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Temporal course of the threshold and size of the receptive field of the Babinski sign.

The changes of threshold and receptive field of the Babinski reflex, with time, were assessed in ten patients with acute cerebrovascular lesions. It was found that the threshold of the reflex decreased gradually and the size of the cutaneous afferent reflex field enlarged with the passage of time. These findings suggest that there is a gradual release or organisation of the reflex flexor synergy of which the Babinski sign is a modified part.

Afferent Pathways↗

Stretch hyperreflexia of triceps surae muscles in the conscious cat after dorsolateral spinal lesions.

Resistive force and electromyograms from triceps surae muscles were measured during dorsiflexion of both ankles of awake cats before and after interruption of one dorsolateral funiculus (DLF). DLF lesions produced ipsilateral increases in dynamic and static reflex force that persisted over 66 weeks. The increase in dynamic reflex force was velocity sensitive, as demonstrated by a greater effect for 60 degrees /sec than for 10 degrees /sec dorsiflexion. Also, the lesions increased dynamic force to a greater extent than static force (increased dynamic index). Background force (recorded immediately before each reflex response) was elevated ipsilaterally. However, increases in reflex force were observed when preoperative and postoperative background forces were matched within 10% and were associated with equivalent resting levels of electromyographic (EMG) activity. Resistive reflex force was significantly correlated with EMG responses to dorsiflexion and was not determined by nonreflexive mechanical stiffness of the muscles. Contralateral background and reflex force and associated EMG activity were decreased slightly, comparing preoperative and postoperative records. Clinical testing revealed ipsilateral postoperative increases in extensor tone, increased resistance to hindlimb flexion, hypermetria during positive support responses, and appearance of the Babinski reflex. However, the most reliable tests of DLF lesion effects were the quantitative measures of dynamic and static reflex amplitude. The enhancement of stretch reflexes is suggestive of spasticity. However, hyperactive stretch reflexes, hypertonicity, and the Babinski reflex were observed soon after interruption of the ipsilateral DLF, in contrast to a gradual development of positive signs that is characteristic of a more broadly defined spastic syndrome from large spinal lesions. Also, other signs that often are included in the spastic syndrome, including clonus, increased flexor reflex activity, and flexor spasms, did not result from DLF lesions. Thus, unilateral DLF lesions provide a model of spasticity but produce only several components of a more inclusive spastic syndrome.

Animals↗

[A case of thoracic meningioma presenting paraplegia at 4.5 years after removal of a falx meningioma].

A case of a thoracic meningioma presenting paraplegia 4.5 years after removal of a falx meningioma is reported. A 73-year-old woman, complaining of diplopia, was admitted to our department. Neurological examination revealed right abducens palsy. CT demonstrated a well-enhanced right frontal mass beneath the falx. The mass was totally removed under right frontal craniotomy. Its histology was transitional meningioma with rich fibroblasts. 4.5 years after craniotomy, she complained of progressing gait disturbance and nocturnal leg pain. Neurological examination revealed paraplegia, complete loss of leg sensation, loss of patellar and ankle reflex, bilateral positive Babinski reflex and urinary disturbance. Rectal function and anal reflex were preserved. Thoracic MRI demonstrated an intradural extramedullary mass which was well enhanced with Gd-DTPA at Th6-7. Under laminectomy, the mass was totally removed. Its histology was transitional meningioma with rich psammoma bodies and whirl formations. 4 months after removal, her palsy and sensory loss were almost completely recovered. We were able to find 15 cases of combined intracranial and spinal meningiomas in the literature. A young woman of neurofibromatosis suffered from tentorial, intraventricular and C1-2 meningiomas. Of 15 cases without neurofibromatosis including our case, 4 cases were of young boys and 11 cases were of women. Their initial symptoms originated from intracranial meningiomas in 8 cases. Multiple intracranial meningiomas were revealed in only 4 cases. In 9 cases, one case presented a combination of one intracranial meningioma and one spinal meningioma. Histology of intracranial meningioma was almost the same that of spinal meningioma in almost half of the 10 cases. These findings suggest the multi sentricity theory of multiple meningiomas originating in other neuroaxial compartments. Severe spinal dysfunction was recovered after removal in our case. Rectal function and anal reflex were preserved. These anorectal findings suggest that spinal dysfunction is either complete or incomplete. Motor evoked potentials are hopeful tools which can select reversible spinal motor dysfunctions.

Aged↗

[Clinical studies on chaddock reflex].

