Fig. 6D(x).5: Brudzinski’s leg sign/reflex.

Fig. 6D(x).6: Illustration of Brudzinski’s sign.

Fig. 6D(x).8: Tripod sign (Amoss’s sign).

Tripod sign, also known as the “Amoss’s sign”, is a useful sign of meningeal irritation.

The patient is asked to sit up in bed. This action requires active movement involving flexion of the

neck. Although a normal patient sits up without supporting himself, a patient with meningeal irritation

tries to sit up by supporting himself with his hands placed far behind him in the bed (like a tripod), in

order to take the weight off the spine and prevent its flexion [Fig. 6D(x).8]. Severe meningeal irritation

may result in the patient assuming the tripod position with the knees and hips flexed, the back arched

lordotically, the neck extended, and the arms brought back in a plane posterior to the pelvis to support

the thorax.

MENINGISM

Meningism, also called meningismus or pseudomeningitis, is a set of symptoms similar to those of

meningitis but not caused by meningitis. Whereas meningitis is inflammation of the meninges

(membranes that cover the central nervous system), meningism is caused by nonmeningitic irritation of

the meninges usually associated with acute febrile illness, especially in children and adolescents.

Causes

Meningism:

Meningitis

Subarachnoid hemorrhage.

Other conditions that mimic meningism (also resist cervical rotation):

Cervical spondylosis

After cervical fusion

Parkinson’s disease

Raised intracranial pressure especially if there is impending tonsillar herniation

Acute dystonic reaction

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Tetanus

Strychnine poisoning.

Intermittent neck stiffness is characteristic of Arnold-Chiari malformation.

EXAMINATION OF SKULL

Size of skull—microcephaly, macrocephaly

Shape/deformities

Tenderness—fracture/metastasis

Crackpot sound on percussion—hydrocephalus

Bruits on auscultation—arteriovenous malformation (AVM), hemangioma.

EXAMINATION OF SPINE

Inspection—deformities, curvature—kyphosis, scoliosis, lordosis, dimple, tuft of hair, Pott’s spine, and

meningioma

Palpation—tenderness, paraspinal spasm, and deformities

Movements [Figs. 6D(x).9A and B].

Figs. 6D(x).9A and B: Movements of spine. (Details discussed under rheumatology section)

AUTONOMIC NERVOUS SYSTEM TESTING

Common autonomic

symptoms

Signs

Orthostatic

intolerance

Dizziness

Lightheadedness

Fatigue

Pupils—mid-dilated sluggish reacting pupil

Pedal edema

Resting tachycardia

Postural hypotension

Palpable urinary bladder

Sweating abnormalities

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“Coat hanger”

headache

Nausea

Palpitations

Near syncope and

syncope

Genitourinary

Bladder urgency or

frequency

Incontinence

Nocturia

Erectile dysfunction

Ejaculatory

disturbances

Common autonomic

symptoms

Signs

Gastrointestinal

Diarrhea

Constipation

Fecal incontinence

Postprandial

fullness, cramping,

or bloating

Sudomotor

Hyperhidrosis

Hypohidrosis and

anhidrosis

Tests

Cardiovagal

innervation

(parasympathetic

innervation)

Heart rate (HR)

response to deep

breathing

Valsalva ratio, and

HR response to

standing (30:15

ratio)

“Spoon test”: A kitchen soup spoon, with its curved surface resting on the skin, was held between the

thumb and forefinger, and was drawn slowly on the skin, using sufficient energy to overcome its weight

without lifting it from the skin. When “sympathectomized” skin was crossed, the pull was smooth and

unopposed; but where sweat gland innervation and sympathetic function was intact, the skin was moist,

and the flow of the spoon was interrupted, and became sticky requiring readjustment of the strength of

pull

Adrenergic

Beat-to-beat blood

pressure (BP)

responses to the

Valsalva maneuver,

sustained

handgrip/diastolic

hand grip test ** and

BP and HR

responses to tilt-up

or active standing

“Sustained handgrip test (SHT): This parameter indicates cardiac sympathetic response and DBP

response to the sustained handgrip test—taken as the difference between the DBP just before release

of handgrip and the mean of three resting DBP readings. The change in mean DBP in response to

sustained handgrip test was interpreted as:

≥16 mm Hg was taken as normal

11–15 mm Hg as borderline

≤10 mm Hg as abnormal

Sudomotor:

Quantitative

sudomotor axon

reflex test (QSART)

Thermoregulatory

sweat test (TST)

Sympathetic skin

response (SSR),

and

Silastic sweat imprint

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Head-Up Tilt-Table Testing

The patient lies supine on the tilt table. Beat-to-beat and oscillometric BP instruments are attached to

each arm. ECG monitoring should take place throughout the test. Once the patient is comfortable, with

feet resting on the footboard, a baseline BP is recorded for at least 3 minutes. The patient is then slowly

tilted upright to an angle of 60–80°.

