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Asterixis: a study of 103 patients

Abstract

In 1949, asterixis was first described in patients with hepatic encephalopathy. It was quickly recognized that this phenomenon also occurs in other generalized encephalopathies and sometimes results from structural brain lesions. This paper is a study of asterixis in the general neurology clinic and on the inpatient neurology consultation service. The neurologists recorded the findings on inpatients and clinic patients for 12 consecutive months. Of the 1,109 inpatients with adequate examination, asterixis was documented in 97. Eighteen of the 97 cases were unilateral (18.6 %) and 79 cases were bilateral (81.4 %). Of the 614 outpatient visits with well documented examination, 6 (1 %) individuals had asterixis. Since a small number of patients were examined more than once, the study yielded 103 individuals with adequate data for analysis. Asterixis resulted from varied causes: medications, renal disorder, hepatic dysfunction, pulmonary insufficiency, stroke and other brain lesions (including malignancy, subdural hematoma, and epidural abscess). Asterixis occurred in various patterns: in some cases it was easier to elicit in the upper extremities, in some it was easier to elicit in the lower limbs, and some it was solely or predominantly unilateral. The findings are discussed in light of the literature on asterixis with regard to its varied causes, patterns and presentations. Lastly, asterixis is examined from a historical perspective and the terminology is elucidated.

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References

  1. Adair JC, Gilmore RL (1994) Meperidine neurotoxicity after organ transplantation. J Toxicol Clin Toxicol 32(3):325–328

    CAS  PubMed  Google Scholar 

  2. Adams RD, Foley JM (1949) The neurological changes in the more common types of severe liver disease. Trans Am Neurol Assoc 74:217–219

    Google Scholar 

  3. Adams RD, Foley JM (1953a) The disorder of movement in more common varieties of liver disease. Electroenceph Clin Neurophysiol 51(Suppl 3):51

    Google Scholar 

  4. Adams RD, Foley JM (1953b) The neurological disorder associated with liver disease. Res Publ Assoc Res Nerv Ment Dis 32:198–237

    CAS  PubMed  Google Scholar 

  5. Adams RD, Victor M (1975) Adams and Victor’s principles of neurology, 1st edn. McGraw Hill Medical, New York

    Google Scholar 

  6. Alvarez-Cermeño JC, Martinez-Castrillo JC, Gobernado JM (1988) Sudden headache associated with unilateral asterixis. Headache 28(5):352–353

    PubMed  Google Scholar 

  7. Ambrosetto G, Riva R, Baruzzi A (1984) Hyperammonemia in asterixis induced by carbamazepine: two case reports. Acta Neurol Scand 69(3):186–189

    CAS  PubMed  Google Scholar 

  8. Anderson RJ (1981) Asterixis as a manifestation of salicylate toxicity. Ann Intern Med 95(2):188–189

    CAS  PubMed  Google Scholar 

  9. Argov Z, Melamed E, Katz S (1979) Hyperparathyroidism presenting with unusual neurological features. Eur Neurol 18(5):338–340

    CAS  PubMed  Google Scholar 

  10. Austen FK, Carmichael MW, Adams RD (1957) Neurologic manifestations of chronic pulmonary insufficiency. N Engl J Med 257(13):579–590

    CAS  PubMed  Google Scholar 

  11. Babiy M, Stubblefield MD, Herklotz M, Hand M (2005) Asterixis related to gabapentin as a cause of falls. Am J Phys Med Rehabil 84(2):136–140

    PubMed  Google Scholar 

  12. Bertoni JM, Schwartzman RJ, Van Horn G, Partin J (1981) Asterixis and encephalopathy following metrizamide myelography: investigations into possible mechanisms and review of the literature. Ann Neurol 9(4):366–370

    CAS  PubMed  Google Scholar 

  13. Bodensteiner JB, Morris HH, Golden GS (1981) Asterixis associated with sodium valproate. Neurology 31(2):194–195

    CAS  PubMed  Google Scholar 

  14. Bonnaud I, Salama J (2003) An ischemic syndrome of the oculumotor nucleus: associated clinical and anatomical variations on a theme. Rev Neurol (Paris) 159(8–9):781–785

