Dear Editor,
With great interest we read the article by Novis and colleagues recently published
in Arquivos de Neuro-Psiquiatria
[1]. Where they present the life and work of Professor Faustino Esposel, considered
the father of Brazilian neurology, who along with Antõnio Austregésilo, described
a substitute sign for Babinski’s phenomenon eliciting of the extensor plantar response
upon squeezing of the thigh: “Le phénomene de Babinski, provoqué par l’excitation de la cuisse”, now known as the Austregésilo-Esposel sign[2]. Upon a search of the literature, we were unable to find recent visual documentation
of the sign. Therefore, to illustrate the excellent article by Novis and colleagues,
we considered it appropriate to present the case of a patient with stroke in whom
the Austregésilo-Esposel sign was present, along with the Babinski, Chaddock, and
Oppenheim signs.
An 89-year-old female with a long-standing history of untreated hypertension, presents
to the emergency department 7 hours after sudden-onset of mutism and right hemiparesis.
Neurological examination reveals global aphasia, right dense hemiplegia (0/5 in Modified
Research Council scale), with hyperactive deep tendon reflexes and abnormal plantar
responses ([Figure 1]), with toe extension on squeezing of the thigh ([Figure 2]): the Austregésilo-Esposel sign. A non-contrast enhanced computed tomography of
the brain revealed a large left-hemispheric stroke ([Figure 3]). Etiological work up for the cause of stroke ruled out cardiac embolism sources,
large-artery, and small-vessel disease, and was thus classified as an embolic stroke
of unknown source (ESUS)[3].
Figure 1 Signs eliciting extensor plantar response. Toe extension on stroking the sole of
the foot (Babinski, 1), the lateral aspect of the foot (Chaddock, 2) and downward
stroking of the tibia (Oppenheim, 3).
Figure 2 Austregésilo-Esposel sign. Toe extension on squeezing of the anterior aspect of the
thigh.
Figure 3 Computed tomography scan. Axial projection showing a hypodensity in the left hemisphere,
compromising the complete left middle cerebral artery territory, which appears hyperdense
(yellow arrows).
With over 30 surrogate or substitute signs for the original Babinski sign[4], it has become a common rite of passage in some centers to test trainees on how
many signs they can remember. Despite their widespread use as markers of corticospinal
disease, their diagnostic yield remains controversial; and their sensitivity for detecting
pyramidal tract dysfunction and inter observer agreement remains low[5]. Thus, regardless of the eponym remembered when eliciting the plantar response,
it is paramount to interpret it in the patient’s context and not in isolation.
SUPPLEMENTARY FILES
The following material is available online for this letter:
Supplementary video. The Austregésilo-Esposel Sign. Upon stimulation of the anterior
aspect of the thigh, we observe an extensor plantar reflex (https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2021/09/ANP-2021.0310-video.mov)
