Hyperreflexia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Hyperreflexia suggests an upper motor neuron dysfunction. Hyperreflexia usually has a positive Babinkski's sign and spasticity. Usually develops over a period of days to weeks (as opposed to immediate presentation).

Causes

Common Causes

• Alcohol withdrawal
• Amyotrophic Lateral Sclerosis (ALS)
• Anxiety
• Apoplexy
• Athetosis
• Autonomic dystonia
• Brainstem lesions
• Cerebral lesions
• Cervical or thoracic myelopathy
• Compressive myelopathy
• Drugs, toxins: Artemether and lumefantrin
• Electrolyte disorders
• Epidural abscess
• Familial spastic paraparesis
• General paralysis
• Hepatic coma
• Homocystinuria
• Human T-lymphotropic virus type I (HTLV-I) associated myelopathy
• Hydrocephalus
• Hyperbaric liquor pressure
• Hyperthyroidism
• Hypocalcemia
• Infantile diplegia
• Intracranial bleeding
• Lithium overdose
• Maple syrup urine disease
• Meningitis
• Monoamine oxide inhibitor overdose
• Multiple Sclerosis
• Parkinsonism
• Perphenazine
• Phenylketonuria
• Poliomyelitis
• Primary lateral sclerosis
• Progressive alcoholic dementia
• Rabies
• Serotonin syndrome
• Spastic spinal paralysis
• Spinal cord infarction
• Spinocerebellar ataxia
• Syringobulbia
• Tetanus
• Thyrotoxicosis