    CAS  Google Scholar 

  15. Bril V, Sharpe JA, Ashby P (1979) Midbrain asterixis. Ann Neurol 6(4):362–364

    CAS  PubMed  Google Scholar 

  16. Chehrazi B, Virapongse C (1981) Transient encephalopathy and asterixis following metrizamide myelography. Case report. J Neurosurg 55(5):826–829

    CAS  PubMed  Google Scholar 

  17. Chi WM, Chua KS, Kong KH (2000) Phenytoin-induced asterixis—uncommon or under-diagnozed? Brain Inj 14(9):847–850

    CAS  PubMed  Google Scholar 

  18. Conn HO (1960) Asterixis in non-hepatic disorders. Am J Med 29:647–661

    CAS  PubMed  Google Scholar 

  19. Coulter D (1981) Hyperammonemia and asterixis with valproic acid. Neurology 31(12):1580

    CAS  PubMed  Google Scholar 

  20. Davalos A, Titus F, Cervera C (1982) Unilateral asterixis: a sign of brain focal lesions. Rev Neurol 10(47):127–131

    Google Scholar 

  21. de Pablo-Fernández E, Villarejo A, Domínguez-González C, Hidalgo FS, Callero EC (2009) Astasia, asymmetrical asterixis and pretectal syndrome in thalamo-mesencephalic hemorrhage. Clin Neurol Neurosurg 111(9):766–767

    PubMed  Google Scholar 

  22. De Troyer A, Demanet JC (1976) Clinical, biological and pathogenic features of the syndrome of inappropriate secretion of antidiuretic hormone. A review of 26 cases with marked hyponatraemia. Q J Med 45(180):521–531

    PubMed  Google Scholar 

  23. Deuschl G, Bain P, Brin M (1998) Consensus statement of the movement disorder society on tremor Ad Hoc scientific committee. Mov Disord 13(Suppl 3):2–23

    PubMed  Google Scholar 

  24. Donat JR (1980) Unilateral asterixis due to thalamic hemorrhage. Neurology 30(1):83–84

    CAS  PubMed  Google Scholar 

  25. Dorland (2000) Dorland’s illustrated medical dictionary. Saunders, Philadelphia

    Google Scholar 

  26. Dysken MW, Halaris AE (1978) Post-ECT asterixis associated with primary hyperparathyroidism. Am J Psychiatry 135(10):1237–1238

    CAS  PubMed  Google Scholar 

  27. Dysken MW, Comaty JE, Pandey GN, Davis JM (1979) Asterixis associated with a high RBC lithium concentration. Am J Psychiatry 136(12):1610

    CAS  PubMed  Google Scholar 

  28. Feldmeyer JJ, Bogousslavsky J, Regli F (1984) Unilateral or bilateral asterixis in cases of thalamic or parietal lesions: an afferent motor disorder? Schweiz Med Wochenschr 114(5):167–171

    CAS  PubMed  Google Scholar 

  29. Foulk WT, Butt HR, Stauffer MH, Baggenstoss AH, Gross JB (1955) Hepatic coma: a clinical and pathologic study. Gastroenterology 29(2):171–183

    CAS  PubMed  Google Scholar 

  30. Foundas M, Donaldson MD, McAllister IL, Bridges LR (2008) Vision loss due to coincident ocular and central causes in a patient with Heidenhain variant Creutzfeldt-Jakob disease. Age Ageing 37(2):231–232

    PubMed  Google Scholar 

  31. Gastaut JL, Mege JL (1985) Encephalopathy with asterixis induced by sodium valproate role of hyperammonemia without hepatic insufficiency. Presse Med 14(7):431

    CAS  PubMed  Google Scholar 

  32. Gila L, García Díaz JJ, Campos C, Gil Pujades A, Otal M (1991) Unilateral asterixis associated with anatomic cerebral lesions. Rev Clin Esp 188(7):355–357

    CAS  PubMed  Google Scholar 

  33. Gimenez M, Martinez F, Feijoo M (1981) Asterixis of myoclonus after metrizamide myelography. Arch Neurol 38(7):472

    CAS  PubMed  Google Scholar 

  34. Glantz R, Weiner WJ, Goetz CG, Nausieda PA, Klawans HL (1982) Drug-induced asterixis in Parkinson disease. Neurology 32(5):553–555

