Sunday, 24 April 2011

What I learnt in Neurology

1. A whole lotta pathologic reflexes. The first days we were all flabbergasted at the tricks our attendings did. We know Babinski, Chaddock, and Oppenheim, but Schaeffer? Gordon? Gonda? Rossolimo? Hoffman-Trommer? Like, what?? And then we of course found out about the Babinski-like responses bunch and felt ridiculous. I mean, even Wikipedia knows more about it.

2. Turns out in addition to Brudzinski's signs I and II, there are Brudzinski III and IV. Brudzinski III is when you press the zygomatic bones to see if the patient will flex his/her upper arms. Brudzinski IV is when you press slightly above the pubic symphysis to elicit flexions of the hips and knees.
What I don't know is whether these signs are known at all in the Western world, because every time I Google them I always get Indonesian sources. Please help me on this. Do they exist with another name or what? I'm dying to know.

3. Tension-type headache can manifest as tightness of the shoulder and neck muscles.

4. Patients with myasthenia gravis should remain in a temperate environment. Extreme heat increases the destruction of the precious acetylcholine by acetylcholinesterase. On the other hand, cold temperature is reported to significantly improve the symptoms; however, even references to this matter vary in opinion.

5. Don't catheterize a delirious patient! He/she might try to yank it out.

6. The primary sources of metastatic carcinoma of the brain are prostate, lung, and GI tract carcinomas.

7. Stroke patients who develop dysphagia can get pneumonia. Two reasons:

  • Decreased level of consciousness in many stroke patients leads to "attenuation of protective reflexes, impaired function of lower esophageal sphincters, delayed gastric emptying, and the worsening of the coordination of breathing and swallowing."

  • While nasogastric tube aids the feeding in stroke patients, it is also controversial because it may actually precipitate aspiration pneumonia through "increased oropharyngeal secretions, impairment of laryngeal elevation, and disruption of the upper and lower esophageal sphincters."

8. Distinguish carefully between tetraparesis and double hemiparesis.

9. Yes, it's possible to have a monoparesis / monoplegia that is a UMN lesion.

10. Four cerebral lobes? Think again! There are five!

11. The degree of sensory aphasia can be measured roughly by giving two instructions, one simple and one harder. An example of simple instruction would be telling the patient to raise his/her left arm. A harder instruction is telling him/her to take a piece of paper with the right hand, fold it into half, and place it on his/her right side. A patient with mild aphasia may have some difficulties in following the latter.

12. Meningeal irritations and associated signs are not specific for meningitis. They can also indicate meningeal inflammation (as in the case of neoplasm) and hemorrhage (e.g.: subarachnoid hemorrhage). They can even be absent in patients with GCS <8.

13. MRI is more sensitive in detecting infratentorial lesions than CT scan.

14. Lactate is the base complement of lactic acid! This was especially confusing because the Indonesian word for lactic acid is "asam laktat", with "laktat" being a direct translation from "lactate". That's why Ringer's lactate is okay for stroke patients undergoing anaerobic metabolism!

15. Nimodipine is given to attenuate vasospasm in cases of subarachnoid hemorrhage.

16. A whole new world of hypokalemic periodic paralysis.

Also, our terrific attending gave each of us a copy of stroke guidelines. It contains EVERYTHING we need to know about the management of stroke and its associated conditions (hyperglycemia, hypertension).

We are very lucky.

EDIT on April 25, 2011:

One more thing: I have Hoffman-Trommer reflex! It is NOT pathological if it exists bilaterally in an otherwise normal healthy sane people.


  1. Are you from Indonesia? I think it's caused by google location identification that made you search results come only from Indonesia. It's known that Brudzinki is available from I - IV. Brundzinki itself is found by french doctor with Poland origin. But I have no idea why the "most" literature... Brudzinki examination is limited from I and II... CMIIW

    1. Yes I am. But I have "the web" selected for my search results, instead of "pages from Indonesia", so that shouldn't be a problem. However when I input Brudzinski III and IV, most results are Indonesian pages. Funny thing.


Any thoughts...?