The Babinski Sign: A comprehensive review

Demonstration of therapeutic effect of plasma-synthesized polypyrrole/iodine biopolymer in rhesus monkey with complete spinal cord section

Spinal cord injury (SCI) can cause paralysis, and although multiple therapeutic proposals have been developed in murine models, results have hardly been replicated in humans. As non-human primates (NHP) are more similar to humans than rodents, the current study investigated whether it was possible to reproduce in a NHP, the previously obtained beneficial results by using a plasma-synthesized polypyrrole/iodine (PPy/I) biopolymer, which reduce glial scar formation and inflammatory response and promotes nerve tissue preservation, regenerative processes and functional recovery in rats. In NHPs (Rhesus monkey) with SCI by complete transection (SCT) and with plasma-synthesized PPy/I application (experimental) or without (control), the expression of pro-inflammatory cytokines in blood, preservation of nervous tissue through magnetic resonance imaging and histological and morphometric techniques, regeneration through immunohistochemistry study and functional recovery through clinical examination, were evaluated. Control NHP showed a markedly increased of pro-inflammatory cytokines vs. experimental NHP, which preserved more nerve tissue. At the end of the follow-up, a thinner glial scar in the injured spinal cord was observed in the experimental NHP as well as regenerative nerve processes (NeuN and β-III tubulin expression), while control NHP had a marked glial scar, large cysts and less nerve tissue at the injured zone. Plasma-synthesized PPy/I also reduced the loss of pelvic limb muscle mass and allowed the experimental NHP recovered knee-jerk, withdrawal and plantar reflexes as well as movement in the hind limbs. Since most of the beneficial effects of plasma-synthesized PPy/I previously reported in rats were also observed in the NHP, these preliminary findings make their replication in humans with SCI more likely.

Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study

Background

In-hospital stroke is a serious event, associated with poor outcomes and high mortality. However, identifying signs of stroke may be more difficult in critically ill patients.

Objectives

This study investigated the prevalence and independent predictors of in-hospital stroke among patients with acute alteration of consciousness in the medical intensive care unit (MICU) who underwent subsequent brain computed tomography (CT).

Methods

This retrospective study enrolled eligible patients during the period 2007 - 2017. The alterations researched were radiologically confirmed acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH).

Results

Of 4 360 patients, 113 underwent brain CT. Among these, 31% had AIS, while 15% had ICH. They had higher diastolic blood pressures and arterial pH than non-stroke patients. ICH patients had higher mean (standard deviation (SD) systolic blood pressures (152 (48) v. 129 (25) mmHg; p=0.01), lower mean (SD) Glasgow Coma Scale scores (4 (3) v. 7 (4); p=0.004), and more pupillary abnormalities (75% v. 9%; p<0.001) than AIS patients. AIS patients were older (65 (18) v. 57 (18) years; p=0.03), had more hypertension (60% v. 39%; p=0.04), and more commonly presented with the Babinski sign (26% v. 9%; p=0.04). Multivariate analysis found that pupillary abnormalities independently predicted ICH (adjusted odds ratio (aOR) 26.9; 95% CI 3.7 - 196.3; p=0.001). The Babinski sign (aOR 5.1; 95% CI 1.1 - 23.5; p=0.04) and alkalaemia (arterial pH >7.4; aOR 3.6; 95% CI 1.0 - 12.3; p=0.05) independently predicted AIS.

Conclusion

Forty-six percent of the cohort had ICH or AIS. Both conditions had high mortality. The presence of pupillary abnormalities predicts ICH, whereas the Babinski sign and alkalaemia predict AIS.

Contributions of the study

The present study reports that almost half (46%) of critically ill patients with alterations of consciousness had an acute stroke. Of these, two-thirds had an acute ischaemic stroke (AIS), and one-third had an intracranial haemorrhage (ICH). Multivariate analysis revealed that a pupillary abnormality was a predictor for ICH and the Babinski sign was identified as a predictor of AIS.

Camillo Negro (1861-1927) and his method for eliciting the extensor toe sign

The "toe phenomenon", or extensor toe sign, is characterized by the extension (dorsiflexion) of the great toe elicited by plantar stimulation, and indicates pyramidal tract dysfunction. This phenomenon was first extensively described and studied by Joseph Jules François Félix Babiński (1857-1932), who introduced it in clinical practice. In 1912, the famous Italian neurologist Camillo Negro (1861-1927) proposed a new method of eliciting the extensor toe sign by inviting the patient, lying in bed in dorsal decubitus position, to raise the paretic limb with the leg extended on the thigh. This sign appeared during voluntary effort and could not be elicited by raising the unaffected lower limb. Negro was also the first to investigate the influence of cold upon the appearance of the "toe phenomenon" and to propose the use of (faradic) electrical stimulation to evoke it.

Would Francisco Soca have been the first to relate toe phenomenon as pyramidal disorders?