One hundred neurological cases were evaluated for the positive rates of 6 pathological reflexes by the same examiner (author). Chaddock and Babinski reflexes were highly sensitive, their positive occurrence being 97.1% and 80.3% of the cases respectively, compared with other pathological reflexes. In patients with paresthesia on the soles, cold feet or foot grasping, Chaddock reflex was superior to Babinski, but in some cases Chaddock became definitely positive despite negative Babinski without attributable reasons, suggestive of the former is more sensitive than the latter. The original stimulation site in Chaddock reflex is the skin area just beneath the external malleolus, and within sural nerve distribution. The elicitation of Chaddock reflex was attempted by stimulating the dorsum of the foot from medial to lateral border, with definite positive responses from the areas of sural nerve distribution. To evaluate the sensitivity and receptive field of Chaddock reflex more objectively, the electromyographic method was employed in 13 cases. The needle electrode was inserted into the extensor hallucis longus (EHL) to monitor the up-going toe, as well as flexor hallucis brevis (FHB) for the plantar flexion of the toe, and the surface electric stimulator was applied to 7 different points of the foot and leg, including original Chaddock and Babinski zones. The results of electrical stimulations to 7 different sites revealed that definitely better responses of EHL in sural nerve distribution, compared with other nerve supply. The threshold strength to evoke the action potentials in EHL proved that Chaddock's area was significantly more sensitive than Babinski's area. The relationship of latencies between EHL and FHB on electrical stimulations to the Chaddock's and Babinski's areas showed that earlier and better responses in EHL than in FHB in Chaddock, which could be another reason that Chaddock reflex was more sensitive than Babinski. From the clinical and electromyographic evaluations mentioned above, Chaddock reflex is not just a variant of Babinski reflex, more sensitive and accurate, and its receptive field is considered to be in sural nerve distribution.

Adolescent↗

[Myxopapillary ependymoma of the filum terminale with a holocord cyst: a case report].

This paper describes a case of myxopapillary ependymoma of the filum terminale with a holocord cyst. A fifteen-year-old boy was admitted because of dysarthria, dysphagia and tetraparesis. He also suffered from severe lumbago and ankle pain for three years. On admission his vital signs were stable and neurological examination revealed lower cranial nerve palsies (from 9th through 12th), tetraparesis, bilateral impairment of vibratory and position sense of the lower extremities and urinary incontinence. All deep tendon reflexes were hypoactive bilaterally. Babinski reflex and Lasègue sign were negative bilaterally. The spine roentgenograms revealed widening of the interpedicular distance from C 1 to L5 except L2, 3 vertebrae. Lumber puncture at the L 1-2 interspace revealed a cyst at the site and the protein content of the cyst fluid was 2400 mg/dl. MRI demonstrated a syrinx extending from the medulla to the entire cervical cord. From these results, it was concluded that the medulla and the entire spinal cord were occupied by the tumor and some parts of the lesion were cystic. First Operation: After a suboccipital craniectomy and a laminectomy from C 1 to Th 2, the medulla and the cervical cord were decompressed by evacuating the cyst at the 4th cervical segment. After the first operation, the C 1-2 myelography and MRI confirmed that the medulla and the spinal cord above the Th 11 vertebra were decompressed and the lower end of the cyst was extending to the Th 11 level. Second Operation: After a laminectomy from Th 12 to L4, a solid tumor arising from the filum terminale was completely removed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

[A case of dural arteriovenous malformation with bilateral thalamic infarction].

A 59-year-old man was admitted because of frequent vomiting and obtundation in February 1982. Neurological examination on admission revealed only slight impairment of consciousness. Papilledema, meningeal irritation sign and paralysis were not elicited. The plain CT scan was normal, but the CT scan with contrast material showed patchy enhancement in the left temporal lobe and around the third ventricle. Cerebral angiography showed a dural arteriovenous malformation (dural AVM) in the left transverse sinus fed by the left occipital artery, and the retrograde flow into the straight sinus. By the third day following admission, the level of consciousness became alert. The patient did not complain of headache, bruit and visual disturbance. He showed mild disorientation and memory disturbance. But his ordinary daily-living was independent. In August 1982, the patient gradually became inactive and apathetic. At times he lay in bed with moving his eyes, swallowing foods. At other times, he lay in bed with closing his eyes, immobile, and unresponsive except to strong painful stimuli. The patient was incontinent and required nursing care. During three month periods, the patient progressively became somnolent, speechless and immobile. Eventually, he was in a state of akinetic mutism. The patient became unresponsive. The state of consciousness fluctuated within a narrow range. The pupils were isocoric and did not react to light. He sometimes moved his eyes horizontally, but the vertical eye movement was limited. Deep tendon reflexes were hyperactive with Babinski reflex bilaterally. Passive mobilization of extremities revealed hypertonic. The CT scan disclosed the bilateral symmetrical infarction of the thalamus.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriovenous Malformations↗

Post-traumatic myelopathy following flopping high jump: a pilot case of spinal manipulation.