    CAS  PubMed  Google Scholar 

  35. Goldblatt D, Griggs RC (1979) Unilateral asterixis in a paretic limb: an involuntary movement accentuated by upper motor neuron lesion. 31st Annual Meeting Program of American Academy of Neurology. Neurology 29:541–542

    Google Scholar 

  36. González I, Obeso JA, Artieda J, Pastor A, Luquin MR, Viteri C, Martínez-Lage JM (1986) Subdural hematoma: an infrequent cause of asterixis. Rev Clin Esp 179(1):28–30

    PubMed  Google Scholar 

  37. Grill MF, Maganti R (2008) Cephalosporin-induced neurotoxicity: clinical manifestations, potential pathogenic mechanisms, and the role of electroencephalographic monitoring. Ann Pharmacother 42(12):1843–1850

    CAS  PubMed  Google Scholar 

  38. Guberman A, Stuss D (1983) The syndrome of bilateral paramedian thalamic infarction. Neurology 33(5):540–546

    CAS  PubMed  Google Scholar 

  39. Hammarsten JF, Smith WO (1957) Symptomatic magnesium deficiency in man. N Engl J Med 256(19):897–899

    CAS  PubMed  Google Scholar 

  40. Heckmann JG, Ulrich K, Dütsch M, Neundörfer B (2005) Pregabalin associated asterixis. Am J Phys Med Rehabil 84(9):724

    CAS  PubMed  Google Scholar 

  41. Hillsley RE, Massey EW (1991) Truncal asterixis associated with ceftazidime, a third-generation cephalosporin. Neurology 41(12):2008

    CAS  PubMed  Google Scholar 

  42. Jacob PC, Chand RP, Omeima S (2000) Asterixis induced by gabapentin. Clin Neuropharmacol 23(1):53

    CAS  PubMed  Google Scholar 

  43. Jacome DE (2001) Blepharoclonus, pseudoasterixis, and restless feet. Am J Med Sci 322(3):137–140

    CAS  PubMed  Google Scholar 

  44. Katano H, Fukushima T, Karasawa K, Sugiyama N, Ohkura A, Kamiya K (2002) Primidone-induced hyperammonemic encephalopathy in a patient with cerebral astrocytoma. J Clin Neurosci 9(1):79–81

    PubMed  Google Scholar 

  45. Kim JS (2001a) Involuntary movements after anterior cerebral artery territory infarction. Stroke 32(1):258–261

    CAS  PubMed  Google Scholar 

  46. Kim JS (2001b) Asterixis after unilateral stroke: lesion location of 30 patients. Neurology 56(4):533–536

    CAS  PubMed  Google Scholar 

  47. Kobayashi I, Osawa M, Ohta K, Maruyama S (1985) L-dopa-induced asterixis. Folia Psychiatr Neurol Jpn 39(4):507–513

    CAS  PubMed  Google Scholar 

  48. Laureno R (2009) Raymond Adams: a life of mind and muscle. Oxford University Press, USA

    Google Scholar 

  49. Leavitt S, Tyler HR (1964) Studies in asterixis I. Arch Neurol 10:360–368

    CAS  PubMed  Google Scholar 

  50. Limketkai BN, Zucker SD (2008) Hyperammonemic encephalopathy caused by carnitine deficiency. J Gen Intern Med 23(2):210–213

    PubMed Central  PubMed  Google Scholar 

  51. Lu CS, Chu NS (1988) Acute dystonic reaction with asterixis and myoclonus following metoclopramide therapy. J Neurol Neurosurg Psychiatry 51(7):1002–1003

    CAS  PubMed Central  PubMed  Google Scholar 

  52. Massey EW, Goodman JC (1979) Unilateral asterixis. JAMA 241(2):133–134

    CAS  PubMed  Google Scholar 

  53. Massey EW, Bowman MH, Rozear MP (1988) Asterixis mimicking drop attacks in chronic renal failure. Neurology 38(4):663

