HYPERACTIVE REFLEXES
HYPERACTIVE REFLEXES: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Are they intermittent or persistent? If the hyperactive reflexes are intermittent, one should consider multiple sclerosis and cerebral vascular insufficiency.
- Are they focal? If the hyperactive reflexes are focal, and especially if they are unilateral, one should consider vascular diseases, space-occupying lesions, or multiple sclerosis. Certain degenerative diseases such as amyotrophic lateral sclerosis may also present with focal hyperactive reflexes.
- If the hyperactive reflexes are focal, are they unilateral? Unilateral hyperactive reflexes are characteristic of hemiplegia. Hemiplegia is usually associated with a cerebral vascular disease or space-occupying lesion of the brain, especially if there are cranial nerve signs. However, early spinal cord tumors may present with unilateral hyperactive reflexes.
- Are there cranial nerve signs? The presence of cranial nerve signs suggests that the lesion is above the foramen magnum, and a cerebral or brain stem tumor is the first thing to be considered. A cerebral vascular lesion or multiple sclerosis must also be considered.
- Is there dementia? The presence of dementia along with the hyperactive reflexes, especially if they are diffuse, suggests Alzheimer's disease, Pick's disease, general paresis, and Korsakoff's syndrome. There are many other causes of dementia to consider.
- Are there other long tract signs? The presence of hyperactive reflexes with sensory changes should suggest pernicious anemia, syringomyelia, and Friedreich's ataxia. It may also indicate multiple sclerosis, a spinal cord tumor, a brain stem tumor, or basilar artery insufficiency.
DIAGNOSTIC WORKUP
Hyperactive reflexes, especially if they are unilateral, are a clear indication for an imaging study. It is wise to consult a neurologist or neurosurgeon before determining which imaging study to order. If there are cranial nerve findings and dementia, a CT scan or MRI of the brain should be ordered.
If there are hyperactive reflexes of all four extremities without dementia or cranial nerve signs, MRI of the cervical spine would probably be the most appropriate procedure. It may, however, be necessary to get a CT scan or MRI of the brain anyway.
If only the lower extremities are involved, MRI of the thoracic cord would probably be most appropriate, but then MRI of the cervical spine should be done if the thoracic MRI is negative. Spinal fluid analysis will help diagnose multiple sclerosis, central nervous system syphilis, cerebral hemorrhages, or abscess. A CBC, serum B
12
and folic acid, and Schilling test will help diagnose pernicious anemia. Plain films of the appropriate level of the spine are necessary in trauma cases. An EEG and psychometric testing should be done in cases of dementia. SSEP, VEP, and BSEP studies are helpful in diagnosing multiple sclerosis. Carotid duplex scans and four-vessel angiography may be necessary for diagnosing cerebral vascular disease.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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