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In his essay, Dr Shafqat (December 2005 JRSM1) takes the view that the advent of modern neuroimaging has liberated neurology from the `shackles of cerebral localization'.1 My experience is exactly the opposite—it has reinforced even more strongly the importance of clinical localization in neurology. It is our ability and confidence in appropriate clinical localizations that allows us not to recommend a magnetic resonance imaging brain scan for every patient with headache and dizziness. Surely, one would not change the clinical diagnosis of migraine even if the brain scan revealed an incidental lipoma or small area of calcification.
Dr Shafqat also suggests that emphasis on anatomical localization has hindered the development of therapies in neurological diseases `including epilepsy, migraine, Guillain-Barré syndrome, Parkinson's disease, multiple sclerosis and ischaemic stroke'.1 It is probably not true. The diagnosis of idiopathic epilepsy, migraine and Parkinson's disease still remains clinical, and neuroimaging would not be normally expected to change it. Effective therapy for these conditions was available before modern neuroimaging and levodopa remains as the gold standard for the treatment of Parkinson's disease. Aspirin is still widely used for ischaemic stroke, and warfarin in fewer cases—both of which are very old treatments. Neuroimaging is not necessary in order to diagnose Guillain-Barré syndrome and, with few exceptions, treatment can be initiated after clinical examination alone. I agree that the MRI scan has helped with the diagnosis of multiple sclerosis—but is there an efficacious treatment for it yet, other than the corticosteroids? I am not so certain.2
I believe a neurologist who can happily spend 3 days examining a patient for challenging anatomical localization will also be able to make a correct diagnosis under 3 minutes in acute stroke. The most important outcome of a neurological examination is anatomical localization. I can only hope that Dr Shafqat will agree.