    CAS  PubMed  Google Scholar 

  54. Mateos V, Caminal L, Colosía VP, Feliu R (1991) Ipsilateral asterixis secondary to subdural hematoma. Med Clin (Barc) 97(9):353

    CAS  Google Scholar 

  55. Mateos V, Campos DM, Colosía VP, Salas-Puig J, Fernández JM, Lahoz CH (1992) Nuclear syndrome of the oculomotor nerve caused by a mesencephalic infarction confirmed by MRI. Arch Neurobiol (Madr) 55(4):183–187

    CAS  Google Scholar 

  56. McDermott WV Jr, Adams RD (1954) Episodic stupor associated with an Eck fistula in the human with particular reference to the metabolism of ammonia. J Clin Invest 33(1):1–9

    CAS  PubMed Central  PubMed  Google Scholar 

  57. Meyer T, Ludolph AC, Münch C (2002) Ifosfamide encephalopathy presenting with asterixis. J Neurol Sci 199(1–2):85–88

    PubMed  Google Scholar 

  58. Milandre L, Brosset C, Gabriel B, Khalil R (1993) Transient involuntary movement disorders and thalamic infarction. Rev Neurol (Paris) 149(6–7):402–406

    CAS  Google Scholar 

  59. Mizutani T, Shiozawa R, Nozawa T, Nozawa Y (1990) Unilateral asterixis. J Neurol 237(8):480–482

    CAS  PubMed  Google Scholar 

  60. Muneta S, Yamashita Y, Fukuda H, Watanabe S, Imamura Y, Matsumoto I (1995) Asterixis and astatic seizures in association with bilateral insular lesions in a patient with viral encephalitis. Intern Med 34(8):756–761

    CAS  PubMed  Google Scholar 

  61. Murphy MJ, Goldstein MN (1974) Diphenylhydantoin-induced asterixis A clinical study. JAMA 229(5):538–540

    CAS  PubMed  Google Scholar 

  62. Ng K, Silbert PL, Edis RH (1991) Complete external ophthalmoplegia and asterixis with carbamazepine toxicity. Aust N Z J Med 21(6):886–887

    CAS  PubMed  Google Scholar 

  63. Noda S, Umezaki H (1985) Bilateral asterixis in frontal tumor. Ann Neurol 18(3):366

    CAS  PubMed  Google Scholar 

  64. Noda S, Ito H, Umezaki H, Minato S (1985) Hip flexion-abduction to elicit asterixis in unresponsive patients. Ann Neurol 18(1):96–97

    CAS  PubMed  Google Scholar 

  65. Nokura K, Kanbayashi T, Ozeki T, Koga H, Zettsu T, Yamamoto H, Ozaki N, Shimizu T, Kawase T (2004) Hypersomnia, asterixis and cataplexy in association with orexin A-reduced hypothalamic tumor. J Neurol 251(12):1534–1535

    PubMed  Google Scholar 

  66. Palomo F, Cabrera F (1990) Asterixis in bilateral subdural hematoma. Med Clin (Barc) 95(2):77

    CAS  Google Scholar 

  67. Peterson DI, Peterson GW (1986) Unilateral asterixis. Bull Clin Neurosci 51:77–80

    CAS  PubMed  Google Scholar 

  68. Peterson DI, Peterson GW (1987) Unilateral asterixis due to ipsilateral lesions in the pons and medulla. Ann Neurol 22(5):661–663

    CAS  PubMed  Google Scholar 

  69. Phillips GB, Schwartz R, Gabuzda GJ Jr, Davidson CS (1952) The syndrome of impending hepatic coma in patients with cirrhosis of the liver given certain nitrogenous substances. N Engl J Med 247(7):239–246

    CAS  PubMed  Google Scholar 

  70. Poersch M (1994) Drug-induced asterixis. Dtsch Med Wochenschr 119(36):1221–1222

    CAS  PubMed  Google Scholar 

  71. Prajapati KD, Sharma SS, Roy N (2011) Current perspectives on potential role of albumin in neuroprotection. Rev Neurosci 22(3):355–363

    CAS  PubMed  Google Scholar 

  72. Pullicino P, Xuereb M, Farrugia B (1990) Cerebellar hemorrhage and unilateral asterixis. Rev Neurol (Paris) 146(11):697–698