Causes by Organ System

Cardiovascular	Apoplexy, Portal hypertension, Preeclampsia, Stroke
Chemical/Poisoning	Acute pesticide poisoning , Amitriptyline toxicity, Ammonium bifluoride, Amoxapine toxicity, Arizona bark scorpion poisoning , Black widow spider envenomation, Clomipramine toxicity, Desipramine toxicity , Fluoride , Imipramine toxicity, Lysergic acid diethylamide , Mescal poisoning , Metaldehyde , Molybdenum, Monoamine oxide inhibitor overdose, Nortriptyline toxicity , Protriptyline toxicity, Trimipramine toxicity
Dental	No underlying causes
Dermatologic	Sturge-weber syndrome
Drug Side Effect	Artemether, Lumefantrin, Perphenazine, Phenothiazine antenatal infection
Ear Nose Throat	Fara-chlupackova syndrome
Endocrine	Homocystinuria, Hyperthyroidism, Methylmalonic aciduria , Phenylketonuria, Thyrotoxicosis
Environmental	No underlying causes
Gastroenterologic	Hepatic coma, Reye's syndrome
Genetic	Arthrogryposis, Baraitser brett piesowicz syndrome, Bickerstaff's brainstem encephalitis, Cerebral autosomal recessive arteriopathy , Chromosome 1, 1p36 deletion syndrome -, Chromosome 9q duplication , Coenzyme q 10 (coq10),, De barsy syndrome, Dihydropyrimidine dehydrogenase deficiency, Gamma-aminobutyrate transaminase deficiency, Gangliosidosis generalized gm1, Gaucher's disease, Glut-1 deficiency syndrome, Gm1 gangliosidosis , Hartnup's disease, Holoprosencephaly deletion , Homocystinuria, Lesch-nyhan syndrome, Mohr-tranebjaerg syndrome, Monosomy 1p36 , Neuraminidase deficiency , Neuronal intranuclear inclusion disease , Sialidosis , Smith-fineman-myers syndrome, Soto's syndrome , Wolman syndrome , Woods black norbury syndrome, Young mckeever squier syndrome
Hematologic	Hypocalcemia, Intracranial bleeding, Subarachnoid hemorrhage
Iatrogenic	Reye's syndrome
Infectious Disease	Epidural abscess, Human t-lymphotropic virus type i (htlv-i) associated myelopathy, Malaria, Phenothiazine antenatal infection, Poliomyelitis, Rabies, Tetanus , Western equine encephalitis
Musculoskeletal/Orthopedic	Ataxia spastic congenital miosis , Ataxia, Autonomic dysreflexia, Autonomic dystonia, Autosomal recessive spastic paraplegia, Bahemuka brown syndrome, Cerebellar ataxia, Cerebral palsy, Cerebro oculo skeleto renal syndrome, Cervical or thoracic myelopathy, Charcot-marie-tooth disease , Choreoathetosis, Choroido cerebral calcification syndrome , Congenital ichthyosis, Diomedi-bernardi-placidi syndrome , Dysequilibrium syndrome, Dysmorphism, Dystonia with cerebellar atrophy , Familial spastic paraparesis, Fitzsimmons-mclachlan-gilbert syndrome, Fitzsimmons-walson-mellor syndrome -, Friedreich's ataxia, General paralysis, Guillain-barré syndrome, Hyperexplexia , Mitochondrial protein-associated neurodegeneration, Neuropathy sensory spastic paraplegia , Paine syndrome , Parkinson's disease, Poliomyelitis, Richards-rundle syndrome, Roy-maroteaux-kremp syndrome , Rubinstein-taybi syndrome, Spastic paraparesis , Spastic spinal paralysis, Spinal cord injury, Spinal shock , Spinocerebellar ataxia, Tome-brune-fardeau syndrome
Neurologic	Amyotrophic lateral sclerosis , Angelman syndrome , Ataxia spastic congenital miosis , Ataxia, Athetosis, Autonomic dysreflexia, Autonomic dystonia, Autosomal recessive spastic paraplegia, Bahemuka brown syndrome, Baraitser brett piesowicz syndrome, Bickerstaff's brainstem encephalitis, Brain tumour, Brainstem lesions, Cerebellar ataxia, Cerebral autosomal recessive arteriopathy , Cerebral lesions, Cerebral palsy, Cerebro oculo skeleto renal syndrome, Cervical or thoracic myelopathy, Charcot-marie-tooth disease , Choreoathetosis, Choroido cerebral calcification syndrome , Chromosome 1, 1p36 deletion syndrome -, Chromosome 9q duplication , Coenzyme q 10 (coq10),, Compressive myelopathy, Congenital ichthyosis, Dermatoleukodystrophy, Diomedi-bernardi-placidi syndrome , Dysequilibrium syndrome, Dysmorphism, Dystonia with cerebellar atrophy , Encephalopathy progressive , Epidural abscess, Epileptic encephalopathy, Familial spastic paraparesis, Fara-chlupackova syndrome , Fitzsimmons-mclachlan-gilbert syndrome, Fitzsimmons-walson-mellor syndrome -, Friedreich's ataxia, Fryns macrocephaly, General paralysis, Guillain-barré syndrome, Haas-robinson syndrome , Head trauma, Hepatic coma, Human t-lymphotropic virus type i (htlv-i) associated myelopathy, Hydrocephalus, Hyperexplexia , Hypomyelination and congenital cataract, Infantile diplegia, Intracranial bleeding, Lesch-nyhan syndrome, Leukoencephalopathy, Macrogyria, Meningitis, Mental retardation, Microcephaly , Migraine , Mitochondrial protein-associated neurodegeneration, Mohr-tranebjaerg syndrome, Multiple sclerosis, Neuronal intranuclear inclusion disease , Neuropathy sensory spastic paraplegia , Oculorenocerebellar syndrome, Olivopontocerebellar atrophy , Ovarioleukodystrophy, Paine syndrome , Pallidopyramidal syndrome , Parkinson's disease, Phenylketonuria, Polymicrogyria, Polyneuropathy, Primary lateral sclerosis, Progressive alcoholic dementia, Richards-rundle syndrome, Rubinstein-taybi syndrome, Seemanova-lesny syndrome, Segawa syndrome, Serotonin syndrome, Serotoninergic syndrome , Severe brain trauma, Smith-fineman-myers syndrome, Soto's syndrome , Spastic paraparesis , Spastic spinal paralysis, Spinocerebellar ataxia, Sturge-weber syndrome , Subarachnoid hemorrhage, Syringobulbia, Tetanus , Tome-brune-fardeau syndrome , Wells jankovic syndrome , Western equine encephalitis
Nutritional/Metabolic	Gaucher's disease, Haas-robinson syndrome , Hartnup's disease, Hypernatraemia, Sialidosis
Obstetric/Gynecologic	Preeclampsia
Oncologic	Brain tumour, Brainstem lesions
Ophthalmologic	Hypomyelination and congenital cataract, Oculorenocerebellar syndrome
Overdose/Toxicity	Alcohol withdrawal, Dexedrine overdose, Doxepin toxicity, Lithium overdose, Monoamine oxide inhibitor overdose, Nortriptyline toxicity , Progressive alcoholic dementia, Ritalin overdose
Psychiatric	Anxiety
Pulmonary	No underlying causes
Renal/Electrolyte	Electrolyte disorders, Electrolyte imbalance, Fanconi syndrome, Hypernatraemia, Renal syndrome
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	Cervical or thoracic myelopathy, Head trauma, Severe brain trauma, Spinal cord injury, Spinal shock
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