During testing, the patient is asked to report any symptoms. Both BP and HR are recorded

throughout tilt-table testing, after which the patient is returned to a horizontal supine position.

Three well-described patterns of neurally-mediated syncope can occur during head-up tilt-table

testing:

Vasodepression resulting in hypotension without bradycardia.

Cardioinhibition with a marked bradycardia (fewer than 40 beats/min) with or without significant

hypotension.

Mixed, with both bradycardia and hypotension.

Valsalva Ratio

The Valsalva maneuver consists of respiratory strain which increases intrathoracic and intra-abdominal

pressures and alters hemodynamic and cardiac functions.

The patient is supine or with head slightly elevated to about 30°.

Have the patient strain against 40 mm Hg applied for 15 seconds by blowing into a mouthpiece

attached to a sphygmomanometer.

Following cessation of the Valsalva strain, the patient relaxes and breathes at a normal comfortable

rate.

The ECG is monitored during the strain and 30–45 seconds following its release.

The maximal heart rate of phase II actually occurs about 1 seconds following cessation of the strain.

The minimal heart rate occurs about 15–20 seconds after releasing the strain.

DISEASES ASSOCIATED WITH AUTONOMIC DYSFUNCTION [TABLE

6D(X).1]

Table 6D(x).1: Diseases commonly associated with autonomic dysfunction.

Preganglionic autonomic failure:

Multiple system atrophy

Parkinson’s disease with autonomic failure

Ganglionic and postganglionic disorders

Pure autonomic failure

Peripheral neuropathies and neuronopathies with autonomic dysfunction

Acute and subacute (preganglionic and postganglionic):

Acute pandysautonomia

Guillain-Barré syndrome

Paraneoplastic pandysautonomia

Others (porphyria, toxins, durgs)

Chronic small-fiber (postganglionic) neruopathies:

Diabetes

Amyloidosis

Hereditary (familial dysautonomia, Fabry’s disease)

Subacute or chronic sensory and autonomic ganglionopathies:

Paraneoplastic

Sjogren’s syndrome

Other peripheral neuropathies:

Infections (human immunodeficiency virus)

Connective tissue disease (systemic lupus erythematosus)

Metabolic-nutritional (alcohol, uremia, vitamin B12 deficiency)

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E. A PPROACH TO COMMON NEUROLOGICAL CASES

Approach to following cases have been discussed in this section:

Approach to cerebrovascular accident

Approach to spinal cord diseases

Approach to neuropathy

Approach to movement disorders

Flowchart 6E.1: Diseases stratification of nervous system.

(UMN: upper motor neuron; LMN: lower motor neuron; CVA: cerebrovascular accident; TIA: transient

ischemic attack; CVST: cerebral venous sinus thrombosis; SAH: subarachnoid hemorrhage; TBM:

tuberculous meningitis; HSV: herpes simplex virus; PML: promyelocytic leukemia; SACD: subacute

combined degeneration; AIDP: acute inflammatory demyelinating polyneuropathy; CIDP: chronic

inflammatory demyelinating polyneuropathy; NMJ: neuromuscular junction)

1. APPROACH TO CEREBROVASCULAR ACCIDENT

Table 6E.1: Signs of upper and lower motor neuron disease.

Sign Upper motor neuron Lower motor neuron

Atrophy None (rarely disuse atrophy) Severe wasting

Fasciculations None Common

Tone Hypertonia—rigidity/spasticity Decreased (hypotonia)

Distribution of weakness Distal predominant/regional Predominantly proximal (except neuropathy)/segmental

Tendon reflexes Exaggerated/hyperactive Hypoactive/lost

Babinski sign Present Absent

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