OBJECTIVE: To present the first case of spinal cord injury from high jump and the first pilot case of spinal manipulation for post-traumatic myelopathy. CLINICAL FEATURES: An 11-yr-old tetraplegic boy was admitted to the hospital, where he had a thorough neurological examination, including myelogram, EEG and skull and spinal X rays, with normal findings. The author revealed subtle subluxations on plain X-ray films. Triceps hyperreflexia was detected bilaterally. Bilateral patella and ankle clonus with hyperreflexia, basic and excess spasticity, and bilateral extensor plantar responses were noted in the lower limbs. A clinical diagnosis of early post-traumatic incomplete spastic tetraplegia below C7 was made. INTERVENTION AND OUTCOME: He did not respond to 3 months of orthodox conservative hospital management, including steroid therapy. Spinal manipulation of the lower cervical and upper thoracic spine was performed in a private chiropractic clinic for 2 wk. He apparently recovered after 3 months of spinal manipulation. On recent examination, he has virtually completely recovered. He still suffers from hand muscle atrophy, hyperreflexia of the triceps and ankle reflex and bilateral positive Babinski reflex; ankle and patellar clonus are almost absent. CONCLUSIONS: The early response and long-term (9-yr follow-up) benefits of spinal manipulation to the early delayed traumatic myelopathy of this patient suggest spinal cord ischemia as its pathophysiology. Mechanisms of post-traumatic myelopathy are postulated. Biomechanical mechanisms of spinal manipulation for neurological recovery of post-traumatic myelopathy and/or radiculopathy are advanced. Further pilot spinal manipulation by experienced chiropractors after adequate anti-edematous (steroid) therapy is recommended for selected patients with post-traumatic myelopathy and/or radiculopathy, especially in a multidisciplinary spinal injury unit.

Athletic Injuries↗

Nontraumatic spinal intramedullary hemorrhage in an infant.

After an uncomplicated pregnancy and delivery, this female child suddenly became quadriplegic on the fifth day of life. She gradually regained movement in her upper extremities. At 2 months of age, she exhibited paraplegia with exaggerated deep tendon reflexes in the lower extremities. Babinski reflex was present bilaterally and sensory disturbances below the trunk were suspected. Somatosensory evoked potentials after median and ulnar nerve stimulation revealed preserved conduction from the upper extremities through the cervical spinal cord to the cortex. Somatosensory evoked potentials after posterior tibial nerve stimulation suggested disturbed conduction in the upper thoracic spinal cord. Magnetic resonance imaging disclosed a hypodense area in the thoracic cord between T1 and T4 on both the T1-weighted and gradient echo images consonant with an old hematoma cavity. Digital subtraction angiography failed to demonstrate any vascular malformation.

Evoked Potentials, Somatosensory↗

[Case presenting both clinical features of progressive supranuclear palsy and amyotrophic lateral sclerosis].

A 70-year-old Japanese male farmer, born and living in Kyoto prefecture, developed gait disturbance, with tendency to fall at age 68, and muscle atrophy and weakness of the right shoulder and arm a year and half later. All symptoms have been progressive ever since. The patient manifested marked dementia, parkinsonism associated with limitation of ocular movements in all directions with slow saccade, loss of startle reflex, asymmetric muscle atrophy and weakness in shoulder girdles and upper limbs with hyperreflexia, and positive Babinski reflexes. The needle electromyogram showed evidence of active denervation. Brain MRI showed cortical atrophy in the frontal and temporal lobes, and midbrain tegmentum. Cerebral blood flow image on SPECT suggested hypoperfusion in the frontal, temporal and parietal cortices and basal ganglia bilaterally. Thus, it is most likely that the present case suffered from clinical features of amyotrophic lateral sclerosis (ALS) and progressive supranuclear palsy at the same time. Relation to the ALS/Parkinsonism/Dementia complex reported from Kii peninsula and Guam was discussed.

Aged↗

[Regarding the clinical diagnosis of the monotopical spinal forms of multiple sclerosis. The value of the fan sign in the adult].

