Paul Brazis - Localization in Clinical Neurology

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This volume is dedicated to all neurology residents/fellows/future colleagues.

The new edition of Localization in Clinical Neurology is again directed at frontline clinicians caring for patients with neurologic disease processes who are confronted with the Where is it? of neurologic disorders. Much new material has been added reflecting multiple additions to the neurologic literature concerning neuroanatomy and principles of neurologic localization. There is still no substitute for an accurate neurologic history and examination to focalize appropriate neuroimaging and electrophysiologic studies to diagnose neurologic problems.

Dr. Brazis would like to express his appreciation to his colleagues at the Mayo Clinics in Jacksonville, Scottsdale, and Rochester and expresses his gratitude and admiration for his teachers and friends: Drs. Neil Miller, Andrew G. Lee, Eric R. Eggenberger, Frank A. Rubino, Sudhansu Chokroverty, Jonathan D. Trobe, James J. Corbett, Daniel Broderick, James Bolling, and Michael Stewart.

Dr. Masdeu thanks his family and all his colleagues at the Houston Methodist Neurological and Research Institutes and at the NIH Intramural Research Program.

Dr. Biller would like to express his gratitude to his family for their encouragement and to his patients for all they have taught him during his ongoing journey as a neurologist.

Paul W. Brazis

Joseph C. Masdeu

Jos Biller

Fittingly, a book on localization in clinical neurology should begin with a chapter explaining what the term localization means. Localization derives from the Latin term locus or site. Localization is the diagnostic exercise of determining from the signs (most often) or symptoms of the patient what site of the nervous system has been affected by a disease process. Important injury to the nervous system results in abnormal function, be it behavioral, motor, or sensory. Characteristics of the dysfunction often pave the way for a topographic (from the Greek term topos or place) diagnosis. Localization and topographic diagnosis refer to the same thing: the determination of where in the nervous system the damage has occurred.

Even in the age of sophisticated neurophysiology, structural and functional neuroimaging, and molecular biology, the clinical diagnosis should precede the use of these other techniques if their full diagnostic potential is to be realized. Clinical localization has particular relevance to the adequate use of ancillary procedures. For instance, false-positive findings from gunshot approach neuroimaging can only be avoided by careful localization. As an example, congenital brain cysts, strikingly visible on imaging procedures, are often wrongly blamed for a variety of neurologic disorders, while the actual disease remains overlooked and untreated. The thoughtful use of ancillary procedures in neurology, guided by clinical localization, minimizes discomfort for patients and the waste of resources.

The history of localization is the history of early neurology, concerned with topographic diagnosis that would eventually lead to therapy. In few areas of neurology was the development of localization as interesting and so much at the center of famous controversies as it was in the case of aphasia. In fact, the oldest known document on neurologic localization concerns aphasia. It was recorded in an Egyptian papyrus from the Age of the Pyramids (about 30002500 bc), where an Egyptian surgeon described the behavior of an aphasic individual:

If thou examinest a man having a wound in his temple, penetrating to the bone, (and) perforating his temporal bone; if thou ask of him concerning his malady and he speak not to thee; while copious tears fall from both his eyes, so that he thrusts his hand often to his face so that he may wipe both his eyes with the back of his hand Edwin Smith surgical papyrus, Case 20, 2800 bc [].