    CAS  Google Scholar 

  73. Reinfeld H, Louis S (1983) Unilateral asterixis clinical significance of the sign. N Y State J Med 83(2):206–208

    CAS  PubMed  Google Scholar 

  74. Reuben A (2005) The liver has a body–a Cook’s tour. Hepatology 41(2):408–415

    PubMed  Google Scholar 

  75. Rittmannsberger H (1996) Asterixis induced by psychotropic drug treatment. Clin Neuropharmacol 19(4):349–355

    CAS  PubMed  Google Scholar 

  76. Rittmannsberger H, Leblhuber F (1992) Asterixis induced by carbamazepine therapy. Biol Psychiatry 32(4):364–368

    CAS  PubMed  Google Scholar 

  77. Rittmannsberger H, Leblhuber F (1994) Drug-induced asterixis. Dtsch Med Wochenschr 119(16):585–588

    CAS  PubMed  Google Scholar 

  78. Rittmannsberger H, Leblhuber F, Sommer R (1991) Asterixis as a side effect of carbamazepine therapy. Klin Wochenschr 69(6):279–281

    CAS  PubMed  Google Scholar 

  79. Rivelli M, el-Mallakh RS, Nelson WH (1988) Carbamazepine-associated asterixis and hyperammonemia. Am J Psychiatry 145(2):269–270

    CAS  PubMed  Google Scholar 

  80. Rottach KG, Weiss-Brummer J, Wieland U, Schmauss M (2000) Valproic acid in prophylaxis of bipolar disorder A case of valproate-induced encephalopathy. Nervenarzt 71(5):401–403

    CAS  PubMed  Google Scholar 

  81. Rubin B, Horowitz G, Katz RI (1980) Asterixis following metrizamide myelography. Arch Neurol 37(8):522

    CAS  PubMed  Google Scholar 

  82. Santamaría Cano J, Graus Ribas F, Martínez Matos J, Rubio Borrero F, Arbizu Urdiain T, Peres Serra J (1983) Asterixis in focal lesions of the nervous system. Rev Clin Esp 168(1):37–39

    PubMed  Google Scholar 

  83. Santamaría J, Graus F, Genís D (1983) Bilateral asterixis in unilateral subdural hematoma. J Neurol 229(2):87–89

    PubMed  Google Scholar 

  84. Savica R, Rabinstein AA, Josephs KA (2011) Ifosfamide associated myoclonus-encephalopathy syndrome. J Neurol 258(9):1729–1731

    CAS  PubMed  Google Scholar 

  85. Sechi G, Murgia B, Sau G, Peddone L, Tirotto A, Barrocu M, Rosati G (2004) Asterixis and toxic encephalopathy induced by gabapentin. Prog Neuropsychopharmacol Biol Psychiatry 28(1):195–199

    CAS  PubMed  Google Scholar 

  86. Shahani BT, Young RR (1976) The motor system-neurophysiology and muscle mechanisms. Shahani M editor. Amsterdam: Elsevier Scientific Publishing Co; 1976. Chapter 7, Asterixis: A disorder of the neural mechanisms underlying sustained muscle contraction 301–306p

  87. Sherlock S, Riddell AG, Summerskill WH, Cooke WT, Wooler G, Gould J (1955) Discussion on hepatic coma. Proc R Soc Med 48(6):479–488

    CAS  PubMed  Google Scholar 

  88. Shibasaki H, Hallett M (2005) Electrophysiological studies of myoclonus. Muscle Nerve 31(2):157–174

    PubMed  Google Scholar 

  89. Smith MS, Laguna JF (1980) Confusion, dysphasia, and asterixis following metrizamide myelography. Can J Neurol Sci 7(4):309–311

    CAS  PubMed  Google Scholar 

  90. Song IU, Kim JS, An JY, Kim YI, Lee KS (2007) Co-occurrence of astasia and unilateral asterixis caused by acute mesencephalic infarction. Eur Neurol 57(2):106–108

    PubMed  Google Scholar 

  91. Stell R, Davis S, Carroll WM (1994) Unilateral asterixis due to a lesion of the ventrolateral thalamus. J Neurol Neurosurg Psychiatry 57(7):878–880

