Isaac Lamb, MD Profile picture
Mar 4, 2023 10 tweets 5 min read Read on X
I'm a collector, a neurology nerd, and a history fan by nature. The result of all of those is that I now own every major type of #neurology reflex hammer, and I've done the work for you to rank them.

Check out my reasoning below.

#neurotwitter #medtwitter
Tromner (S)
It's simultaneously the Cadillac and the Toyota Camry of reflex hammers. Most (American) neurologists carry one for a simple reason: it's the best. Best length, best weight, pointed tip for Babinski sign... There's really nothing negative to say.
Berliner (A)
Doesn’t get enough love. Has a great weight and pointed tip. It's slightly shorter and thinner so it can fit in your pocket. While the shorter handle and off-balance head are actually advantageous, I can't deny that it doesn't feel as good in your hand as a Tromner.
Déjerine (A)
Good length, great striking surface. It's got the weight and feel of a Tromner, but it looks more "balanced" without the little hammer on the side. It lacks a pointed tip for getting a Babinski, though.
Buck (B)
It's a little too short and a little too light, although not as light as a Taylor. It's small enough to fit in a pants pocket, which is nice, but it's double-headed so it usually gets stuck.
Babinski (C)
Good weight, great striking surface, good length, and has a point for checking a, well, Babinski. The round head makes it a little harder to store in your pocket. The handle is also too skinny and it tends to roll off the table. Telescoping versions feel gimmicky.
Queen Square (C)
Brits can get on my level: your hammer is just not good. Sorry, not sorry. The handle is so long it constantly gets snagged on stuff. See my complaints about the Babinski above. Popular doesn’t mean good. See also: the Taylor hammer.
Taylor (D)
The standard American 60 gm Taylor just sucks. It’s too light, too short, and has a weird striking surface. Generations of medical students think they can’t get a brachioradialis reflex because all they’ve used is the Taylor that came with their stethoscope.
Finger method (D)
I’m not actually recommending this strategy, but… it actually works decently well, at least on the wards. You’ll look like a neurology god when you do it. Attendings love it. EM docs SHOULD love it. But they’ve given their hearts, for some reason, to…
Stethoscope (F)
Checking reflexes with a flexible stethoscope is like playing billiards with a rope. Just use your fingers, it’s easier and more accurate.

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More from @IsaacLamb01

Feb 3
We’d like to think that our medicines are perfectly effective, but the reality is that sometimes bad outcomes like recurrent stroke still happen despite optimal medical therapy. What should we do next?
#neurology #cardiology #MedEd #medschool #FOAMed #stroke #neuroX
A middle-aged woman w/ nonvalvular afib on apixaban presents to neurology clinic. Months prior, she had a CRAO causing monocular vision loss. Workup showed additional acute, silent embolic infarcts in the anterior and posterior circulation, confirming embolic etiology.
Workup also revealed only mild ipsilateral carotid stenosis, well-controlled lipids/A1c/BP, and no atrial appendage or ventricular cardiac thrombus. She took her apixaban as directed and never missed doses.
Read 12 tweets
Jul 24, 2025
INPATIENT STROKE WORKUP
Pt 4: Other

We’ve done the other three, so let’s wrap up our tour of the TOAST stroke criteria with a grab bag of etiologies, including such diverse causes as dissection, endocarditis, and vasculitis.

#neurology #neuroX #MedEd #FOAMed
There are too many subtypes to mention in one post, but we will touch briefly on the most common. These are all comparatively rare, but collectively not uncommon.
CERVICAL ARTERY DISSECTION
This is the most common type of stroke on this list, and it’s a very important cause of stroke in the young: up to 25% of strokes in young adults.
Read 19 tweets
Jul 7, 2025
INPATIENT STROKE WORKUP

Part 2: Small Vessel Disease (SVD)
If there’s large artery (atherosclerosis), then you know there must be a small vessel disease! The vessels may be small, but the deficits are not. Neither are they rare: they account for about 25% of ischemic strokes.
As before, we will be following the TOAST framework. While the trial itself bears little significance today, the framework it used to categorize strokes is a very helpful cognitive tool and has been repeatedly used in subsequent research. Image
PATHOPHYSIOLOGY

Small vessel occlusions refer to ischemic strokes impacting vessels too small to have names. These small perforating arteries are at right angles to larger vessels and primarily supply the basal ganglia, thalami, white matter, and brainstem. Image
Read 14 tweets
Jun 24, 2025
Brainstem anatomy is notoriously tricky, but it’s made 10x easier by the Rule of 4s! Whether you are a medical student or studying for neurology boards, this powerful mnemonic will take you far!

#neurology #FOAMed #MedEd #neuroX #MedSchool #tweetorial

🧵⬇️
This is a revamp of a topic I did several years ago, newly expanded. Original credit for the Rule of 4s goes to Peter Gates.
4 cranial nerves per brainstem level
- Above pons: 1-4
- Pons: 5-8
- Below pons: 9-12

* CNs 1 and 11 do not connect with the brainstem
* CN5 enters in the pons, but has nuclei at all three levels
Read 15 tweets
Aug 20, 2024
Idiopathic intracranial hypertension (IIH)

This relatively common disorder is an important secondary cause of headache and can cause permanent vision loss. Let’s dive into the presentation, work up, and diagnosis together!

#neurology #FOAMed #MedEd #neurotwitter #tweetorial
IIH is a syndrome characterized by CSF hypertension which is not due to obstruction or other mass-occupying lesion.

The prevalence is about 1 in 100,000 in the general population, but it’s 20 times more common in the highest risk population, obese women < 45.
The cause is not known, but one theory involves a positive feedback loop of disordered CSF production in response to intracranial hypertension. Image
Read 19 tweets
Jun 10, 2024
NEUROLOGICAL APPROACH TO DIZZINESS

Dizziness is one of the most common reasons for a neurology consult. The murky waters of the vestibular system are scary to us mere mortals. But having a framework provides a map to sail these choppy seas!

Thread below: Image
The first step, we’ve all been told, is to find out what a patient means by dizzy:
⁃Vertigo
⁃Presyncope
⁃Imbalance
⁃Other
When it comes to acute dizziness, we neurologists tend to care most about vertigo.
But it turns out asking about a rotational spinning sensation lacks both sensitivity and specificity.

PMID: 17976352

True vertigo can cause tunnel vision and cardiac presyncope can cause a spinning sensation.
Read 17 tweets

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