkinsonism to hyperkinetic movement disorders in the next article, I have provided a series of pearls covering the main categories of movements as well as drug-induced and psychogenic movement disorders.

I asked Dr. Adolfo Bronstein to co-author the next article, on dizziness, after reading his outstanding book: Bronstein AM, Lempert Th: Dizziness—A Practical Approach to Diagnosis and Management. Dizziness is one of the most challenging complaints but he and fellow neurootologist Dr. Barry Seemungal take the reader through an easily understandable approach to the history and examination of the dizzy patient. They demonstrate that sorting out the cause of dizziness is not as difficult as it seems initially when one knows what to ask about from the history and what to check at the bedside.

From dizziness, the pearls next focus on neuromuscular disorders with expert clinician Dr. Steven Greenberg. Despite the diagnostic utility of EMG, the laboratory, biopsy, and molecular testing, the diagnostic starting point for neuromuscular disorders still begins at the bedside. His article is followed by pearls on myasthenia by Dr. Michael Benatar. As done with previous authors, I want to also take this opportunity to plug Dr. Benatar’s latest book: Neuromuscular Disease: Evidence and Analysis in Clinical Neurology. Its unique and highly effective style poses a series of questions about neuromuscular disorders and uses a critical review of evidence to supply answers.

Dr. Neeraj Kumar next takes the reader through the diagnostic twists and turns of sorting out a myelopathy. He has a depth of experience in this area, and particularly has been a leading contributor to the recognition and understanding of copper deficiency myelopathy, combined with a broader interest in metals and the nervous system. The next three articles cover neuroophthalmology. Dr. Wayne Cornblath emphasizes that the key to diagnosing most cases of visual loss lies in getting a good history followed by a detailed examination. His recently edited volume of Continuum on “Neuroophthalmology” by the American Academy of Neurology is a natural place to turn for more in-depth coverage. Nystagmus is covered by Dr. Janet Rucker, a highly sought out educator whose article demonstrates why she is such a popular teacher. Dr. Rucker takes the reader through the classification and phenomenology of nystagmus—a vitally important topic since nystagmus often has important localizing value.

The final chapter in the neuroophthalmology trilogy, on diplopia, is by Dr. Debbie Friedman, a medical school classmate. Aside from very obvious causes of diplopia such as an oculomotor or abducens palsy, many cases are tough for the general neurologist to sort out. Dr. Friedman shows us that the key is to understand some basics of ocular motor physiology and anatomy and have an organized approach to the history and examination.

Two of the heaviest hitters on neurologic infections are up next: Dr. Joseph Berger on neurological complications of HIV, and Dr. Karen Roos on other CNS infections. Needing no introduction, every neurologist is familiar with their writings and lectures and I am grateful for their contributions to this edition. Likewise, the next author, Dr. David Dodick is one of the first names one runs across when looking up anything on headache. Appreciating how busy he is, I had some reluctance about asking him to write a chapter. He wrote back right away and told me that although he had vowed not to accept any more writing projects at the time, he would make an exception as the opportunity to present a series of “Pearls” appealed to him and we are fortunate to have his expertise.

The next three articles were written by colleagues at The University of Maryland. Epilepsy is covered by Dr. Jennifer Hopp, a popular clinician and teacher at our program. Dr. Marcella Wozniak, who, like Dr. Hopp has received the “Golden Hammer” teaching award from our residents, shares her expertise in the area of stroke. Next are pearls on sleep disorders by Dr. Susan Lesage who has recently moved to Walter Reed. The final article, on multiple sclerosis (MS), was written by two former Hopkins trainees—Drs. Elliot Frohman and Benjamin Greenberg. One of the most prolific authors on MS and simultaneously one of the busiest clinicians and investigators, Dr. Frohman is a whirlwind of energy and productivity. His extensive experience in the diagnosis and management of MS, complemented by his junior colleague Dr. Greenberg, is laid down in a series of pearls reflecting their knowledge and wisdom.

I enjoyed editing this volume and learned a lot of bedside neurology from the expert contributors, to whom I am appreciative. I hope that all readers of this volume will have the same experience and come away better clinicians.