INTRODUCTION: We wish to discuss the value of the clinical history and examination in orientation of the diagnosis of probable multiple sclerosis (MS). CLINICAL CASE: We report the two year study of a woman who over the previous ten years had had three episodes of paraesthesia, with pins and needles in her left leg and other parts of the left side of her body, although never affecting head or neck. She also complained of tiring more than usual. In an outpatient clinic she was found to have a syndrome affecting the upper segments of the spinal cord, mainly involving the right side and resembling an incomplete Brown Sequard type syndrome. There were increased clinical muscle and deep reflexes. The most marked was that of the right deltoid (C5), bilateral fanning of the toes when the Babinski reflex was tested, Barré positive in the right leg, pins and needles and dysaesthesia on the left to an undetermined level. Function was well preserved when compared with the clinical signs found. The case was considered to be of monotopical MS. Spinal magnetic resonance findings confirmed the clinical diagnosis. CONCLUSIONS: We emphasise the value of careful clinical investigation directed towards the diagnosis of probable MS. We draw attention to the diagnostic value of the dissociation between the severe clinical alterations and the functional performance, which was surprisingly well maintained. Also we report the originality of the presence of bilateral fanning sign supporting the diagnosis of MS, occurring in a disease of adult life.

Adult↗

"Extensor toe sign" by various methods in spastic children with cerebral palsy.

Upper motor neuron lesion in adults is usually associated with spasticity and "extensor toe sign" on plantar stimulation (extensor plantar response). There are various methods of eliciting this sign including the classic method by Babinski. Other methods produce this response when the area of reflexogenic zone is increased due to upper motor neuron lesion. There are varying reports of Babinski positivity in spastic cerebral palsy. This study was undertaken to assess the sensitivity of different methods of eliciting "extensor toe sign." An attempt has also been made to correlate the severity of spasticity with the combined "extensor toe sign" positivity by various methods and with the increase in reflexogenic zone. Eighty-one children with spastic cerebral palsy were examined. Twelve had hemiplegia; therefore, a total of 150 limbs were tested. "Extensor toe sign" was elicited by 12 different methods in each patient. The sensitivity of each method was calculated and compared with each other one. The assessment of spasticity was done using the Ashworth Tone Scale. The severity of spasticity was correlated with "extensor toe sign" positivity using various methods. Classic Babinski reflex was positive in 75% of cases, whereas Gonda-Allen sign was positive in 90% of cases followed by Allen-Cleckley (82%), Chaddock (74%), and Cornell (54%). All other signs had sensitivity of less than 30%. There was no increase in sensitivity after combining them. There was significant negative correlation between the spasticity and the combined "extensor toe sign" positivity (by all the methods). This study, therefore, suggests that the majority of patients with spastic cerebral palsy have positive "extensor toe sign." The Gonda-Allen method is more sensitive than the classic Babinski method. A positive "extensor toe sign" is negatively correlated to the degree of spasticity.

Adolescent↗

[Explanation of an unclear neurological syndrome by toxicologic investigation].

HISTORY AND CLINICAL FINDINGS: A 51-year-old man without relevant previous illness developed vomiting and diarrhoea, later also tingling and hypaesthesias in the limbs, as well as optical hallucinations that had occurred after a mid-day meal and drinking red wine. Neurological examination revealed variable pupillary reactions with anisocoria that would change from one side to the other. There was no paresis, muscle reflexes were brisk, more so on the right. Babinski reflex was positive on the right, there was an unsustained clonus of the right foot and the coordination tests were normal. Distal symmetrical hypaesthesias and paraesthesias were present in all limbs. An exogenous psychosis with restlessness and optical hallucinations was observed. INVESTIGATIONS: Routine blood count revealed leukocytosis. Serum concentrations of cGt and GPT were raised. Cerebral computed tomography and cerebrospinal fluid as well as microbiological tests of the mid-day meal were normal. DIAGNOSIS, TREATMENT AND COURSE: As the cause of the symptoms was initially unclear the patient was admitted to hospital and monitored without any specific treatment. Within one night all symptoms had disappeared and he was discharged the next morning without any complaints. Later the red wine which he had drunk was examined toxicologically and found to contain the "designer drug" DOB (2,5-dimethoxy-4-bromamphetamine). CONCLUSION: Accidental poisoning with DOB is probably a rare event which can hardly be included in routine differential diagnosis. If an acute cerebral organic syndrome has been excluded, only toxicological investigation can help in establishing the diagnosis in such cases.

DOM 2,5-Dimethoxy-4-Methylamphetamine↗