Neurology

History

Modern neurology had its beginnings in the 16th century with Vesalius. He described the anatomy of the brain but offered little insight into its function. Thomas Willis was the first to remove the brain from the skull intact and later went on to publish his Anatomy of the Brain in 1664. Willis was the first to describe the circle of Willis, the vascular structure at the base of the brain that ensures blood flow and perfusion bilaterally. He introduced the idea of localization and vaguely described epilepsy, apoplexy, and paralysis.

Training

A neurologist's training varies from country to country, but generally, it involves obtaining a medical degree followed by three to five years of postgraduate specialty training. Opportunities exist to subspecialize even further in areas such as stroke and epilepsy. Sine qua non to neurology and irreplaceable to the neurologist's skills is the neurological physical exam. Typically, it begins with assessing the cranial nerves I–XII. Strength of each limb is then measured on a scale from 0 to 5—5 representing full strength and 0 being paralysis. It is important to compare both sides of the body during an examination because a substantial amount of information about a neurological disorder and its specific location can be derived from its pattern of effects: unilateral, bilateral, or contralateral involvement. Sensations to pain, temperature, or vibration in addition to proprioception (the unconscious perception of movement and spatial orientation) are examined next. This is followed by eliciting deep tendon reflexes to distinguish between upper and lower motor neuron diseases (CNS versus PNS, respectively). The neurological exam normally concludes by testing coordination and gait in order to assess cerebellar function.

Imaging

Imaging has become commonplace in neurology, particularly in the developed world. Computerized tomography (CT) scans, magnetic resonance imaging (MRI), and magnetic resonance angiography/venog-raphy (MRA/MRV) have revolutionized the way neurologists diagnose and manage patients. Etiologies that once remained allusive or inconclusive can now be more readily confirmed or rebuked than in the past. In addition, pathologies are being localized and followed in a relatively noninvasive way, increasing patient compliance and overall management efficacy. Imaging is also being used in academia as a tool to train medical students, residents, and subspecialists.

Management

Discussing each therapeutic strategy separately is difficult because of the diversity of etiologies. In many instances, the initial insult is irreversible, and so, the primary goal is to limit secondary injury. In the case of suspected head or neck trauma, immobilization and spinal stabilization has become the mainstay of initial management, often occurring concomitantly with hemodynamic stabilization. Generally, neurological diseases are managed in a multidisciplinary fashion. This can involve medications, radiation therapy, and possibly referral to a neurosurgeon. Medical therapy varies with etiology, but it most commonly includes antiepileptics, fibrinolytic therapy for stroke patients, behavioral modifiers, steroids, analgesics, and neuromuscular agents. Fibrinolytic therapy, such as tissue plasminogen activator (t-PA), has had significant media coverage in recent years. This has been in part due to their exorbitant cost and to the potentially fatal consequences associated with their usage in some patients. Their ability to “dissolve” clots and prevent progressive damage in stroke patients cannot be disputed, however. As a result, the American Stroke Association has published strict guidelines outlining absolute and relative contraindications regarding the usage of fibrinolytics.

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