PATHOLOGIC REFLEXES
PATHOLOGIC REFLEXES: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Are the findings intermittent? If the pathologic reflexes come and go, transient ischemic attacks, multiple sclerosis, migraine, epilepsy, and hypoglycemia should be considered in the differential diagnosis.
- Are they unilateral or bilateral? Unilateral pathologic reflexes should signify either a brain tumor or vascular lesion. Bilateral pathologic reflexes should suggest an inflammatory or degenerative disease. However, multiple sclerosis may present with either unilateral or bilateral pathologic reflexes. Vascular lesions in the basilar circulation may also present with bilateral pathologic reflexes. It should be pointed out that there is no hard-and-fast rule.
- Is there associated facial palsy or other cranial nerve signs? The presence of facial palsy or other cranial nerve signs should make one look for a lesion in the brain or brain stem.
- Is there headache or papilledema? The presence of headache or papilledema should prompt the investigation for a space-occupying lesion of the brain or brain stem.
- Is there hypertension or a possible source for an embolism? These findings would suggest a cerebral vascular accident such as cerebral hemorrhage or embolism.
- Is the sensory examination normal? The findings of bilateral pathologic reflexes or unilateral pathologic reflexes with a normal sensory exam and no cranial nerve signs would suggest amyotrophic lateral sclerosis or primarily lateral sclerosis.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, urinalysis, chemistry panel, ANA assay, serum B
12
and folic acid, VDRL test, chest x-ray, and EKG. If there are cranial nerve signs, a CT scan or MRI of the brain will usually be necessary. However, it is wise to get a neurology consultation before undertaking these expensive tests. A spinal tap may be done if the imaging study is negative.
If vascular disease is suspected, carotid scans to rule out carotid stenosis or plaque and a search for an embolic source using echocardiography and blood culture should be done. A cardiologist can assist in this search. Four-vessel cerebral angiography may be necessary. In fact, if a cerebral hemorrhage has been ruled out and there is no significant hypertension, a four-vessel cerebral angiographic study should probably be done. Evoked potential studies and HIV antibody titers should also be done. If there are no cranial nerve signs, MRI of the cervical spine or thoracic spine should be done, depending on the level of the lesion. Myelography may also be helpful. Serum protein electrophoresis and immunoelectrophoresis all may be necessary in the workup.
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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