ANKLE CLONUS AND HYPERACTIVE AND PATHOLOGIC REFLEXES
ANKLE CLONUS AND HYPERACTIVE AND PATHOLOGIC REFLEXES: Excerpt from Differential Diagnosis in Primary Care
As with most neurologic signs, the differential diagnosis of ankle clonus, hyperactive and pathologic reflexes can be developed by using anatomy. The most commonly used pathologic reflexes are the Babinski and Hoffman signs. The reader is referred to physical diagnosis texts for a more extensive list. Ankle clonus and hyperactive and pathologic reflexes are usually caused by a pyramidal tract lesion. If we follow this tract from its origin in the cerebrum to its termination in the spinal cord, we will be able to recall the many disorders that may cause them. It is helpful to cross-index these with the mnemonic VINDICATE at each level.
ANKLE CLONUS AND HYPERACTIVE AND PATHOLOGIC REFLEXES
ANKLE CLONUS AND HYPERACTIVE AND PATHOLOGIC REFLEXES
Cerebrum
- V—Vascular disorders include cerebral hemorrhage, thrombosis, aneurysms and embolism.
- I—Inflammation will help recall viral encephalitis, encephalomyelitis, cerebral abscess, venous sinus thrombosis, and central nervous system (CNS) syphilis.
- N—Neoplasms include gliomas, meningiomas, and metastasis.
- D—Degenerative disorders will help recall Alzheimer disease and the other degenerative diseases.
- I—Intoxication reminds one of lead encephalopathy, alcoholism, and other toxins that affect the brain.
- C—Congenital disorders include the reticuloendothelioses, Schilder disease, and cerebral palsy.
- A—Autoimmune disorders include multiple sclerosis and the various collagen diseases that may affect the brain.
- T—Traumatic disorders include epidural and subdural hematomas, intracerebral hematomas, and depressed skull fractures.
- E—Endocrine disorders rarely cause pyramidal tract lesions.
Brainstem
Applying the mnemonic VINDICATE to the brainstem we can recall the following possibilities:
- V—Vascular disorders include basilar and vertebral aneurysms, thrombosis and insufficiency.
- I—Inflammatory disorders associated with pyramidal tract signs include encephalomyelitis, abscess, and basilar meningitis.
- N—Neoplasms in the brainstem are similar to the cerebrum but also include the acoustic neuroma, colloid cyst of the third ventricle, and chordomas.
- D—Degenerative disorders include syringobulbia, lateral sclerosis, and Friedreich ataxia. Deficiency diseases include Wernicke encephalopathy and pernicious anemia.
- I—Intoxication includes lead, alcohol, bromide, and drug reactions.
- C—Congenital disorders with pyramidal tract involvement in the brainstem include platybasia and Arnold–Chiari malformation.
- A—Autoimmune disorders bring to mind multiple sclerosis and other demyelinating diseases.
- T—Traumatic disorders include basilar skull fracture and posterior fossa subdural hematoma.
- E—Endocrine disorders of the brainstem prompt recall of an advanced chromophobe adenoma or craniopharyngioma.
Spinal Cord
- V—Vascular lesions of the spinal cord are anterior spinal artery occlusion and dissecting aneurysm of the aorta.
- I—Inflammatory lesions of the spinal cord include epidural abscess, transverse myelitis, and meningovascular lues.
- N—Neoplasms of the spinal cord include neurofibromas, meningiomas, and metastatic tumors. These frequently compress the pyramidal tracts.
- D— There are a large number of degenerative diseases that affect the pyramidal tracts. These include amyotrophic lateral sclerosis, syringomyelia, subacute combined degeneration, and Friedreich ataxia.
- I—Intoxication will help recall radiation myelitis and the side effects of spinal anesthesia.
- C—Congenital disorders of the spinal cord include arteriovenous malformations and diastematomyelia. Cervical spondylosis associated with a progressive myelopathy is often associated with a congenital narrowing of the cervical spinal canal.
- A—Autoimmune helps recall multiple sclerosis as a common cause of pyramidal tract lesions in the spinal cord.
- T—Trauma will help recall fractures, epidural hematomas, and ruptured discs that compress the spinal cord.
- E—Endocrine disorders do not usually affect the spinal cord and pyramidal tracts unless there is metastasis from an endocrine tumor to the spine.
Approach to the Diagnosis
A neurologist should be consulted at the outset. The neurologist will be able to determine whether a CT scan or magnetic MRI should be ordered and whether it should be of the brain, brainstem, or spinal cord. If there are obvious cranial nerve signs, the imaging study will include the brain and brainstem. Spinal cord lesions usually require x-ray of the spine and possibly myelography and spinal fluid analysis. In suspected intracranial pathology, a spinal tap should not be done until a CT scan or MRI has ruled out a space-occupying lesion.
Other Useful Tests
- Carotid sonogram (carotid thrombosis)
- ECG (cardiac arrhythmia)
- Blood cultures [subacute bacterial endocarditis (SBE)]
- VDRL test (neurosyphilis)
- Four-vessel cerebral angiogram (carotid embolism, thrombosis)
- Chemistry panel (myocardial infarct with embolism)
- Urine drug screen (drug abuse)
- Antinuclear antibody (ANA) test (collagen disease)
- Blood lead level (lead encephalopathy)
- Serum B12 and folate levels (pernicious anemia)
- Tuberculin test
- Fluorescent treponemal antibody absorption (FTA-ABS) test (neurosyphilis)
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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