• Acute pesticide poisoning
• Alcohol withdrawal
• Amitriptyline toxicity
• Ammonium bifluoride
• Amoxapine toxicity
• Amyotrophic lateral sclerosis
• Angelman syndrome 
• Anxiety
• Apoplexy
• Arizona bark scorpion poisoning 
• Artemether
• Arthrogryposis
• Ataxia
• Ataxia spastic congenital miosis 
• Athetosis
• Autonomic dysreflexia
• Autonomic dystonia
• Autosomal recessive spastic paraplegia
• Bahemuka brown syndrome
• Baraitser brett piesowicz syndrome
• Bickerstaff's brainstem encephalitis
• Black widow spider envenomation
• Brain tumour
• Brainstem lesions
• Cerebellar ataxia
• Cerebral autosomal recessive arteriopathy
• Cerebral lesions
• Cerebral palsy
• Cerebro oculo skeleto renal syndrome
• Cervical or thoracic myelopathy
• Charcot-marie-tooth disease
• Choreoathetosis
• Choroido cerebral calcification syndrome
• Chromosome 1, 1p36 deletion syndrome -
• Chromosome 9q duplication 
• Clomipramine toxicity
• Coenzyme q 10 (coq10),
• Compressive myelopathy
• Congenital ichthyosis
• De barsy syndrome
• Dermatoleukodystrophy
• Desipramine toxicity 
• Dexedrine overdose
• Dihydropyrimidine dehydrogenase deficiency
• Diomedi-bernardi-placidi syndrome 
• Doxepin toxicity
• Dysequilibrium syndrome
• Dysmorphism
• Dystonia with cerebellar atrophy 
• Electrolyte disorders
• Electrolyte imbalance
• Encephalopathy progressive
• Epidural abscess
• Epileptic encephalopathy
• Familial spastic paraparesis
• Fanconi syndrome
• Fara-chlupackova syndrome 
• Fitzsimmons-mclachlan-gilbert syndrome
• Fitzsimmons-walson-mellor syndrome -
• Fluoride
• Friedreich's ataxia
• Fryns macrocephaly
• Gamma-aminobutyrate transaminase deficiency
• Gangliosidosis generalized gm1
• Gaucher's disease
• General paralysis
• Glut-1 deficiency syndrome
• Gm1 gangliosidosis 
• Guillain-barré syndrome
• Haas-robinson syndrome 
• Hartnup's disease
• Head trauma
• Hepatic coma
• Holoprosencephaly deletion
• Homocystinuria
• Human t-lymphotropic virus type i (htlv-i) associated myelopathy
• Hydrocephalus
• Hyperbaric liquor pressure
• Hyperexplexia 
• Hypernatraemia
• Hyperthyroidism
• Hypocalcemia
• Hypomyelination and congenital cataract
• Imipramine toxicity
• Infantile diplegia
• Intracranial bleeding
• Lesch-nyhan syndrome
• Leukoencephalopathy
• Lithium overdose
• Lumefantrin
• Lysergic acid diethylamide 
• Macrogyria
• Malaria
• Meningitis
• Mental retardation
• Mescal poisoning 
• Metaldehyde 
• Methylmalonic aciduria
• Microcephaly
• Migraine
• Mitochondrial protein-associated neurodegeneration
• Mohr-tranebjaerg syndrome
• Molybdenum
• Monoamine oxide inhibitor overdose
• Monosomy 1p36 
• Multiple sclerosis
• Neuraminidase deficiency 
• Neuronal intranuclear inclusion disease 
• Neuropathy sensory spastic paraplegia 
• Nortriptyline toxicity 
• Oculorenocerebellar syndrome
• Olivopontocerebellar atrophy
• Ovarioleukodystrophy
• Paine syndrome 
• Pallidopyramidal syndrome 
• Parkinson's disease
• Perphenazine
• Phenothiazine antenatal infection
• Phenylketonuria
• Pilo dento ungular dysplasia
• Poliomyelitis
• Polymicrogyria
• Polyneuropathy
• Portal hypertension
• Preeclampsia
• Primary lateral sclerosis
• Progressive alcoholic dementia
• Protriptyline toxicity
• Rabies
• Renal syndrome
• Reye's syndrome
• Richards-rundle syndrome
• Ritalin overdose 
• Roy-maroteaux-kremp syndrome 
• Rubinstein-taybi syndrome
• Seemanova-lesny syndrome
• Segawa syndrome
• Serotonin syndrome
• Serotoninergic syndrome 
• Severe brain trauma
• Sialidosis
• Smith-fineman-myers syndrome
• Soto's syndrome 
• Spastic paraparesis 
• Spastic spinal paralysis
• Spinal cord injury
• Spinal shock 
• Spinocerebellar ataxia
• Stroke
• Sturge-weber syndrome 
• Subarachnoid hemorrhage
• Syringobulbia
• Tetanus 
• Thyrotoxicosis
• Tome-brune-fardeau syndrome 
• Trimipramine toxicity
• Wells jankovic syndrome 
• Western equine encephalitis
• Wolman syndrome 
• Woods black norbury syndrome
• Young mckeever squier syndrome
• Ziehen-oppenheim syndrome

Laboratory Findings

• Calcium
• Lithium
• Drug screen
• Magnesium
• DNA testing
• Serologies for:

  • HTLV-I
  • HIV
  • Rapid plasma reagin (RPR)

Electrolyte and Biomarker Studies

• Electrolytes

MRI and CT

• CT scan for suspected intracranial lesions
• MRI is a better measure for hyperreflexia

Other Diagnostic Studies

• Cerebrospinal fluid analysis (for suspected multiple sclerosis)

Treatment

• Replace electrolytes

Acute Pharmacotherapies

• Antispasicity agents
• Steroids
• Interferon
• Glatiramer acetate
• Mitoxantrone
• Cyproheptadine
• Antiretroviral therapy

Surgery and Device Based Therapy

• Surgical intervention to relieve compression (in compressive myelopathies)
• Syringomyelia may require surgical therapy
• Some congenital conditions may require surgical intervention