INTRODUCTION

The Uruguayan physician Francisco Soca, who specialized in neurology in Jean-Martin Charcot's clinic, defended a thesis at the Paris Faculty of Medicine in 1888 on Friedreich's ataxia in eleven patients. In this work he described the presence of toe phenomenon.

OBJECTIVE

This historical note presents a toe sign described by the Soca eight years before Babiński's classic description.

DISCUSSION

In the late 1800s Soca completed a specialization in neurology at the service run by Charcot in Paris. He defended an important thesis in 1888 assessing data from 11 Friedreich's ataxia. In his thesis, Soca also described the toe phenomenon and the presence of structural changes in the feet of these patients that were not described in the Friedreich study published in 1863.

CONCLUSION

The Soca's thesis contained the description of toe extension associated with pyramidal tract lesions, eight years later described and further immortalized as Babiński's sign. Therefore, Soca had already publicized this sign as being representative of a pyramidal dysfunction before Babiński or any other neurologist.

Spinal Cord Anatomy and Localization

PURPOSE OF REVIEW

This article focuses on clinically relevant teaching points in spinal anatomy and localizing the lesion in myelopathy.

RECENT FINDINGS

The principles underlying spinal cord lesion localization are well established, but improvements in MRI and the discovery of pathologic antibodies associated with causes of transverse myelitis distinct from multiple sclerosis, such as aquaporin-4 IgG and myelin oligodendrocyte glycoprotein IgG, have assisted in diagnosis.

SUMMARY

The spinal cord has a highly organized neuroanatomy of ascending and descending tracts that convey sensory, motor, and autonomic information. Using integration of clues from the patient's history and neurologic examination, the effective clinician can distinguish spinal cord from peripheral nerve or brain pathology, often determine the level and parts of the spinal cord affected by a lesion, and focus on a likely diagnosis. The advent of MRI of the spine has revolutionized investigation of spinal cord disorders, but an important place for strong clinical acumen still exists in assessing the patient with a myelopathy.

The Babinski sign in the first Italian reports

The Babinski sign, named after Joseph François Félix Babiński (1857-1932), is one of the most important in clinical neurology. It refers to the upward movement of the great toe following stimulation of the foot sole and is associated with a dysfunction of the pyramidal tract. The BS was recognized and adopted by neurologists all over the world immediately after its first description. In 1899, this sign was first introduced to the Italian scientific community at two different medical meetings. Some opinions on its clinical value and underlying pathophysiology were discordant, possibly reflecting suboptimal diagnostic accuracy of the first observations. Giovanni Mingazzini (1859-1929) first suggested that the BS reflects a complex mechanism emerging in patients with pyramidal tract dysfunction, whereas Giovanni Boeri (1867-1946) emphasized that the BS can be elicited if the neuromuscular structures underlying it are intact. Although some of their opinions eventually proved wrong, early Italian neurologists further contributed to the advancement in the understanding of this phenomenon.

Does the Babinski sign predict functional outcome in acute ischemic stroke?

OBJECTIVE

The aim of this prospective cohort study was to determine the incidence and neuroimaging risk factors associated with Babinski sign following acute ischemic stroke, as well as its relationship with the functional outcome of patients.

METHODS

A total of 351 patients were enrolled in the study within 7 days of acute ischemic stroke. The Babinski sign along with other upper motor neuron signs were examined upon admission and between days 1 and 3 and days 5 and 7 after admission. Neuroimaging parameters included site and volume of infarction and white matter lesions. All patients were followed up at 3 months. Functional outcome was assessed with the Lawton Activities of Daily Living scale and modified Rankin Scale.

RESULTS

Babinski sign was observed in 115 of 351 (32.8%) patients in the acute ischemic stroke. These patients had higher National Institutes of Health Stroke Scale (NIHSS) scores at admission and higher rates of atrial fibrillation and cardioembolism; higher frequencies of frontal, temporal, and limbic lobes and basal ganglia infarcts; and larger infarct volume. Higher NIHSS score and basal ganglia infarct were significant predictors of the presence of Babinski sign. After adjusting for confounds, the presence of Babinski sign did not predict poor functional outcome.

CONCLUSION

The incidence of Babinski sign was 32.8% in the acute ischemic stroke. Severe infarction and basal ganglia infarct were independent predictors of Babinski sign. Although Babinski sign is common in acute ischemic stroke patients, it does not predict poor functional outcome 3 months later.

Hand, foot, and spine deformities in parkinsonian disorders

Hand and foot deformities, known as "striatal deformities", and other musculoskeletal abnormalities such as dropped head, bent spine, camptocormia, scoliosis and Pisa syndrome, are poorly understood and often misdiagnosed features of Parkinson's disease and other parkinsonian syndromes. These deformities share some similarities with known rheumatologic conditions and can be wrongly diagnosed as rheumatoid arthritis, osteoarthritis, psoriatic arthritis, Dupuytren's contracture, trigger finger, or other rheumatologic or orthopedic conditions. Neurologists, rheumatologists, and other physicians must be familiar with these deformities to prevent misdiagnosis and unnecessary diagnostic tests, and to recommend appropriate treatment options.