Thread by @DrArunKValsan

🔴 Hepatology Bedside Pearls!

📢Asterixis or "Liver palms" tweetorial!

1st described in HE by Adams RD & Foley JM
(Trans Am Neurol Assoc 1949)
(1/n)

🟣Historical snippet
✔1st observed at Boston City Hospital.
✔Foley described it to a Jesuit scholar, Father Cardigan over a 🥂
✔Called it "An-iso-sterixis"
✔Tongue twister> abbreviated to asterixis
✔Adams on Harrisons editorial bd⏩popular

🔵 Definition
✔brief, arrythmic lapses in sustained voluntary contraction
✔3-5Hz
(3/n)

🟡 Pathophysiology
🤔Exact mech??
💠 Fluid shifts⏩ Astrocytes II, metabolic derangement ⏩BBB dysfn⏩ upreg of BZD ®⏩? Neurosteroids??

Pathway??
Vestibulo-/Reticulo-/rubro-spinal with subcortical & cortical projections
(4/n)

🔴Causes??
Metabolic⏩ bilateral
CVA⏩unilatetal
Phenytoin can unmask unilateral flaps!
(R Agarwal, J Postgrad Med 2016)

🟢Why "negative myoclonus"?

Myoclonus is an " In"voluntary positive ms contraction, as opposed to the brief relapse of contraction.
(5/n)

🟢 Demonstration

✔Extend arm, dorsiflex wrist, spread out fingers
✔Supine position, knees flexed with flat foot on bed (easier in "non-cooperative")
✔Put out tongue 👅

🟢 Prognostic value??

☠️ Worsening enceph
☠️ Component of PSE index, Respiratory failure scores
☠️ Incr mortality? (HardisonWG, NEJM 1966)

🟢 Documentation of asterixis

✔EMG- lapses of 35-200 msec
✔Silent Period Locked Averaging Method(SLPA) (Ugawa, JNNP 1989)
✔Hand EMG+Magneto-encephalograhy(Timmerman, Neurology 2002)
(7/n)

🟡Bonus!

🔔Lance Adams Syndrome
✔It isn't exactly asterixis, but a post anoxic myoclonic jerk!
✔Usually conscious ( c.f post hypoxic seizures)