Abnormal posturing

Causes

Posturing can be caused by conditions that lead to large increases in intracranial pressure. Such conditions include traumatic brain injury, stroke, intracranial hemorrhage, brain tumors, and encephalopathy. Posturing due to stroke usually only occurs on one side of the body and may also be referred to as spastic hemiplegia. Diseases such as malaria are also known to cause the brain to swell and cause this posturing effect.

Decerebrate and decorticate posturing can indicate that brain herniation is occurring or is about to occur. Brain herniation is an extremely dangerous condition in which parts of the brain are pushed past hard structures within the skull. In herniation syndrome, which is indicative of brain herniation, decorticate posturing occurs, and, if the condition is left untreated, develops into decerebrate posturing.

Posturing has also been displayed by patients with Creutzfeldt–Jakob disease, diffuse cerebral hypoxia, and brain abscesses.

Children

In children younger than age two, posturing is not a reliable finding because their nervous systems are not yet developed. However, Reye's syndrome and traumatic brain injury can both cause decorticate posturing in children.

For reasons that are poorly understood, but which may be related to high intracranial pressure, children with malaria frequently exhibit decorticate, decerebrate, and opisthotonic posturing.

Types

Three types of abnormal posturing are decorticate posturing, with the arms flexed over the chest; decerebrate posturing, with the arms extended at the sides; and opisthotonus, in which the head and back are arched backward.

Decorticate

Decorticate posturing is also called decorticate response, decorticate rigidity, flexor posturing, or, colloquially, mummy baby. Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward. A person displaying decorticate posturing in response to pain gets a score of three in the motor section of the Glasgow Coma Scale, due to the flexion of muscles due to the neuro-muscular response to the trauma.

There are two parts to decorticate posturing.

The effects on these two tracts (corticospinal and rubrospinal) by lesions above the red nucleus is what leads to the characteristic flexion posturing of the upper extremities and extensor posturing of the lower extremities.

Decorticate posturing indicates that there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus. It may also indicate damage to the midbrain. While decorticate posturing is still an ominous sign of severe brain damage, decerebrate posturing is usually indicative of more severe damage at the rubrospinal tract, and hence, the red nucleus is also involved, indicating a lesion lower in the brainstem.

Decerebrate

Decerebrate posturing is also called decerebrate response, decerebrate rigidity, or extensor posturing. It describes the involuntary extension of the upper extremities in response to external stimuli. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. A hallmark of decerebrate posturing is extended elbows. The arms and legs are extended and rotated internally. The patient is rigid, with the teeth clenched. The signs can be on just one side of the body or on both sides, and it may be just in the arms and may be intermittent.

A person displaying decerebrate posturing in response to pain gets a score of two in the motor section of the Glasgow Coma Scale (for adults) and the Pediatric Glasgow Coma Scale (for infants), due to his or her muscles extending because of the neuro-muscular response to the trauma.

Decerebrate posturing indicates brain stem damage, specifically damage below the level of the red nucleus (e.g. mid-collicular lesion). It is exhibited by people with lesions or compression in the midbrain and lesions in the cerebellum. Decerebrate posturing is commonly seen in pontine strokes. A patient with decorticate posturing may begin to show decerebrate posturing, or may go from one form of posturing to the other. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation. Activation of gamma motor neurons is thought to be important in decerebrate rigidity due to studies in animals showing that dorsal root transection eliminates decerebrate rigidity symptoms.

In competitive contact sports, posturing (typically of the forearms) can occur with an impact to the head and is termed the fencing response. In this case, the temporary posturing display indicates transient disruption of brain neurochemicals, which wanes within seconds.

Prognosis

Normally people displaying decerebrate or decorticate posturing are in a coma and have poor prognoses, with risks for cardiac arrhythmia or arrest and respiratory failure.

History

Sir Charles Sherrington was first to describe decerebrate posturing after transecting the brain stems of cats and monkeys, causing them to exhibit the posturing.