    CAS  PubMed Central  PubMed  Google Scholar 

  92. Stewart JT, Williams LS (2000) A case of lithium-induced asterixis. J Am Geriatr Soc 48(4):457

    CAS  PubMed  Google Scholar 

  93. Subías Sobrevía R, Darnell Tey A (1984) Asterixis as a neurologic manifestation of hypophosphatemia. Med Clin (Barc) 83(15):651

    Google Scholar 

  94. Terzano MG, Salati MR, Gemignani F (1983) Asterixis associated with carbamazepine. Acta Neurol Belg 83(3):158–165

    CAS  PubMed  Google Scholar 

  95. Tilley LP, Smith FW, Allen D (2000) Stedman’s medical dictionary. Lippincott Williams & Wilkins, Philadelphia

    Google Scholar 

  96. Trejo JM, Giménez-Roldán S, Esteban A (1986) Focal asterixis caused by a small putaminal hemorrhage. Mov Disord 1(4):271–274

    CAS  PubMed  Google Scholar 

  97. Trouillas P, Nighoghossian N, Mauguière F (1990) Cerebellar ataxia and unilateral asterixis caused by thalamic hematoma Presumed mechanisms. Rev Neurol (Paris) 146(8–9):484–489

    CAS  Google Scholar 

  98. Tyler HR, Leavitt S (1965) Asterixis. J Chronic Dis 18:409–411

    CAS  PubMed  Google Scholar 

  99. Ugawa Y, Shimpo T, Mannen T (1989) Physiological analysis of asterixis: silent period locked averaging. J Neurol Neurosurg Psychiatry 52(1):89–93

    CAS  PubMed Central  PubMed  Google Scholar 

  100. Vallat JM, Rkina M, Bokor J (1981) Unilateral asterixis due to subdural hematoma. Arch Neurol 38(8):535

    CAS  PubMed  Google Scholar 

  101. Velasco F, Gomez JC, Zarranz JJ, Lambarri I, Ugalde J (2004) Asterixis in focal brain lesions. Neurologia 19(4):225–229

    CAS  PubMed  Google Scholar 

  102. Verma SK, Pruthi S, Khamesra R, Bordia A (1989) Asterixis in cerebral malaria. J Assoc Physicians India 37(7):484

    CAS  PubMed  Google Scholar 

  103. Vincent FM (1980) Asterixis after metrizamide myelography. JAMA 244(24):2727

    CAS  PubMed  Google Scholar 

  104. Wee AS (1986) Unilateral asterixis: case report and comments. Eur Neurol 25(3):208–211

    CAS  PubMed  Google Scholar 

  105. Weinreb WH, Perry RJ, Jenkyn LR (1982) Rhythmic alternating asterixis. J Neurol Neurosurg Psychiatry 45(9):857–858

    CAS  PubMed Central  PubMed  Google Scholar 

  106. Yagnik P, Dhopesh V (1981) Unilateral asterixis. Arch Neurol 38(9):601–602

    CAS  PubMed  Google Scholar 

  107. Yamada S, Watanabe T, Shibata A, Yuasa T (1980) A case of IgG (k type) multiple myeloma with coma paraproteinemicum and asterixis–hyperviscosity syndrome (author’s transl). Nihon Naika Gakkai Zasshi 69(9):1119–1125

    CAS  PubMed  Google Scholar 

  108. Young RR, Shahani BT (1975) A new sign of minimal motor dysfunction. J Postgrad Med 21:18

    Google Scholar 

  109. Young RR, Shahani BT (1986) Asterixis: one type of negative myoclonus. Adv Neurol 43:137–156

    CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Thanks to Mrs. Louella Baterna for her assistance with preparation of the manuscript.

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This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

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The authors declare that they have no conflict of interest.

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Correspondence to Gian Pal.

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Pal, G., Lin, M.M. & Laureno, R. Asterixis: a study of 103 patients. Metab Brain Dis 29, 813–824 (2014). https://doi.org/10.1007/s11011-014-9514-7

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Keywords

  • Asterixis
  • Encephalopathy
  • Movement disorder
  • History
  • Confusion